Abstract
Background and Aims
Chronic kidney disease-associated pruritus (CKD-aP) is a common yet under-recognised condition in patients with CKD undergoing haemodialysis (HD), in whom it is associated with reduced health-related quality of life (HRQoL), poor sleep quality, and a greater risk of depression. This real-world study obtained insights from nephrologists in Europe and Australia into the current practices, attitudes and unmet medical needs relating to the diagnosis and treatment of CKD-aP.
Method
Qualitative data were obtained from structured interviews conducted Oct–Nov 2019 with 72 nephrologists from France, Germany, Italy, Spain, UK and Australia (n=12 in each country). Quantitative data relating to diagnostic/treatment practices for CKD-aP were collected May–July 2020 by a 20-minute physician survey and collection of patient record forms (PRF). The survey was completed by 301 nephrologists from France (n=50), Germany (n=56), Italy (n=58), Spain (n=55), UK (n=52), and Australia (n=30). Respondents’ level of agreement was assessed using a 7-point scale, from 1 (do not agree at all) to 7 (strongly agree). PRF data were also captured for 1435 HD patients with CKD-aP from all countries. All nephrologists who completed the interviews and surveys were currently treating >5 HD patients with CKD-aP.
Results
Most nephrologists (75%) agreed that CKD-aP is under-diagnosed in HD patients, which is mainly driven by the lack of systematic screening by nephrologists and under-reporting of the condition by patients. The main barriers to screening for CKD-aP identified by nephrologists included the lack of diagnostic guidelines and absence of standardised pruritus intensity scales to consistently diagnose and classify CKD-aP severity. The majority (74%) agreed new clinical guidelines for nephrologists are needed to aid diagnosis. Nephrologists perceived that on average ∼34% of their HD patients experienced CKD-aP, and that 55% of them had moderate-severe symptoms. However, most nephrologists (79%) do not use any itch scales in clinical practice and 71% agreed a consistent international scale to diagnose CKD-aP is needed. 80% of nephrologists agreed diagnosis of CKD-aP is usually patient-driven, indicating there is a reliance on patients mentioning their symptoms. Less than half of nephrologists (46%) agreed that CKD-aP was easy to diagnose by clinical observation alone. The lack of targeted treatment guidelines and approved therapies for CKD-aP leads to an inconsistent, fragmented approach to management. Analysis of prescription data captured in the PRFs of 1435 HD patients with CKD-aP showed treatment in current clinical practice relies on incremental add-on therapy. The majority of patients (∼85-90%) receiving second- or subsequent lines of therapy for CKD-aP were prescribed combinations of different treatments. Commonly prescribed (off-label) medications for CKD-aP included antihistamines, moisturizers/emollients, corticosteroids and gabapentinoids. However, there was no single standard of care for the treatment of CKD-aP, highlighting the uncertainties nephrologists face relating to best treatment practice. Most nephrologists (72%) agreed that treatment options are very limited for patients with bothersome CKD-aP, and the survey responses indicated a high unmet need for novel treatments. The majority of nephrologists felt a major improvement was needed over current treatments, particularly in terms of improved efficacy for reduction of itch intensity (62%) and the ability to improve the patient HRQoL (57%).
Conclusion
This real-world international survey study of nephrologists showed that CKD-aP is a frequent, but under-diagnosed condition affecting many HD patients, with a lack of effective treatment options. Furthermore, there is an urgent need to develop guidelines to assist in the diagnosis of CKD-aP and new targeted treatment options that are both effective and well tolerated.
A Self-learning Knowledge based System for Diagnosis and Treatment of Chronic Kidney Disease
