Pruritus and Patient Reported Outcomes in Non-Dialysis CKD

Abstract

Background and objectives: Among patients on hemodialysis, pruritus has been associated with poorer mental and physical quality of life, sleep quality, depression, and mortality. We evaluated patients with nondialysis CKD to describe the prevalence of pruritus, identify associated factors, and investigate associations with patient-reported outcomes.

Design, setting, participants, & measurements: Using cross-sectional data from patient questionnaires in the CKD Outcomes and Practice Patterns Study (CKDopps), we asked patients with CKD stages 3-5 (nondialysis) from the United States, Brazil, and France to identify how much they were bothered by pruritus. Response options ranged from "not at all" to "extremely." Log-Poisson regression, yielding prevalence ratios, was used to evaluate associations of moderate-to-extreme pruritus with patient characteristics, CKD stage, self-reported depression symptoms, and restless sleep. Mixed linear regression was used to examine associations between pruritus and physical and mental component summary scores, with lower scores indicating poorer quality of life.

Results: Of the 5658 CKDopps patients enrolled in the United States, Brazil, and France, 3780 (67%) answered the pruritus question. The prevalence of moderate-to-extreme pruritus was 24%, and more likely in older patients, women, and those with stage 5 CKD, lung disease, diabetes, and physician-diagnosed depression. In adjusted models, patients with moderate pruritus had physical and mental component summary scores 3.5 (95% confidence interval [95% CI], -4.6 to -2.3) and 2.3 (95% CI, -3.2 to -1.5) points lower, respectively, than patients without pruritus, and they also had a higher adjusted prevalence of patient-reported depression (prevalence ratio, 1.83; 95% CI, 1.58 to 2.11) and restless sleep (prevalence ratio, 1.69; 95% CI, 1.49 to 1.91) compared with patients without pruritus. These patient-reported outcomes were progressively worse with increasing severity of pruritus.

Conclusions: Our findings demonstrate high prevalence of pruritus in nondialysis CKD, as well as strong associations of pruritus with poor health-related quality of life, self-reported depression symptoms, and self-reported poor sleep.

Keywords: Cross-Sectional Studies; Linear Models; Lung Diseases; Patient Reported Outcome Measures; Prevalence; Pruritus; Renal Insufficiency, Chronic; Surveys and Questionnaires; Uremic pruritus; chronic kidney disease; depression; diabetes mellitus; dialysis; quality of life.

Copyright © 2019 by the American Society of Nephrology.

Figures

Graphical abstract

Figure 1.

Prevalence of patient self-reported degree of pruritus, by CKD stage and country. Degree of pruritus among patients with CKD across Brazil, France, and the United States, as well as across CKD stages among these countries. The degree of pruritus experienced by patients with CKD during the preceding 4 weeks of patient questionnaire completion is shown, collected from a prevalent cross-section of patients with CKD across nephrology clinics participating in CKDopps.

Figure 2.

Difference in physical and mental summary scores by degree of patient-reported pruritus (compared with “none”). Prior studies have indicated a 3–5 point difference in MCS or PCS scores to be a minimal clinically significant difference (49,50).

Figure 3.

Adjusted prevalence ratio of having symptoms of depression (CES-D score ≥10) by degree of patient-reported pruritus (compared with “none”).

Figure 4.

Adjusted prevalence ratio of having self-reported restless sleep ≥3 days in a week by degree of patient-reported pruritus (compared with “none”).