Unmasking the Silent Agony: Delving into CKD-aP: Q&A Session with an Expert.
(Focus - India)
Amid the complex landscape of kidney diseases, a distressing and often underestimated issue silently plagues patients: Chronic Kidney Disease-Associated Pruritus (CKD-aP).
It's a relentless itching that emerges amidst kidney dysfunction, impacting not just the skin but the very essence of life quality. However, amidst the challenges of diagnosing and treating CKD-aP, a crucial question arises: What can be done to enhance early detection and effective management?
In an exclusive interview with Dr. Sishir Gang, a renowned Nephrologist from India, we delve into the depths of CKD-aP, uncovering the hurdles in diagnosis, the power of awareness, evolving trends, and the quest for improved treatment strategies. As you journey through the insights shared by Dr. Sishir, you'll come to recognize the significance of addressing CKD-aP, not just as a medical dilemma but as a mission to restore both quantity and quality of life.
Dr. Sishir Gang (MD, DM, DNB) is a Chairman, Dept. of Nephrology, currently serving at Muljibhai Patel Urological Hospital, Gujarat, India.
If there are local skin infections, fungal infections, or other causes of the itch, they are excluded. Once they are excluded, then it is mostly because of kidney dysfunction. It is very important that all itches are not attributed to kidney failure.
Despite being common amongst end-stage kidney disease (ESKD), pruritis remains underestimated and underdiagnosed in CKD patients . According to you, what are the challenges associated with diagnosing CKD-aP, and what can be done to improve early detection and treatment of this condition?
Dr. Sishir - Pruritus is a common problem in CKD patients, especially patients on dialysis. Many patients think that because it's a life-saving procedure, they accept the itch. There needs to be more awareness among patients and that they should complain about the itch. Right now, our aim is both quantity and quality of life. So many times, patients, when they have minor complaints, usually don't come up with the complaints.
Both the nursing technicians and the physician are less aware of asking about this symptomatology. Many doctors will not ask. Usually, it will be more cursory than a very definitive question. I think, in general, both the patients and the healthcare workers must address all the symptoms, and if they address the symptoms, the awareness will increase.
We understand that misdiagnosis of CKD-aP can lead to inappropriate treatment and delays in pruritis treatment. How common is the misdiagnosis of CKD-aP in India?
Dr. Sishir - I would rather say a diagnosis of CKD or dialysis-associated pruritus is usually a diagnosis of exclusion. If there are local skin infections, fungal infections, or other causes of the itch, they are excluded. Once they are excluded, then it is mostly because of kidney dysfunction. It is very important that all itches are not attributed to kidney failure. We need to be sure that we have excluded all other causes that are more amenable to treatment before making a diagnosis of dialysis associated itching.
Doctor, you mentioned that awareness is necessary. So, what strategies can be implemented in India to raise awareness and improve education about CKD-aP among healthcare professionals and the general public?
Dr. Sishir - It is now a part of the education for the nephrologist, so most of the nephrologists are aware. What's important is that we must administer certain questionnaires to the patients about different symptomatology. If they have itching, we can even ask them to grade. There is a visual analog scale on which the patients can grade how much it bothers them. And if it's more than moderate or severe, then we need to address that very specifically.
What interesting trends do you foresee in the accurate diagnosis of CKD-aP in India which would guide management decisions?
Dr. Sishir - First, as we discussed, we need to make people aware of this problem. We must use some of the tools to be more accurate in our diagnosis and understand its degree and severity. Recently, numerous studies have shown that the itch which you normally find in dialysis patients is different from that you find in the normal population. The itch is driven by different mechanisms, there is a histamine-driven itch and a non-histamine-driven itch. The histamine-driven itch usually responds very well to antihistamines. But the itch of dialysis patients typically is not non-histamine dependent, and they will generally not respond very well to the routine antihistamines we use.
Moreover, antihistamines are also sedating. So here some education is needed. Generally, people prescribe antihistamines for itching, which you normally find with drug allergies or certain substances. But here it is different. Now some therapies are more directed toward dialysis-associated itching. And it is more beneficial than the earlier treatments.
Once we know that a patient has significant itching, we try emollient creams. Usually, creams have a very mild beneficial effect. If the itching is still not relieved and it is bothering them too much, we try drugs like Gabapentin and Pregabalin. Many patients benefit from these drugs. Recently, a new drug known as Difelikefalin, a kappa opioid agonist, has been shown to be more beneficial in patients with - severe itching.
What is the prevalence of CKD-aP among patients who undergo hemodialysis or peritoneal dialysis in India, doctor?
Dr. Sishir - About 15 to 30 percent of the patients have significant itching and amongst them, about 10 percent would have severe itching.
So, what approach do you take to co-manage CKD along with pruritis in your patients?
Dr. Sishir - Generally, as I said, we ask them about the history of the symptoms. And then, we ask them how much the symptoms are bothering them. Is it daytime or nighttime? Is it interfering with their activity or not? We would do a thorough physical examination to see if there are scratch marks as evidence of severe itching.
Once we know that a patient has significant itching, we try emollient creams. Usually, creams have a very mild beneficial effect. If the itching is still not relieved and it is bothering them too much, we try drugs like Gabapentin and Pregabalin. Many patients benefit from these drugs. Recently, a new drug known as Difelikefalin, a kappa opioid agonist, has been shown to be more beneficial in patients with - severe itching. It is unavailable in India, but we will soon see that drug coming. New pharmacotherapies are in pipeline, and hopefully, they will work in resistant cases.
Do you foresee any interesting future trends in the treatment and management of CKD-aP?
Dr. Sishir - Drugs like Nalfurafine and Nalbuphine have been used Japan, but not so much in India; at least, I have not tried it with our patients here. But that's another option apart from the Difelikefalin. There is also Ondansetron, but I have not tried it personally. I have generally tried Pregabalin and Gabapentin in our practice.
Our aim should be both quantity and quality of life. Patients with itching should be identified and categorized as mild moderate and severe. Try step wise treatment. Creams followed by gabapentinoid and Pregabalin. If they do not respond, then newer therapies like Difelikefalin may be of use.
Apart from awareness in the patients, is there any other challenge you see in treating and managing CKD-aP in India?
Dr. Sishir - You must realize that all these therapies are not 100 percent. They work with about 15 to 60 percent of patients. But as treatments improve and patients and doctors see benefits in that, I'm sure the awareness increases. And now we have more patients on chronic dialysis; earlier, what used to happen was that patients were on short-term dialysis awaiting a transplant. Chronic dialysis was not as popular because of financial reasons. With the government's support, many patients are now on chronic dialysis as it is funded by the government. And chronic dialysis patients will suffer from itching at some point.
We understand that CKD-aP impacts a person's overall health and well-being. What is your key takeaway message to CKD-aP patients for effective management of their condition?
Dr. Sishir - Our aim should be both quantity and quality of life. Patients with itching should be identified and categorized as mild moderate and severe. Try step wise treatment. Creams followed by gabapentinoid and Pregabalin. If they do not respond, then newer therapies like Difelikefalin may be of use.
Again, these patients must also have adequate dialysis because though there is not a strong association between phosphates and PTH with itching; adequate dialysis is also important because once you dialyze them adequately, there is an improvement in the itching. I'd like to add that kidney transplants eliminate all the symptoms of itching, Of course, not every patient will be suitable for kidney transplant or have a kidney donor available to them. But if that is possible, that would be the final and best treatment for this situation.
Thank you so much for your time. It was insightful!