Pruritus Cases From the Field: Real-World Perspectives on Managing CKD-aP

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Dr. Reddy:
Patients with advanced kidney disease undergoing dialysis are frequently affected by chronic kidney disease-associated pruritus, or CKD-aP for short. This condition has the potential to significantly diminish patients’ quality of life but remains underreported and underdiagnosed. Today, we’ll hear from actual patients about their experiences with the itching and discuss how to effectively manage the care of the patients with CKD-aP to alleviate their symptom.

This is CME on ReachMD, and I’m Dr. Jay Reddy.

Dr. Narváez:
And I am Dr. Carlos Narváez.

Dr. Reddy:
Patients with moderate to severe pruritus related to ESRD [end-stage renal disease] are very much bothered by the pruritus. Some of them do mention, and some of them do not mention, but they are bothered. Their sleep is affected, their overall quality of life is affected, and sometimes the amount of the time that they stay for the treatment, due to intense pruritus and associated symptoms with it, such as depression and anxiety.

It’s important to ask the patients proactively, because we have a lot of issues that we cover during our dialysis rounds, and quite often patients may not volunteer the information. And there’s different ways to measure the pruritus, but WI-NRS [Worst Itch Numeric Rating Scale] scale, I believe, is probably the simplest, and we can create uniformity through this scale.

And, in general, as these dialysis patients are seen a lot more often by the nurses and the care team at the dialysis clinic, and it is very important for the admitting nurse and the treating nurse to ask these questions, to identify the patients, and also watch and monitor for any side effect profile.

Dr. Narváez:
So, Dr. Reddy, let’s begin with your patient case.

Dr. Reddy:
Nothing more powerful than hearing from the patient themselves about their experience with the itching. Let’s meet Charles Gurley.

Mr. Gurley:
The itching was really quite like torture. At some point after I had been on dialysis a while, it got to be almost unbearable. Now, I would itch from the time I was in the dialysis chair to the time I got home and sometimes through the night. So I had to just sit there and endure it through the whole dialysis session. Then when I got home, the first thing I would do was get my wife to scratch those spots that I couldn’t reach.

Dr. Reddy:
How we arrived at the diagnosis on Charles is that we have asked a questionnaire called WI-NRS scale. And we asked him about how severe his itching was. His itching was very severe, initially ranked at 9/10, and it was causing him symptoms not only during the dialysis, before and after the dialysis. And we have tried a different antihistaminics you know, gabapentin and with no significant improvement from both of these measures.

Mr. Gurley:
And, of course, when you’re scratching all the time, it just makes for a miserable day. I know I would wake up with welts on my back from where, unknowingly during the night, I was scratching.

Dr. Reddy:
So at this point, we had the opportunity and heard about this new drug and studied about this kappa-opioid receptor agonist, difelikefalin, and I carefully reviewed the studies that were done – KALM-1 and KALM-2 study – and we went ahead and initiated his treatment in November of 2022, and he seemed to have a complete symptom improvement and has been tolerating this drug very well.

Now let’s hear from Charles about his experiences following this intervention.

Mr. Gurley:
Since I’ve been on the medication, it pretty much alleviated all of the problems I was having, and I’ve been able to feel so much better. I don’t have to worry, when I go to dialysis, that while I’m sitting in the chair I’m going to be squirming. I don’t have that anymore. And when I come home, I’m generally free from any itching. And so it’s been like a lifesaver for me.

Dr. Reddy:
The impact on the sleep was significant in this gentleman. He reported a good sleep and improved quality of life, and there were less signs of itching and scratching, so it kind of implies that he did have a significant improvement.

For those just tuning in, you’re listening to CME on ReachMD. I’m Dr. Jay Reddy, and here with me today is Dr. Carlos Narváez. We are discussing how to improve quality of life in patients with CKD-aP using real-world patient cases. 

Now, Carlos, let’s hear about your patient.

Dr. Narváez:
I'd like to introduce you to a 61-year-old patient with a history of polycystic liver and kidney disease, PCKD, leading to chronic kidney disease. Over the past 6 months, he has been battling persistent pruritus, a debilitating itch that hindered his daily life and even made him abandon his passion for fishing. Let’s hear from Juan Manuel.

Mr. Garcia Martin:
Well, the itching started even before I got sick, let’s put it in that way, before my kidneys didn't even work. I had mild itching. It became quite unbearable. And then I started dialysis.

With the passing of time and with dialysis, it got worse and worse, up to the point in which I no longer felt like doing anything. I had a lethargy that was just not normal. When I had that itching, I had no desire for anything. I didn't even talk to my wife. I had no enthusiasm for anything.

I gave up fishing. I didn't feel like fishing. It was one of my greatest hobbies; however, I didn’t go fishing because my body just didn’t allow me to do that as the itching was unbearable. Touching one leg with the other felt like needles were pricking my skin.

Dr. Narváez:
Despite multiple topical and oral treatments, including antihistamines, the patient's itch persisted, severely impacting his quality of life. After ruling out dermatological conditions by physical examinations and optimizing his dialysis treatment, he scored 9 in the WI-NRS, indicating significant CKD-associated pruritus. Recognizing the urgency of his condition, we initiated treatment with difelikefalin at the end of each dialysis session. Remarkably, within just 2 weeks, he reported a more than 3-point improvement on the WI-NRS scale. Today, a year into the treatment, he experiences minimal itching. The most heartwarming part of his recovery is seeing him return to what he loves most: fishing on his boat every weekend.

Mr. Garcia Martin:
Well, since I started taking the medication, the truth is it worked for me really well. I feel so relaxed, as I used to before. Prior to that, it was just unbearable. And, as I told you before, since I took the medication, I’m feeling great. I go fishing, I enjoy it, and I have almost a normal life. And since then, everything has disappeared. At the moment, thank God, I don’t have any itching at all.

Dr. Reddy:
Carlos, is there anything else you’d like to share based on your experience?

Dr. Narváez:
Based on my extensive experience and observations, KOR agonist therapy with difelikefalin has consistently demonstrated effectiveness in managing CKD-associated pruritus. One of the significant attributes that I note about this therapy is its impact on patient adherence. The convenience of administration, especially when given at the end of each dialysis session, not only ensures consistent dosing but also reduces the burden on the patient. This streamlined process can lead to better outcomes, as regularity and adherence to therapy are pivotal in managing conditions like CKD-aP.

Moreover, I cannot stress enough the importance of shared decision-making in the management of our patients. It’s essential to take into account the patient's perspective, their experiences with the symptoms, and their expectations from the treatment. By incorporating their feedback and educating them about the therapeutic options, we can craft a treatment plan that resonates with the patient's needs and preferences.

Dr. Reddy:
Well, this has certainly been an intriguing conversation, but before we wrap up, Carlos, can you share your one take-home message with our audience?

Dr. Narváez:
The main takeaway from our discussion today is the importance of a comprehensive, patient-centric approach in managing CKD-associated pruritus. Early diagnosis, patient education, and the right therapeutic interventions to improve symptoms can truly transform lives and the quality of life, as seen in our patient cases.

Dr. Reddy:
My take-home message is that CKD-aP is more prevalent than what we think. And I certainly recommend that we screen proactively for this symptom and appropriate patients be treated with the specific treatment that we have available that we never had before, and monitor the improvement of the symptoms, and thereby improvement of the quality of the life in these CKD/ESRD patients.

Well, that’s all the time we have today, so I want to thank our audience for listening in and thank you, Dr. Carlos Narváez, for joining me and sharing all of your valuable insights. It was great speaking with you today.

Dr. Narváez:
Thank you, Dr. Reddy.

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