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      Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges

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          Abstract

          Chronic kidney disease-associated pruritus (CKD-aP) is a distressing, often overlooked condition in patients with CKD and end-stage renal disease. It affects ~40% of patients with end-stage renal disease and has been associated with poor quality of life, poor sleep, depression, and mortality. Prevalence estimates vary based on the instruments used to diagnose CKD-aP, and standardized diagnostic instruments are sorely needed. Treatment studies have often yielded conflicting results. This is likely related to studies that are limited by small sample size, flawed designs, and nonstandardized diagnostic instruments. Several large well-designed treatment trials have recently been completed and may soon influence CKD-aP management.

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          Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus.

          Ngoc Quan Phan, Christine Blome, Fleur Fritz … (2012)
          The most commonly used tool for self-report of pruritus intensity is the visual analogue scale (VAS). Similar tools are the numerical rating scale (NRS) and verbal rating scale (VRS). In the present study, initiated by the International Forum for the Study of Itch assessing reliability of these tools, 471 randomly selected patients with chronic itch (200 males, 271 females, mean age 58.44 years) recorded their pruritus intensity on VAS (100-mm line), NRS (0-10) and VRS (four-point) scales. Re-test reliability was analysed in a subgroup of 250 patients after one hour. Statistical analysis showed a high reliability and concurrent validity (r>0.8; p<0.01) for all tools. Mean values of all scales showed a high correlation. In conclusion, high reliability and concurrent validity was found for VAS, NRS and VRS. On re-test, higher correlation and less missing values were observed. A training session before starting a clinical trial is recommended.
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            The 5-D itch scale: a new measure of pruritus.

            L Hynan, Gwenda Mayo, V Gabriel … (2010)
            Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being unidimensional, for example only measuring intensity without impact on quality of life, or only measuring scratching activity. None has actually been demonstrated to be able to detect change over time, which is essential to using them as an outcome measure of response to an intervention. The 5-D itch scale was developed as a brief but multidimensional questionnaire designed to be useful as an outcome measure in clinical trials. The five dimensions are degree, duration, direction, disability and distribution. To study the 5-D with respect to validity, reliability and response to change. The 5-D was administered to 234 individuals with chronic pruritus due to liver disease (n = 63), kidney disease (n = 36), dermatological disorders (n = 56), HIV/AIDS (n = 28) and burn injuries (n = 51). The 5-D was administered at baseline and after a 6-week follow-up period. A subset of 50 untreated patients was retested after 3 days to assess test-retest reliability. The 5-D score correlated strongly with a visual analogue score: r = 0.727 at baseline (P < 0.0001), r = 0.868 at the 3-day repeat (P < 0.0001), and r = 0.892 at the 6-week follow-up (P < 0.0001). There was no change in mean 5-D score between day 1 and day 3 in untreated individuals (intraclass correlation coefficient = 0.96, P < 0.0001). The 5-D did, however, detect significant changes in pruritus over the 6-week follow-up period (P < 0.0001). Subanalysis of the different patient groups revealed similar response patterns and scores, with the exception of lower total scores for the burn victims due to lower scores on the distribution domain because they itched only at the site of their burn. The 5-D, therefore, is a reliable, multidimensional measure of itching that has been validated in patients with chronic pruritus to able to detect changes over time. The 5-D should be useful as an outcome measure in clinical trials.
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              Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients.

              S. Maruyama, K Akazawa, Junichiro J. Kazama … (2006)
              Although uremia is well known as the most common cause of pruritus, the mechanisms of pruritus in chronic hemodialysis patients remain unclear. The purpose was to characterize uremic pruritus in more detail and to investigate whether severe pruritus is a marker for poor prognosis. A total of 1773 adult hemodialysis patients were studied. A questionnaire was given to each patient to assess the intensity and frequency, as well as pruritus-related sleep disturbance. We analyzed the relationship between clinical and laboratory data and the severity of pruritus in hemodialysis patients and followed them for 24 months prospectively. In total, 453 patients had severe pruritus with a visual analogue scale (VAS) score more than or equal to 7.0. Among them, more than 70% complained of sleep disturbance, whereas the majority of patients with a VAS score of less than 7.0 had no sleep disturbance. Male gender, high levels of blood urea nitrogen, beta2-microglobulin (beta2MG), hypercalcemia, and hyperphosphatemia were identified as independent risk factors for the development of severe pruritus, whereas a low level of calcium and intact-parathyroid hormone were associated with reduced risk. During the follow-up, 171 (9.64%) patients died. The prognosis of patients with severe pruritus was significantly worse than the others. Moreover, severe pruritus was independently associated with death even after adjusting for other clinical factors including diabetes mellitus, age, beta2MG, and albumin. Severe uremic pruritus caused by multiple factors, not only affects the quality of life but may also be associated with poor outcome in chronic hemodialysis patients.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Nephrol Renovasc Dis
                Journal ID (iso-abbrev): Int J Nephrol Renovasc Dis
                Journal ID (publisher-id): International Journal of Nephrology and Renovascular Disease
                Title: International Journal of Nephrology and Renovascular Disease
                Publisher: Dove Medical Press
                ISSN (Electronic): 1178-7058
                Publication date Collection: 2017
                Publication date (Electronic): 23 January 2017
                Volume: 10
                Pages: 11-26
                Affiliations
                [1 ]Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
                [2 ]Mathur Consulting, Woodside, CA, USA
                Author notes
                Correspondence: Shayan Shirazian, Division of Nephrology, Department of Medicine, Winthrop University Hospital, 200 Old Country Road, Suite 135, Mineola, NY 11501, USA, Tel +1 516 663 2169, Fax +1 516 663 2179, Email sshirazian@ 123456winthrop.org
                Article
                Publisher ID: ijnrd-10-011
                DOI: 10.2147/IJNRD.S108045
                PMC ID: 5271405
                PubMed ID: 28176969
                SO-VID: 7dde8a5a-c3d5-4ee2-b351-292694c2c956
                Copyright © © 2017 Shirazian et al. This work is published and licensed by Dove Medical Press Limited
                License:

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Subject: Review

                ScienceOpen disciplines: Nephrology
                Keywords: pruritus,chronic kidney disease,uremia,end-stage renal disease,itching,depression
                Data availability:
                ScienceOpen disciplines: Nephrology
                Keywords: pruritus, chronic kidney disease, uremia, end-stage renal disease, itching, depression

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