Scherer Jennifer S, Tu Charlotte, Pisoni Ronald L, Speyer Elodie, Lopes Antonio A, Wen Warren, Menzaghi Frederique, Cirulli Joshua, Alencar de Pinho Natalia, Pecoits-Filho Roberto, Karaboyas Angelo
Division of Geriatrics and Palliative Care and Division of Nephrology, NYU Grossman School of Medicine, New York, NY.
Arbor Research Collaborative for Health, Ann Arbor, MI.
Kidney Med. 2023 Nov 28;6(1):100754. doi: 10.1016/j.xkme.2023.100754. eCollection 2024 Jan.
RATIONALE & OBJECTIVE: Itching is a frequent symptom experienced by people with chronic kidney disease (CKD). We investigated the associations of CKD-associated pruritus (CKD-aP) with clinical outcomes.
This was a longitudinal cohort study.
SETTING & PARTICIPANTS: Patients from Brazil, France, and the United States enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013 to 2021, an international prospective cohort study of adults with nondialysis dependent CKD, and an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m were included.
CKD-aP was self-reported by response to the question: "During the past 4 weeks, to what extent were you bothered by itchy skin?"
The outcomes were as follows: CKD progression, kidney replacement therapy (KRT) initiation, mortality, hospitalization, cardiovascular events, infection events.
Associations with time-to-event outcomes were investigated using Cox proportional hazards models adjusted for potential confounders.
There were 4,410 patients from 91 clinics with a median age of 69 years and a median eGFR at patient questionnaire completion of 29 (21-38) mL/min/1.73 m. The proportion of patients not at all, somewhat, moderately, very much, and extremely bothered by itchy skin was 49%, 27%, 13%, 7%, and 3%, respectively. Patients with more advanced stages of CKD, older age, and greater comorbidities reported to be more likely bothered by itchy skin. Among patients at least moderately bothered, 23% were prescribed at least 1 pharmacotherapy (35% in the United States, 19% in France, 4% in Brazil), including antihistamine (10%), gabapentin (6%), topical corticosteroids (4%), pregabalin (3%), or sedating antihistamine (3%). The HR (95% CI) for patients extremely (vs not at all) bothered was 1.74 (1.11-2.73) for all-cause mortality, 1.56 (1.11-2.18) for all-cause hospitalization, and 1.84 (1.22-2.75) for cardiovascular events. As CKD-aP severity increased, patients also had higher rates of infection events ( = 0.04); CKD-aP severity was not associated with KRT initiation ( = 0.20) or CKD progression ( = 0.87).
The limitations were 25% nonresponse rate, recall bias, and residual confounding factors.
These results demonstrate a strong association between severe itch and clinical outcomes, providing the nephrology community new insights into the possible adverse consequences of CKD-aP in individuals with nondialysis CKD, and warrant further exploration.
PLAIN-LANGUAGE SUMMARY: Chronic kidney disease-associated pruritus (CKD-aP) is a common disturbing symptom of chronic kidney disease (CKD). This article analyzes longitudinal data from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) to describe prevalence of CKD-aP in 4,410 individuals with nondialysis CKD, and its association with clinical outcomes. We found that 51% of the surveyed population were bothered by pruritus. CKD-aP was more prevalent in those with more advanced stages of CKD, older age, and with more comorbid conditions. Compared to those not at all bothered by pruritus, those who were extremely bothered had a higher risk of all-cause mortality, hospitalizations, and cardiovascular events. Severity of CKD-aP was not associated with CKD progression or initiation of kidney replacement therapy.
瘙痒是慢性肾脏病（CKD）患者常见的症状。我们研究了CKD相关瘙痒症（CKD-aP）与临床结局之间的关联。
这是一项纵向队列研究。
来自巴西、法国和美国的患者于2013年至2021年参加了慢性肾脏病结局与实践模式研究（CKDopps），这是一项针对非透析依赖型CKD成人的国际前瞻性队列研究，纳入了估计肾小球滤过率（eGFR）<60 mL/min/1.73 m²的患者。
CKD-aP通过对以下问题的回答进行自我报告：“在过去4周内，您的皮肤瘙痒给您带来了多大困扰？”
结局如下：CKD进展、开始肾脏替代治疗（KRT）、死亡率、住院率、心血管事件、感染事件。
使用针对潜在混杂因素进行调整的Cox比例风险模型研究与事件发生时间结局的关联。
来自91个诊所的4410名患者，中位年龄为69岁，在完成患者问卷调查时的中位eGFR为29（21-38）mL/min/1.73 m²。完全没有、有点、中度、非常、极其受到皮肤瘙痒困扰的患者比例分别为49%、27%、13%、7%和3%。CKD分期越晚、年龄越大、合并症越多的患者报告更容易受到皮肤瘙痒的困扰。在至少中度受到困扰的患者中，23%接受了至少1种药物治疗（美国为35%，法国为19%，巴西为4%），包括抗组胺药（10%）、加巴喷丁（6%）、外用糖皮质激素（4%）、普瑞巴林（3%）或镇静性抗组胺药（3%）。极度（与完全没有）受到困扰的患者全因死亡率的HR（95%CI）为1.74（1.11-2.73），全因住院率为1.56（1.11-2.18），心血管事件为1.84（1.22-2.75）。随着CKD-aP严重程度增加，患者感染事件发生率也更高（P = 0.04）；CKD-aP严重程度与开始KRT（P = 0.20）或CKD进展（P = 0.87）无关。
局限性包括25%的无应答率、回忆偏倚和残余混杂因素。
这些结果表明严重瘙痒与临床结局之间存在密切关联，为肾脏病学界提供了关于非透析CKD个体中CKD-aP可能的不良后果的新见解，值得进一步探索。
慢性肾脏病相关瘙痒症（CKD-aP）是慢性肾脏病（CKD）常见的令人困扰的症状。本文分析了慢性肾脏病结局与实践模式研究（CKDopps）的纵向数据，以描述4410名非透析CKD个体中CKD-aP的患病率及其与临床结局的关联。我们发现51%的调查人群受到瘙痒困扰。CKD-aP在CKD分期更晚、年龄更大且合并症更多的人群中更普遍。与完全没有受到瘙痒困扰的人相比，极度受到困扰的人全因死亡率、住院率和心血管事件的风险更高。CKD-aP的严重程度与CKD进展或开始肾脏替代治疗无关。
