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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 890-895
Association of high-sensitive C-reactive protein and dialysis adequacy with uremic pruritus


1 Community Medicine Department, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Resident of Elderly Care (Geriatric), VUMC, Amsterdam, Netherlands
3 Cardiovascular Research Center, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
4 Internal Medicine Department, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
5 Dermatology Department and Shiraz Skin Research Center, Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication7-Sep-2015
 

   Abstract 

Uremic pruritus is a difficult symptom in chronic hemodialysis (HD) patients, and its patho-physiological mechanism remains unknown. To determine the relationship between pruritus and C-reactive protein as well as dialysis adequacy among the HD patients, we studied 241 chronic HD patients in Shiraz dialysis centers, Iran. The patients were selected by convenient sampling and the data were collected using a checklist, interview and lab tests. The mean age of our patients was 53.9 ± 16.3 years and 128 (53.1%) of them were male. There were 97 (40.2%) patients who complained of pruritus. A significant association was found between high-sensitive C-reactive protein and pruritus (P = 0.004). Also, a significant positive relationship was observed between pruritus and dialysis adequacy (P <0.001). Our results suggested a correlation between the inflammatory reaction and pruritus. Furthermore, a positive correlation was found between dialysis adequacy and pruritus. A better understanding of the factors implicated in the cause of uremic pruritus is essential in the development of more-effective treatments and improved quality of life in HD patients.

How to cite this article:
Malekmakan L, Malekmakan A, Sayadi M, Pakfetrat M, Sepaskhah M, Roozbeh J. Association of high-sensitive C-reactive protein and dialysis adequacy with uremic pruritus. Saudi J Kidney Dis Transpl 2015;26:890-5

How to cite this URL:
Malekmakan L, Malekmakan A, Sayadi M, Pakfetrat M, Sepaskhah M, Roozbeh J. Association of high-sensitive C-reactive protein and dialysis adequacy with uremic pruritus. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Dec 4];26:890-5. Available from: https://www.sjkdt.org/text.asp?2015/26/5/890/164565

   Introduction Top


Uremic pruritus is one of the most common and complicated symptoms affecting end-stage renal disease (ESRD) and hemodialysis (HD) patients. [1],[2],[3],[4] The prevalence of uremic pruritus varies from 50% to 90% in various studies. [2] Chronic pruritus can be persistent and distressing, have a significant impact on the quality of life and physical comfort and is accompanied by potential psychological, functional and social impacts as well as increased morbidity. [5]

Uremic pruritus has many proposed mechanisms, including xerosis, the presence of pruritogenic cytokines, secondary hyperparathyroidism and immune-inflammatory reactions. [2],[10] However, the pathogenic mechanism of pruritus in these patients has not yet been clarified, which limits the use of effective treatments. [6],[7],[8],[9],[10]

Previous studies demonstrated inflammation reaction or inflammatory cytokines to be associated with uremic pruritus in ESRD patients. [11],[12],[13] A few previous studies on hemodialysis (HD) patients with severe uremic pruritus showed that these patients had higher high-sensitive C-reactive protein (hs-CRP) levels. [11],[13]

In addition, Kt/V is the most commonly used indicator for dialysis adequacy, which assesses the clearance of small molecules in uremic patients. Some studies have suggested that the aggravation of pruritus can be associated with inadequate dialysis. [3],[14],[15],[16],[17]

The present study aimed to assess the uremic pruritus characteristics and its related factors in the HD population, including the C-reactive protein and dialysis adequacy.


   Materials and Methods Top


We studied 241 chronic HD patients selected by convenient sampling, with 95% confidence interval and 80% power, to provide information regarding their uremic pruritus. The inclusion criteria of the study were age >18 years and HD for ≥3 months. They were dialyzed three times a week for 4 h using Fresenius 4008B machines (Fresenius medical care AG, Homburg, Germany). All the patients were examined regarding pruritus by a trained dermatologist. The patients who were known cases of dermatology, suffered from pruritus-related liver or metabolic diseases, had serum parathyroid >300 pg/mL and were not willing to cooperate were excluded from the study.

The study data were collected through observation, interview and laboratory tests. The Kt/V was calculated according to the Daugirdas formula. [18] Fasting blood samples were obtained from the HD patients from the arterial line immediately before the mid-week dialysis session before heparin administration. The samples were then centrifuged and frozen at -70°C before the measurements. Biochemical determinations included levels of serum albumin (Alb), lipid profile, blood urea nitrogen, serum creatinine (Cr), calcium (Ca), phosphorus (P) and parathyroid hormone (PTH). The levels of hs-CRP were assayed using the Nephelometric method.


   Statistical analysis Top


The study data were analyzed using the SPSS software. The quantitative data were presented as mean and standard deviation and analyzed using the independent sample t-test. In addition, the chi-square test was used to compare the proportions. Logistic regression was also used when appropriate. P-value <0.05 was considered as statistically significant.


   Results Top


A total of 241 patients participated in this study, and their demographic and clinical characteristics are summarized in [Table 1]. The mean age of the study participants was 53.9 ± 16.3 years; 128 (53.1%) patients were male and 44 (18.3%) patients were diabetic. Skin diseases were found in 26.6% of the HD patients. Furthermore, pruritus was reported by 40.2% of the HD patients [Table 1]. The results revealed no significant difference between the patients with pruritus compared with the non-pruritus patients regarding the skin problems (32.0% vs. 22.9%; P = 0.226). Also, no significant difference was observed regarding the proportion of male patients in the pruritus and non-pruritus patients (53.6% vs. 52.8%; P = 0.948). Moreover, no significant difference was observed between the pruritus and non-pruritus patients with respect to the regular use of medications (P >0.05).
Table 1: Demographic and clinical characteristics of the study patients.

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No statistically significant difference was found between the pruritus and non-pruritus patients regarding the laboratory parameters [Table 2] (P >0.05), except the CRP blood levels, which were significantly higher in patients with pruritus compared with that in non-pruritus (P = 0.004, power = 81%) patients.
Table 2: Chemical characteristics of the study patients.

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A significantly higher Kt/V (Kt/V >1.2) was found in the patients suffering from pruritus compared with the non-pruritus patients (53.60% vs. 24.30%, OR = 3.59 with 95% CI: 2.07-6.24, power = 75%, and P <0.001). However, no significant difference was observed between the pruritus and non-pruritus patients concerning the duration of dialysis (P = 0.495).

The results of multivariate logistic regression showed that pruritus was positively associated with both CRP and Kt/V (OR = 1.26 with 95% CI: 1.07-1.48, P = 0.005 and OR = 4.67 with 95% CI: 1.24-17.54, P = 0.022, respectively). Other parameters such as Ca, P, Hb and lipid profiles were not significantly associated with pruritus [Table 3].
Table 3: Logistic regression results for multivariate analysis.

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   Discussion Top


Our results showed that the prevalence of uremic pruritus was 40.2%. Similar prevalence rates have also been reported in the studies published over the past few decades. [16],[19],[20],[21] However, the prevalence of pruritus in this study was lower than the 67% prevalence rate reported from Saudi Arabia. [22]

The results of the present study showed no correlation between the uremic pruritus and the population-based characteristics of the patients, duration of renal failure, cause of renal failure or the medications.

Similar to some studies, [11],[13],[23] uremic pruritus was shown in the current study to be associated with high levels of CRP. Inflammation is principally associated with uremic pruritus in the HD patients, and the patients with severe skin pruritus may have higher CRP levels. CRP elevation predicts a worse outcome and high mortality in the HD patients. [2],[11],[24],[25] Nevertheless, other researchers have not confirmed the significant association between CRP concentration and pruritus. [3],[26],[27] Higher CRP concentration in the HD patients may reflect increased inflammatory status, method per se or higher ages of the patients, which result in more concomitant inflammatory disorders. [26] It appears that clinicians need to resolve the underlying inflammatory status to improve the patients' survival on dialysis. In general, the skin of the ESRD patients with uremic pruritus has an increased number of mast cells, and they release some substances that can initiate the inflammatory processes. The skin inflammation is further complicated by the release of interleukin and tumor necrosis factor α secondary to pruritus. Impairment of T Helper (TH) cells balance with TH1 predominance can also support systemic inflammation in uremic pruritus. [13],[24],[25]

KT/V, the most commonly used indicator for dialysis adequacy, assesses the clearance of small molecules in uremic patients. [3],[15] The association between uremic pruritus and the doses of dialysis remains controversial. In accordance with other studies, [3],[14],[15],[16] the present study findings demonstrated a significantly higher Kt/V in the patients with pruritus. Nonetheless, some studies have not reported any association between Kt/V and pruritus. [11],[19],[21],[26] Our results showed that impaired renal function results in an increase of pruritogenic substances. It is possible that the exchange of toxins may reduce pruritus. However, there are no guidelines regarding the optimal levels of Kt/V to improve pruritus. Mei-Ju Ko et al demonstrated that the target dose of Kt/V ≥1.5 might reduce the pruritus intensity in the HD patients, [3] which in turn may improve the quality of life in these patients.

In agreement with our results, several studies have shown that Ca, P and PTH levels were not related to pruritus in the patients on HD. [14],[19],[24],[26],[28]

In contrast to some studies reporting lower Alb levels in the pruritic patients on HD, [11],[13],[26] we did not find any difference between the patients suffering from pruritus and those without pruritus regarding the albumin levels. [14],[19]

We conclude that pruritus in ESRD patients results from multiple factors. This study demonstrated the possible association of hs-CRP and dialysis adequacy with uremic pruritus in ESRD patients. Further cohort studies in a larger patient population will be necessary to assess this problem and to identify pruritogenic substances in order to help relieve uremic pruritus.


   Acknowledgments Top


The Shiraz Nephro-Urology Research Center of the Shiraz University of Medical Sciences funded this study. Hereby, the authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of the Shiraz University of Medical Sciences for providing English language editorial support for this manuscript.

Conflict of interest: None declared.

 
   References Top

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Correspondence Address:
Mehrab Sayadi
Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.164565

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    Tables

  [Table 1], [Table 2], [Table 3]

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