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Uraemic Pruritus Stepwise Management — ESENeph MCQ

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ModerateChronic Kidney DiseaseUraemic Pruritus Stepwise ManagementESENeph

A 62-year-old man with CKD G4 develops pruritus. A stepwise approach is used. After addressing CKD-MBD parameters and trying emollients, what is the next pharmacological step before considering Difelikefalin?

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Correct answer: E — Gabapentin or Pregabalin (renal-adjusted dose) – evidence supports neuropathic/central sensitisation mechanisms of uraemic pruritus

For uraemic pruritus not responding to emollients and CKD-MBD optimisation, Gabapentin (100-300 mg after each HD session, or renally adjusted daily dose for non-dialysis CKD) or Pregabalin has the best evidence among conventional therapies. Multiple RCTs (Naini et al 2007, Gunal et al 2004) showed significant pruritus reduction. The mechanism involves modulation of central sensitisation pathways. Antihistamines have limited efficacy as uraemic pruritus is not primarily histamine-mediated. UVB phototherapy is another option. Difelikefalin (kappa-opioid agonist) is used for refractory cases in HD patients.

Reference: KDIGO 2017 – CKD-MBD (Pruritus section); Naini et al 2007; NICE TA924 – Difelikefalin