What's The Matter With Hemodialysis Uremic Skin Itching? How To Treat And Care?

Skin itching in hemodialysis patients is still a troublesome problem. The etiology, pathogenesis, and pathological changes of pruritus are complex, and its treatment and nursing are also long-term and difficult processes.

 

Uremic pruritus (Uremic pruritus, UP), also known as chronic kidney disease-related pruritus (CKD-rP), referred to as uremic pruritus, is one of the common clinical symptoms in patients with end-stage renal disease. The incidence rate is as high as 50% to 90%. According to the DOPPS study, about 42% of dialysis patients still suffer from moderate to severe pruritus.

 

 

 

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UP is a systemic lesion rather than a simple skin disease, which seriously affects the quality of life of patients. It not only interferes with their sleep and work, but also causes symptoms such as skin infection and skin damage, and affects the outcome of dialysis. The risk of death increases by 15% to 17%.

1. Definition and evaluation method

Uremic pruritus often occurs 6 months after the start of dialysis. The number of episodes is more at night than during the day. Most of them are paroxysmal episodes with different durations. The persistent and aggravated itching often occurs during or shortly after dialysis. The clinical manifestations are systemic or local itching in varying degrees, and the forehead, nape, and forearm palms are typical occurrence sites. Uremic pruritus can be diagnosed when pruritus caused by other disease activities is excluded and any of the following conditions are met:

(1) Pruritus occurs for at least 3 days within 2 weeks, and itching occurs several times within 1 day, each lasting for several minutes;
(2) Pruritus that occurs in a specific pattern and lasts for more than 6 months. As a subjective feeling, itching is affected by many factors and has obvious individual differences. At present, the commonly used method for evaluating the degree of itching is the Visual Analog Scale (VAS), which borrows the scoring method of pain and requires patients to mark their degree of itching on a scale with a scale of 10 cm according to their feelings, and 0 means No itching, 10 means unbearable itching, skin itching is divided into mild, moderate and severe according to the score.

2. Analysis of Influencing Factors of Skin Pruritus

dry skin, lack of moisture

Uremic patients on long-term dialysis are often accompanied by dry skin. pointed out that hemodialysis patients have dry skin due to atrophy of sebaceous glands and sweat glands and exocrine dysfunction, increased pH of the stratum corneum, and increased vitamin A concentration in the epidermis. The prevalence of skin dryness in uremic hemodialysis patients was higher than that of ordinary people, and the range and degree of dryness were more serious than in normal people, while the skin dryness was most prominent in patients with pruritus.

 

The study found that the moisture in the stratum corneum of patients with pruritus decreased, and the degree of dryness of the skin was closely related to the incidence and severity of pruritus. The main factor involved in dry skin was the pathogenesis of pruritus. Dialysis removes excess water from the body of uremic patients. The water imbalance in skin cells is particularly obvious during and after dialysis, and the itching is also severe at this time.

accumulation of toxins

Although dialysis can remove some toxins in patients with uremia, it cannot completely replace the detoxification function of the kidneys. Conventional hemodialysis is not ideal for removing large and medium molecular toxins. Patients often have hypercalcemia, hypermagnesemia, and/or hyperphosphatemia due to the increase of divalent ions, which will promote Molecular toxins accumulation, which in turn causes severe itchy skin symptoms. In addition, the susceptibility and severity of pruritus were positively correlated with the levels of creatinine and urea in the blood.

allergic reaction

The hypersensitivity reaction caused by the proliferation of mast cells and the increase of histamine is another important cause of pruritus in hemodialysis patients. The dialysis process increases the patient's contact with allergens, which increases the frequency and degree of skin itching. When the blood contacts the dialyzer, it will produce the comprehensive effect of first use, and some patients will have an allergic reaction that causes itching. In vitro anticoagulants such as heparin used during dialysis, ethylene oxide used to disinfect dialyzers, and residual peracetic acid disinfectant in reused dialyzer tubing can all enter the bloodstream to stimulate mast cell proliferation and cause itching.

Malnutrition

Although dialysis can alleviate symptoms such as loss of appetite caused by the accumulation of toxins in uremic patients, it cannot eliminate them. Coupled with the restriction of water and salt intake, the intake of nutrients will be reduced; the dialysate will also accelerate protein decomposition and The loss of amino acids will cause the lack of nutrients needed for healthy skin, resulting in obvious skin keratinization and increased susceptibility.

Increased parathyroid hormone

Patients with uremia are often accompanied by hyperparathyroidism, which will stimulate mast cells to release histamine, promote the deposition of calcium salts and magnesium ions in the skin, and then induce itching, but not all patients with hyperparathyroidism have itching.

other diseases

Patients with uremia are often accompanied by other diseases, such as diabetes, malignant lymphoma, hypercalcemia, etc., which can cause an accumulation of toxin molecules in the body of patients with uremia, causing itching. Excess bile salt deposits on the skin can irritate nerve endings and cause itching. Mistik et al. found that hemodialysis patients with itchy skin had elevated total bile acid concentrations in their blood, and patients with positive hepatitis virus antibodies often had higher levels of itching than uninfected patients because of their combined cholestasis. In addition, patients with pruritus before dialysis were more likely to develop dialysis-associated pruritus.

3. Treatment and Nursing of Pruritus

Treatment and Nursing of Basic Diseases

Uremic pruritus is often the pathological result of multiple etiologies. Carol et al. found that many primary causes such as bile excretion disorders, hepatitis C virus infection, endocrine disorders, bone marrow dysplasia, visceral cancer, allergic rashes, and neuropsychiatric disorders can cause pruritus. In addition, patients with iron deficiency anemia, skin inflammation, some metabolic disorders, and diabetic nephropathy have an increased chance of suffering from itchy skin. Therefore, uremic patients with pruritus should be evaluated first to rule out the pruritus caused by the primary disease, and treat and care for it based on understanding the underlying cause.

skincare

Environmental care: Itching can be exacerbated by warm skin, and itching can be relieved by cool skin. The ambient temperature and humidity of the living room and dialysis room should be suitable to avoid excessive skin temperature of the patient. When using the air conditioner, special attention should be paid to the dryness of the air.

 

Medication support: Rational medication is essential for patients with severe pruritus, including topical and oral medications. The external medicine is mainly body lotion, and there is no uniform formula standard at present, but it contains urea, glycerol hydroxy acid, mineral or vegetable oil, and other substances, which have the effect of rehydration and preventing water evaporation, and can reduce the sensitivity of skin nerve endings, is the first-line drug for the treatment of dry and itchy skin.

Eliminate allergens and reduce allergic reactions

Take various measures to reduce itching caused by allergies in patients. Choose an adhesive plaster with a good anti-allergic effect, and try d the needle handle touching the patient's skin when puncturing; use a dialyzer and dialysis membrane with better biocompatibility.

Data from Szepietowski et al showed that pruritus was more common in hemodialysis patients using polysulfone membranes than in patients using blood or copper membranes. Compared with reusable dialyzers, disposable dialyzers are more likely to have allergic reactions, and the proportion and degree of skin itching in patients are increased. Using the method of tubing priming can reduce allergic reactions caused by the use of disposable dialyzers.

The study found that the preflush with 5% GN is more biocompatible than normal saline, and can effectively improve the degree of itching. Wang Dimei found that the low molecular weight heparin anticoagulant method for dialysis can also improve itching symptoms.

Modified Blood Purification Therapy

High-efficiency, high-flux dialysis can better remove toxins and reduce the intensity of itching; increasing the frequency and frequency of dialysis can also help relieve itching. Studies by Vanholder R and others have shown that different dialysis modes have different effects on toxin removal and improvement of pruritus symptoms. Hemofiltration (HDF) is better than hemodialysis (HD), hemoperfusion (HP) is better than HD and HDF, while the purification scheme of hemodialysis combined with hemoperfusion (HD + HP) was better than the scheme of hemodialysis combined with hemofiltration (HDF + HD) in improving pruritus.

Surgical Treatment and Nursing

As early as the 1960s, it was discovered that there is a certain correlation between parathyroid hormone (PTH) and hemodialysis pruritus, and postoperative hemodialysis patients with parathyroid glands removed, pruritus will be significantly reduced. Research by Natalia et al. found that kidney transplantation is a means of treating uremic pruritus, and so far no pruritus has been found in patients with kidney transplantation; and patients with original uremic pruritus after organ transplantation, due to the continuous use of immunosuppressants, the symptoms of itching gradually disappeared.

Physiotherapy and Nursing

Ultraviolet B light (UVB) exposure has long been recognized as an effective remedy for pruritus. However, due to its potential carcinogenic effect, and the anti-itch mechanism is not very clear the irradiation time and the length of the course of treatment has not yet been consistent, so it is not widely used in clinical practice. Research by Mei-Chi et al. found that thermal therapy using infrared rays with a wavelength of 4-1000 μm to irradiate the skin can promote cell metabolism and help the treatment of uremia pruritus. Satisfactory results have also been achieved in patients with uremic pruritus treated with electroacupuncture stimulation, an improved traditional Chinese acupuncture technique.

Dietary care and personal hygiene guidance

Patients who have undergone hemodialysis for a long time are often accompanied by a lack of nutrients, and it is difficult for skin cells to maintain normal metabolism and function. Studies by Kaptein et al. have shown that the accumulation of vitamin A and phosphorus in the body can lead to dry skin and itching, and the lack of iron in the blood is an important reason for the occurrence of pruritus and skin infection.

In addition to having enough calories and protein in the diet of patients with hemodialysis itching, they also need to avoid excessive consumption of foods high in phosphorus, such as animal offal, almonds, raisins, etc. and do not eat irritating foods and drinks. Patients should be instructed to bathe properly, and to achieve the "four taboos", avoid bathing too often, avoid excessive water, avoid excessive rubbing, and avoid alkaline soap. Use petroleum jelly body lotion immediately after bathing to avoid dry skin, wear soft cotton underwear, and trim nails in time to prevent infection from scratches.

Traditional Chinese Medicine

Traditional Chinese medicine believes that itching is related to internal evils. "On the Causes and Symptoms of Various Diseases" records that "wind itching is due to physical weakness and wind. It is pain, so it is also itching." Due to the loss of essence and blood in hemodialysis patients, the skin cannot be nourished due to blood deficiency, and the dry wind moves internally, coupled with the external wind and dry air, which induces dry skin and itching. Traditional Chinese medicine often adopts traditional Chinese medicine fumigation, traditional Chinese medicine bathing, and oral administration of traditional Chinese medicine decoction, etc., all of which have been shown to improve the symptoms of pruritus. However, researchers have different perspectives. The formulation of the medicinal solution has not yet reached an agreement, and the sample size is relatively small, making it difficult to promote the clinical application.

Summary

Skin itching in hemodialysis patients is still a troublesome problem. The etiology, pathogenesis, and pathological changes of pruritus are complex, and its treatment and nursing are also long-term and difficult processes. Due to the lack of understanding of the types of uremic pruritus and the mastery of treatment measures among medical workers, it still has not received enough attention in the clinical practice of renal treatment. Medical personnel should conduct a personalized assessment of patients' pruritus symptoms, analyze the cause, combine the cause of the disease with the pathological mechanism, adopt medical conditioning, surgery, physical therapy, and other methods, integrate the essence of traditional Chinese medicine treatment, and apply the theory of evidence-based medicine to the clinic In practice, seek the best treatment and nursing measures for patients with uremic pruritus.

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