Uraemic Pruritus Clinical Characteristics, Pathophysiology and Treatment Lucio Manenti, 1 Pius Tansinda 1 and Augusto Vaglio 2 1 Division of Nephrology, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy 2 Department of Clinical Medicine and Nephrology, University of Parma, Parma, Italy Contents Abstract ................................................................................. 251 1. Clinical Characteristics ................................................................. 252 2. Pathophysiology ....................................................................... 252 2.1 Skin Xerosis and Cutaneous Alterations ............................................... 253 2.2 Pruritogenic Cytokines Produced in the Dermis ......................................... 253 2.3 Uraemia-Related Alterations ........................................................ 253 2.4 Immune-Inflammatory Hypothesis .................................................... 254 2.5 Opioid Hypothesis ................................................................. 254 2.6 Uraemic Neuropathy Hypothesis and ‘Wind-Up Phenomenon’ ........................... 254 3. Management ......................................................................... 255 3.1 Uraemia Treatment ................................................................ 256 3.2 Topical Treatments ................................................................. 256 3.3 Physical Treatment ................................................................. 258 3.4 Systemic Treatments ............................................................... 258 4. Conclusions ........................................................................... 259 Abstract Pruritus is a common complication of end-stage renal disease (ESRD), affecting about one-third of dialysis patients. It is a chronic, unpleasant symptom with a strong negative impact on patients’ quality of life, often inducing sleeplessness and mood disorders. Recent data show that it is also associated with increased mortality. The pathogenesis of uraemic pruritus (UP) is multifactorial. Triggering factors may include uraemia-related abnormalities (particularly involving calcium, phosphorus and parathyroid hormone metabolism), accumulation of uraemic toxins, systemic inflammation, cutaneous xerosis, and common co-morbidities such as diabetes mellitus and viral hepatitis. Recent findings suggest that the neurophysiology of itch is similar to that of pain; this has led to the hypothesis that the two phenomena also closely interact in ESRD patients, who often also experience uraemic neuropathy. The management of UP needs to address several different issues, such as optimization of dialysis efficacy and skin hydration, and correction of calcium-phosphorus metabolism abnormalities. A wide range of antipruritic drugs have been suggested for the treatment of UP, although most of them have only been tested in small, uncontrolled trials, which have yielded conflicting results. Antihistamines are now known to have little or no THERAPY IN PRACTICE Drugs 2009; 69 (3): 251-263 0012-6667/09/0003-0251/$55.55/0 ª 2009 Adis Data Information BV. All rights reserved.