Transcript
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Dr. Sánchez:
This is CME on Reach MD, and I am Emilio Sánchez. Here with me is my friend Jim Burton. Today, we want to talk about the multidisciplinary management strategies that address physical symptoms and improve quality of life in patients with chronic kidney disease-associated pruritus.
Jim, caring for patients with CKD-aP is often a multidisciplinary team effort. I understand that you have a case to share with us which speaks to the effectiveness of this approach. Let's go, Jim.
Dr. Burton:
Well, thanks, Emilio. Nice to be sharing this space with you again.
I guess before I just kind of mention a case that I was involved with, it’s probably just worth remembering from DOPPS data and data that you and I have been involved with, with surveys since then, from a multidisciplinary approach perspective, if we've got the patient at the center on our dialysis units, we know they come 3 times a week, and they are speaking and talking with and interacting with many members of the dialysis care team.
And we actually know from DOPPS data that less than 50% of people who suffer from pruritus on the dialysis unit would mention that to their nephrologist, and about 1/3 would actually mention it first to their dialysis nurse. Some people mention it to their primary care practitioners. And I know from my practice in the UK that they also mention it to the members of the dietetic team.
So it absolutely is for a multiprofessional approach, because people mention it to those who are around them, who they see on the dialysis unit, and that is not exclusively a nephrologist. In fact, that would be so half the time. So that's the first thing to consider.
But I sort of want to mention a young man that I saw on the dialysis unit. And I run an overnight dialysis program on our unit, so they're getting long, slow, nocturnal dialysis for 6 to 8 hours. And this gentleman came to me, and I'd been seeing him, he had problems with his phosphate, and there were problems with his dialysis clearance. And actually, you can imagine that after 6 to 8 hours of dialysis, 3 times a week, his phosphate was fantastic. His dialysis clearance was well within our target ranges. His fluid balance was good. His PTH and calcium was all improved.
And yet, when I went to see him as part of our CENSUS-EU study, and said, “Oh, I just wanted to ask you this question about itch. Do you suffer from pruritus?” He said, “Oh, yeah, it's terrible. It's 10 out of 10 on the Worst Itch Numerical Rating Score.” And I said to him, “But I only saw you last week, and you didn't even mention it.” And he said, “No, no, it’s been really bothering me for some time.” And even though we'd done all of those things around really good, efficient dialysis, he still suffered from itch as a 10 out of 10, and it was only when I asked him that he told me the answer, and I knew him very well.
And I guess my take-home from that is that you just don't know if someone's got it unless you ask, and they may not tell you, and they may not tell me as a nephrologist. And even when we do the best dialysis we can, this is a chronic condition that's probably going to need treatment for the long term.
And so we started him on a kappa-opioid receptor agonist, on difelikefalin, at a dose of 0.5 mcg/kg 3 times a week, and within actually 6 weeks of treatment, he'd not just got that more than 3-point clinical benefit that we know to be a clinically important difference, but his itch had completely resolved. And we know that that's true in about 25% of patients.
But my key from that individual, who I knew very well, was you don't know unless you ask. Even if you know the patient well, don't expect them to share it with their nephrologist because they won't. And yet, we have something that we can do that might potentially completely resolve their pruritus.
Dr. Sánchez:
Jim, I have another question, and it is about the role of nurses in this multidisciplinary approach to patients with CKD-aP. What do you think a nurse should do in order to promote the diagnosis of pruritus?
Dr. Burton:
Certainly in the UK, the difference between the nursing role and the nephrologist’s role in a time setting is that the nurses are there 3 times a week with the patients. They're looking at their skin. They're seeing if there's any areas that might have cirrhosis or contact dermatitis with the preparations for fistula needling, for example.
So they're constantly inspecting the skin of patients and asking them about that. And I think that is absolutely the prime time to say, “Do you suffer from itch? Have you got any problems with your skin, not just around your fistula, but more broadly?” That's a great segue into asking about skin symptoms that we also know cluster around other symptoms that you've been talking about in other episodes around sleep and mood and quality of life.
And I think the key is that once that information gets from the patient to any member of the team, that that's recorded and fed back to the multiprofessional team so that there can be a conversation about starting effective treatment. So I think that's absolutely key, listening in, taking those opportunities, feeding back, and coming to a management plan together.
Dr. Sánchez:
It is very clear. Thank you very much, Jim.
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