Background. Pruritus affects many haemodialysis (HD) patients. In this study, pruritus and its relationship to morbidity, mortality, quality of life (QoL), sleep quality and patient laboratory measures were analysed in > 300 dialysis units in 12 countries. Methods. Pruritus data were collected from 18 801 HD patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) (1996-2004). Analyses were adjusted for age, gender, black race, Kt/V, haemoglobin, serum albumin, albumin-corrected serum calcium, serum phosphorus, 13 comorbidities, depression, years on dialysis, country and facility clustering effects. Results. Moderate to extreme pruritus was experienced by 42% of prevalent HD patients in DOPPS during 2002/2003. Many patient characteristics were significantly associated with pruritus, but this did not explain the large differences in pruritus between countries (ranging from 36% in France to 50% in the UK) and between facilities (5-75%). Pruritus was slightly less common in patients starting HD than in patients on dialysis > 3 months. Pruritus in new end-stage renal disease (ESRD) patients likely results from pre-existing conditions and not haemodialysis per se, indicating the need to understand development of pruritus before ESRD. Patients with moderate to extreme pruritus were more likely to feel drained [adjusted odds ratio (AOR) = 2.3-5.2, P < 0.0001] and to have poor sleep quality (AOR = 1.9-4.1, P <= 0.0002), physician-diagnosed depression (AOR = 1.3-1.7, P <= 0.004), and QoL mental and physical composite scores 3.1-8.6 points lower (P < 0.0001) than patients with no/mild pruritus. Pruritus in HD patients was associated with a 17% higher mortality risk (P < 0.0001), which was no longer significant after adjusting for sleep quality measures. Conclusions. The pruritus/mortality relationship may be substantially attributed to poor sleep quality. The many poor outcomes associated with pruritus underscore the need for better therapeutic agents to provide relief for the 40-50% of HD patients affected by pruritus.

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Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Vitamin D functions are not limited to skeletal health benefits and may extend to preservation of insulin secretion and insulin sensitivity This review summarizes the literature related to potential vitamin D influences on glucose homeostasis and insulin sensitivity Cross-sectional data provide some evidence that circulating 25-hydroxyvitamin D (25(OH)D) is inversely associated with insulin resistance, although direct measurements of insulin sensitivity are required for confirmation Reported associations with insulin secretion, however, are contradictory Available prospective studies support a protective influence of high 25(OH)D concentrations on type 2 diabetes mellitus risk There is a general lack of consistency in vitamin D intervention outcomes on insulin secretion and sensitivity, likely due to differences in subject populations, length of interventions, and forms of vitamin D supplementation Vitamin D receptor gene polymorphisms and vitamin D interactions with the insulin like growth factor system may further influence glucose homeostasis The ambiguity of optimal vitamin D dosing regimens and optimal therapeutic concentrations of serum 25(OH)D limit available intervention studies Future studies, including cross-sectional and prospective, should be performed in populations at high risk for both vitamin D deficiency and type 2 diabetes mellitus Well-designed, placebo-controlled, randomized intervention studies are required to establish a true protective influence of vitamin D on glucose homeostasis

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Role of Vitamin D in Insulin Secretion and Insulin Sensitivity for Glucose Homeostasis

Background
Epidermal growth factor receptor inhibitors (EGFRI) produce various dermatologic side effects in the majority of patients, and guidelines are crucial for the prevention and treatment of these untoward events. The purpose of this panel was to develop evidence-based recommendations for EGFRI-associated dermatologic toxicities.

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Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities

Worsening fluid balance results in reduced technique and patient survival in peritoneal dialysis. Under these condi- tions, the glucose polymer icodextrin is known to enhance ultrafiltration in the long dwell. A multicenter, randomized, double-blind, controlled trial was undertaken to compare ico- dextrin versus 2.27% glucose to establish whether icodextrin improves fluid status. Fifty patients with urine output 750 ml/d, high solute transport, and either treated hypertension or untreated BP 140/90 mmHg, or a requirement for the equiv- alent of all 2.27% glucose exchanges, were randomized 1:1 and evaluated at 1, 3, and 6 mo. Members of the icodextrin group lost weight, whereas the control group gained weight. Similar differences in total body water were observed, largely ex- plained by reduced extracellular fluid volume in those receiv- ing icodextrin, who also achieved better ultrafiltration and total sodium losses at 3 mo (P 0.05) and had better maintenance of urine volume at 6 mo (P 0.039). In patients fulfilling the study's inclusion criteria, the use of icodextrin, when compared with 2.27% glucose, in the long exchange improves fluid removal and status in peritoneal dialysis. This effect is appar- ent within 1 mo of commencement and was sustained for 6 mo without harmful effects on residual renal function.

Icodextrin Improves the Fluid Status of Peritoneal Dialysis Patients: Results of a Double-Blind Randomized Controlled Trial

Copyright © 2013 Massachusetts Medical Society. An otherwise healthy 55-year-old man reports that he has been itchy all over for 6 months. The itch interferes with falling asleep and wakes him repeatedly during the night. Initially, there was no rash, but during the past 4 months, itchy nodules and plaques have developed on his back, arms, and legs. Treatment with sedating and nonsedating oral antihistamines and topical glucocorticoids has had no effect. How would you evaluate and manage this case?

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Clinical practice. Chronic pruritus

Background Uraemic pruritus is a common and distressing symptom in patients on haemodialysis for chronic renal failure. Gabapentin is an anticonvulsant that alleviates neuropathic pain. We conducted a double-blind, placebo-controlled, crossover study to assess its effectiveness against renal itch. Methods We enrolled in the trial 25 adult patients on haemodialysis who were asked to daily record the severity of their pruritus on a visual analogue scale. The patients were randomly assigned to receive gabapentin for 4 weeks followed by placebo for 4 weeks or the reverse sequence. Gabapentin or placebo were administered thrice weekly, at the end of haemodialysis sessions. Results The mean pruritus score of the cohort before the study was 8.4 +/- 0.94. After placebo intake, it decreased to 7.6 +/- 2.6 (P = 0.098). The score of four patients decreased by >50% following placebo. After gabapentin administration, the mean score decreased significantly, to 1.2 +/- 1.8 (P = 0.0001), although one patient's symptoms did not improve significantly. No patient dropped out of the study due to adverse effects from gabapentin. Conclusions Our study shows that gabapentin is safe and effective for treating uraemic pruritus in haemodialysis patients. Our results also support the neuropathic hypothesis of uraemic pruritus.

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Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial

Strict volume control normalizes hypertension in peritoneal dialysis patients

ObjectivePeritoneal fibrosis (PF) is one of the most serious causes of failure in continuous ambulatory peritoneal dialysis (PD). Although the underlying mechanism responsible for the genesis of PF...

Does enalapril prevent peritoneal fibrosis induced by hypertonic (3.86%) peritoneal dialysis solution?

Background. Left ventricular hypertrophy (LVH) is an important predictor of mortality in dialysis patients. The loss of residual renal function (RRF) appears to occur more rapidly in hemodialysis than continuous ambulatory peritoneal dialysis (CAPD). It is more likely that volume expansion in patients on CAPD may preserve RRF. The aim of this study was to investigate whether there is a cause–effect relationship between volume overload and preserving RRF in new hemodialysis patients. Methods. Nineteen patients with end‐stage renal disease (ESRD) starting hemodialysis therapy were included in the study. At the beginning, their elevated blood pressures (BP) were treated with antihypertensive drugs. Thereafter, until normovolemia and normal BP were obtained, strict volume control was applied. The effects of both treatment modalities on the loss of RRF and LVH were evaluated prospectively. Results. At the initial examination, all of the patients were hypertensive and had markedly increased left ventricular mas...

Should the preservation of residual renal function cost volume overload and its consequence left ventricular hypertrophy in new hemodialysis patients

BACKGROUND The aim of this study was to investigate the effect of chronic administration of interferon-alpha 2b for the prevention of carbon tetrachloride (CCl4)-induced oxidative stress and nephrotoxicity. METHODS Thirty rats were divided into three groups: control, CCl4+placebo (CCl4+P) and CCl4+interferon-alpha 2b (CCl4+INF). Control rats were treated with pure olive oil. The other rats were treated for seven weeks with subcutaneous injections of CCl4 (0.15 mL /kg) in pure olive oil three times a week. Rats were killed at the end of the seventh week and renal histopathological examinations were done: specimens of renal tissue were obtained for investigating oxidative stress parameters, including malondialdehyde (MDA) and glutathione peroxidase (GSH-Px). RESULTS Tubular changes, glomerular hypercellularity, and capillary obliteration were significantly less in the CCl4+INF group than with CCl4+P (p 0.05). CONCLUSIONS Administration of interferon-alpha 2b to CCl4-treated rats prevented interstitial fibrosis, probably as a result of its antifibrogenic effect. It also reduced intrarenal oxidative stress in rats with CCl4-induced nephrotoxicity.

Ali Ihsan Gunal

Papers

Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial

Strict volume control normalizes hypertension in peritoneal dialysis patients

Does enalapril prevent peritoneal fibrosis induced by hypertonic (3.86%) peritoneal dialysis solution?

Should the preservation of residual renal function cost volume overload and its consequence left ventricular hypertrophy in new hemodialysis patients

Protective effect of interferon-alpha on carbon tetrachloride-induced nephrotoxicity.