Uraemic pruritus in RDT patients: is it still a problem?

Marco Gonella Giovanni Calabrese Antonio Mazzotta Giuseppe Vagelli 0 1 2 0 1. Pisoni RL, Wikstrom B, Elder SJ et al. Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2006 ; 21: 3495-3505 2. Mettang T, Pauli-Magnus C, Alscher DM. Uraemic pruritus - new perspectives and insights from recent trials. Nephrol Dial Trasplant 2002; 17: 1558-1563 1 Renal Unit Ospedale S. Spirito Casale Monferrato , Italy 2 The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved Note: Dr Pisoni was invited to provide a reply, but we did not receive a response. Gabapentin use in chronic uraemic itch is in line with emerging pathogenetic hypothesis - Sir, The recent work of Pisoni et al. [1] confirms the importance of an appropriate treatment of pruritus in haemodialysis patients. The authors highlight the impact of pruritus on sleep disorders and consequently the increased patient mortality. As discussed in the earlier paper, other than an immuno or an opioid hypothesis, we believe that the main pathophysiological pathways leading to uraemic itch pathway lie, as is the case of pain, in the central sensitization phenomenon. Itching may indeed be due to a lower threshold of itch perception, following a model similar to that postulated for neuropathic pain [2] and this is the reason why it is a challenge to find an effective treatment for uraemic itch. Recently, our group [3] and Gunal et al. [4] showed the efficacy of low-dose gabapentin in the treatment of uraemic itch. It is worth noting that gabapentin is an emerging drug in the treatment of neuropathic pain and is currently used in brachioradial pruritus, a chronic and localized form of pruritus, probably caused by nerve root injury due to cervical spine disease (a typical neuropathic pruritus); in addition, it can be used for chronic itch unresponsive to other treatments [2]. Last but not least, gabapentin is prescribed as a novel treatment of resistant insomnia [5]. Gabapentin half-life is significantly longer in haemodialysis patients than in those with normal renal function; this Achilles heel turns out to be its strength, as low doses of gabapentin at every haemodialysis session maintain steady-state plasma levels and drug beneficial effect. In summary, we would like to emphasize that gabapentin use is effective, safe and well tolerated in the treatment of pruritus in uraemic patients; additionally, it is in line with the emerging pathogenetic hypotheses on chronic itch [2] and can also be helpful in various diseases (e.g. restless leg syndrome, diabetic neuropathy, insomnia), which affect the quality of life/mortality in haemodialysis patients [1]. On the basis of the above considerations, we believe that gabapentin should be firmly recommended among the treatment options for uraemic itch. Conflict of interest statement. None declared. 1Divisione di Nefrologia e Dialisi Azienda Ospedaliera Desenzano del Garda Via Montecroce 14. 25015 Desenzano d/G (BS) 2Dipartimento di Nefrologia Universita` di Parma Via Gramsci 14. 43100 Parma Email: (...truncated)