Variation in Management of CKD-Associated Pruritus: Results From a Multinational Survey of Kidney Units

Abstract Rationale & Objective Chronic kidney disease-associated pruritus (CKDaP) is a distressing symptom affecting a significant proportion of people with advanced kidney disease. There are many studies of varying quality in the literature, testing a wide variety of CKDaP therapies, and no evidence-based consensus guidelines for management. We aimed to describe the breadth of treatments in use for CKDaP in real-world practice. Study Design Cross-sectional online survey. Setting & Participants Kidney care units in Australia, New Zealand (NZ), and the United Kingdom (UK). Surveyed between April and December 2022. Outcomes Usage of 28 CKDaP therapies (excluding emollients/moisturizers) was categorized as '"first-line," "second-line," "refractory symptoms only," "rarely used," or "never used." Analytical Approach Descriptive analysis with differences between categories assessed by Fisher's exact test. Results One hundred and four responses were received from 171 contacted kidney units (Australia 51 [49%], NZ 6 [6%], UK 47 [45%]) with an overall response rate of 61%. Including "other" responses, 35 treatments were in first- or second-line use. Gabapentinoids (gabapentin or pregabalin) were the most widely used first-line systemic agent (49 units [47%]), followed by antihistamines (27 [26%]). Menthol was the predominant first-line topical agent (41, [39%]). Significant inter-country disparities were noted: doxepin, evening primrose oil, sertraline, and topical gamma-linolenic acid were more frequently used in Australia than in New Zealand and the UK, while hydroxyzine was preferentially used in UK units (P <0.05). Units with a kidney supportive care service were more likely to use gabapentinoids, 5-hydroxytryptamine₃ receptor antagonists, hydroxyzine, and topical therapies, and less likely to use promethazine (P <0.05). Limitations Difelikefalin was not widely available during the survey period, which may limit generalizability. Conclusions There is considerable variation in the management of CKD-aP. Unexplained clinical variation suggests a need for development of evidence-based guidelines and additional high-quality studies to inform care.