Commentary
PRURITUS ON HEMODIAL YSIS
LUIS TAPIA, M.D .
Pruritus is one of the many symptoms ?f the uremic syndrome, but it is not present m Patients with acute renal failure regardless . lt of the cause and the degree of azotemia. subsides following the institution of hemodialysis but in a good percentage of P_atients, recurs while they are on dial~sts. Many drugs have been tried to relieve pruritus during dialysis with an overall ~oor result with the exception of lidocaine gtven intravenously. 1 Some of these patients h~ve secondary hyperparathyroidism and pr~ntus disappears following subtotal parathyrotde~ tomy.2 Kidney transplantation relieves thts symptom immediately following a successful transplant.
Cause The cause of pruritus in chronic renal f~il ure is unknown; it is probably multifacton~l. The fact that it is present in chronic but not m acute renal failure is suggestive of a slow accumulative process of a metabolic and/or hormonal derangement, in the same way that the hematopoietic, cardiovascular, bones, peripheral and centrai nervous system are affected in uremia.' . Lu1s · Tap1a, · M ·D ·• Ne w York Address far repnnts: Hospitai-Cornell Medicai Center, 525 East 68th Street, New York, NY 10021. 0011-9059 / 79 / 0400/ 0217 / $00.60
From the D epa rtm ent of Medicine, Biochemistry and Surgery, th e New York Hospit ai-Cornell M edicai Centèr, New York, New York
Studies done on patients on chronic hemodialysis 3 have shown that predialysis blood-urea-nitrogen tests, alkaline phosphatase, calcium and magnesium content of the skin and degree of xerosis of the skin correlates well with the severity of pruritus. However, why ali these factors produce itching is unknown. Pruritus is a S!Jbjective symptom that may vary widely depending on the psychologic condition of the patient. Many patients who complain of pruritus during dialysis and during the night do not complain even less during their working hours. .. At dialysis centers with self-care un.its, where the patients dialyze themselves , pruritus is less prevalent than in units where the patients are dialyzed by medicai personnel. In self-care units, patients are involved in their own treatment which might distrae! them from minor symptoms. The patients also know the principles of dialysis and are more careful with their diets and medications. The relationship of secondary hyperparathyroidism and pruritus is not well un-
© lnternational 217
Soci ety of Tropi ca l Dermatology, lnc.
218
INTERNATIONAL jOURNAL OF DERMATOLOGY
derstood. Hypercalcemia per se does not correlate with pruritus, however, the increase concentration of calcium content of the skin, that occurs with hyperparathyroidism, may play a role. 3 Calcium serum concentrations decrease by increasing the concentration of magnesium (Mg) in the dialysate; probably by reducing circulating parathormone (PTH) levels.4 High PTH levels seem to stimulate mast celi proliferation in uremic patients. Parathyroidectomy relieves pruritus, but in some patients pruritus recurs months later when PTH levels are norma!. Pruritus is very refractory to treatment, local measures like hot bath and skin emollients can be successful in some cases. Minor tranquilizers, antihistamines and analgesics have been overly used in dialysis patients with poor results or dependency to these drugs. Low protein, high aminoacids diets have been effective in controlling itching in uremic patients but these diets are poorly tolerated by the patients and they are difficult to evaluate because of poor patient's compliance. Cholestyramine,5 used for pruritus associated with liver disease, has been used on dialysis patients wjth good results by some investigators. Unfortunately its many side effects, primarily constipation and nausea, make this treatment usually undesirable. Phototherapy with ultraviolet light has been shown to be effective without major side effects.6 1ntravenous lidocaine given during dialysis is probably the most effective drug for the treatment of pruritus on dialysis. A double blind study demonstrated that lidocaine was more effective than placebo in relieving this symptom but its mechanism of
Aprii 1979
Vol. 18
action is unknown. Perhaps the continued relief from pruritus for up to 36 hours after lidocaine suggests either that a metabolite normally excreted by the kidney is also active as an antipruritic agent or that the lidocaine is acting in a pharmacokinetic compartment with a very slow rate of egress of the drug. Kidney transplantation cures ali the symptoms of uremia, including pruritus, probably by reinstituting the homeostatic regulation and hormonal production of the kidney. Drug Name cholestyramine: Cuemid, Questran
References 1. Tapia, L., Cheigh, J. S., David, D . S. , Sullivan, j. F., Saal, S.., Reidenberg, M . M. , Stenzel, K. H ., and Rubin, A. L. : Pruritus in dial ys is pati ents treated with parenterallidocaine. N. Engl. J. M ed. 296:261 , 1977. 2. Hampers, C. L., Katz , A. 1., Wilson , R. E., et al. : Disappearance of " uremic" itching after subtotal parathyroidectomy . N . Engl. j . M ed. 279 :695 , 1968. 3. Young, A. W. , Jr., Sweeney, E. W ., David , D . S. , et al.: Dermatologi e evaluation of pruritus in pati ents on hemodialysis. NY State J. M ed. 73 :2670, 1973. 4. Pletka, P., Berstein , D. S., Hampers, C. L., M errill , j." P., and Sherwood , L. M .: Relationship between magnesium and secondary hyperparathyroidism during long-t erm hemodialysi s. M etabolism 23 :619, 1974. 5. Silverberg, D. S., laiana, A. , Rei sin, E., Rotzak, R., and Eliaho n, H. E.: Chol estyramine in uraemic pruritus: Br. Med. J. 1:752, 1971. 6. Gilchres, B. A., Row e, j . W. , Brown, R. S., Steinman, T. 1., and Arndt, K. A. : Relief of uremic pruritu s with ultraviolet phototherapy. N . Engl. J. Med. 297:136, 1977.
The appearance of the code at the bottom of the first page of an artic/e in this journal indicates the copyright owner's consent that copies of the article may be made far personal or interna/ use, or far personal or interna/ use of specific c/ients . This consent is given on the condition, however, that the copier pay the stated per-copy fee through the Copyright Clearance Center, /ne. , P.O . Box 765, Schenectady, New York 12301, far copying beyond that permitted by Sections 107 or 108 of the U.S . Copyright Law. This consent does not extend to other kinds of copying, such as copying far genera/ distribution, far advertising or promotional purposes, far creating new collective works, or far resa/e.
PRURITUS ON HEMODIAL YSIS
LUIS TAPIA, M.D .
Pruritus is one of the many symptoms ?f the uremic syndrome, but it is not present m Patients with acute renal failure regardless . lt of the cause and the degree of azotemia. subsides following the institution of hemodialysis but in a good percentage of P_atients, recurs while they are on dial~sts. Many drugs have been tried to relieve pruritus during dialysis with an overall ~oor result with the exception of lidocaine gtven intravenously. 1 Some of these patients h~ve secondary hyperparathyroidism and pr~ntus disappears following subtotal parathyrotde~ tomy.2 Kidney transplantation relieves thts symptom immediately following a successful transplant.
Cause The cause of pruritus in chronic renal f~il ure is unknown; it is probably multifacton~l. The fact that it is present in chronic but not m acute renal failure is suggestive of a slow accumulative process of a metabolic and/or hormonal derangement, in the same way that the hematopoietic, cardiovascular, bones, peripheral and centrai nervous system are affected in uremia.' . Lu1s · Tap1a, · M ·D ·• Ne w York Address far repnnts: Hospitai-Cornell Medicai Center, 525 East 68th Street, New York, NY 10021. 0011-9059 / 79 / 0400/ 0217 / $00.60
From the D epa rtm ent of Medicine, Biochemistry and Surgery, th e New York Hospit ai-Cornell M edicai Centèr, New York, New York
Studies done on patients on chronic hemodialysis 3 have shown that predialysis blood-urea-nitrogen tests, alkaline phosphatase, calcium and magnesium content of the skin and degree of xerosis of the skin correlates well with the severity of pruritus. However, why ali these factors produce itching is unknown. Pruritus is a S!Jbjective symptom that may vary widely depending on the psychologic condition of the patient. Many patients who complain of pruritus during dialysis and during the night do not complain even less during their working hours. .. At dialysis centers with self-care un.its, where the patients dialyze themselves , pruritus is less prevalent than in units where the patients are dialyzed by medicai personnel. In self-care units, patients are involved in their own treatment which might distrae! them from minor symptoms. The patients also know the principles of dialysis and are more careful with their diets and medications. The relationship of secondary hyperparathyroidism and pruritus is not well un-
© lnternational 217
Soci ety of Tropi ca l Dermatology, lnc.
218
INTERNATIONAL jOURNAL OF DERMATOLOGY
derstood. Hypercalcemia per se does not correlate with pruritus, however, the increase concentration of calcium content of the skin, that occurs with hyperparathyroidism, may play a role. 3 Calcium serum concentrations decrease by increasing the concentration of magnesium (Mg) in the dialysate; probably by reducing circulating parathormone (PTH) levels.4 High PTH levels seem to stimulate mast celi proliferation in uremic patients. Parathyroidectomy relieves pruritus, but in some patients pruritus recurs months later when PTH levels are norma!. Pruritus is very refractory to treatment, local measures like hot bath and skin emollients can be successful in some cases. Minor tranquilizers, antihistamines and analgesics have been overly used in dialysis patients with poor results or dependency to these drugs. Low protein, high aminoacids diets have been effective in controlling itching in uremic patients but these diets are poorly tolerated by the patients and they are difficult to evaluate because of poor patient's compliance. Cholestyramine,5 used for pruritus associated with liver disease, has been used on dialysis patients wjth good results by some investigators. Unfortunately its many side effects, primarily constipation and nausea, make this treatment usually undesirable. Phototherapy with ultraviolet light has been shown to be effective without major side effects.6 1ntravenous lidocaine given during dialysis is probably the most effective drug for the treatment of pruritus on dialysis. A double blind study demonstrated that lidocaine was more effective than placebo in relieving this symptom but its mechanism of
Aprii 1979
Vol. 18
action is unknown. Perhaps the continued relief from pruritus for up to 36 hours after lidocaine suggests either that a metabolite normally excreted by the kidney is also active as an antipruritic agent or that the lidocaine is acting in a pharmacokinetic compartment with a very slow rate of egress of the drug. Kidney transplantation cures ali the symptoms of uremia, including pruritus, probably by reinstituting the homeostatic regulation and hormonal production of the kidney. Drug Name cholestyramine: Cuemid, Questran
References 1. Tapia, L., Cheigh, J. S., David, D . S. , Sullivan, j. F., Saal, S.., Reidenberg, M . M. , Stenzel, K. H ., and Rubin, A. L. : Pruritus in dial ys is pati ents treated with parenterallidocaine. N. Engl. J. M ed. 296:261 , 1977. 2. Hampers, C. L., Katz , A. 1., Wilson , R. E., et al. : Disappearance of " uremic" itching after subtotal parathyroidectomy . N . Engl. j . M ed. 279 :695 , 1968. 3. Young, A. W. , Jr., Sweeney, E. W ., David , D . S. , et al.: Dermatologi e evaluation of pruritus in pati ents on hemodialysis. NY State J. M ed. 73 :2670, 1973. 4. Pletka, P., Berstein , D. S., Hampers, C. L., M errill , j." P., and Sherwood , L. M .: Relationship between magnesium and secondary hyperparathyroidism during long-t erm hemodialysi s. M etabolism 23 :619, 1974. 5. Silverberg, D. S., laiana, A. , Rei sin, E., Rotzak, R., and Eliaho n, H. E.: Chol estyramine in uraemic pruritus: Br. Med. J. 1:752, 1971. 6. Gilchres, B. A., Row e, j . W. , Brown, R. S., Steinman, T. 1., and Arndt, K. A. : Relief of uremic pruritu s with ultraviolet phototherapy. N . Engl. J. Med. 297:136, 1977.
The appearance of the code at the bottom of the first page of an artic/e in this journal indicates the copyright owner's consent that copies of the article may be made far personal or interna/ use, or far personal or interna/ use of specific c/ients . This consent is given on the condition, however, that the copier pay the stated per-copy fee through the Copyright Clearance Center, /ne. , P.O . Box 765, Schenectady, New York 12301, far copying beyond that permitted by Sections 107 or 108 of the U.S . Copyright Law. This consent does not extend to other kinds of copying, such as copying far genera/ distribution, far advertising or promotional purposes, far creating new collective works, or far resa/e.
