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

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: A cross-sectional online survey.

Setting & Participants: Kidney care units in Australia, New Zealand (NZ), and the United Kingdom (UK). Surveyed from April 2022, to 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 exact test.

Results: One hundred four responses were received from 171 contacted kidney units (Australia 51 [49%], NZ 6 [6%], and UK 47 [45%]) with an overall response rate of 61%. Including "other" responses, 35 treatments were in first-line 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 γ-linolenic acid were more frequently used in Australia than in NZ, and the UK, whereas hydroxyzine was preferentially used in UK units ( < 0.05). Units with a kidney supportive care service were more likely to use gabapentinoids, 5-hydroxytryptamine receptor antagonists, hydroxyzine, and topical therapies, and less likely to use promethazine ( < 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 CKDaP. Unexplained clinical variation suggests a need for the development of evidence-based guidelines and additional high-quality studies to inform care.