Single-Center Experience from Quebec with Intravenous Difelikefalin to Treat CKD-Associated Pruritus

Introduction: Chronic kidney disease-associated pruritus (CKD-aP) is a debilitating condition associated with several adverse outcomes in end-stage kidney disease patients including reduced quality of life, sleep quality, and increased mortality. There is a lack of formalized practice guidelines integrating approved new treatments for CKD-aP. Difelikefalin (DFK), a highly selective peripherally acting κ-opioid receptor agonist was approved by Health Canada in 2022 for the treatment of moderate-to-severe CKD-aP. Case Description: Here, we report implementation of a practice changing initiative in our hemodialysis center as well as a treatment algorithm for CKD-aP. First, we screened patients for pruritus by asking them about itch. We then used the Worst Itch Numerical Rating Scale (WI-NRS) and Self-Assessed Disease Severity (SADS) scales to measure the intensity of pruritus and evaluate its impact on the patient’s quality of life respectively. If WI-NRS score was ≥7 (severe) and SADS was B (moderate) or C (severe), DFK was prescribed as first-line therapy. In total, 303 patients were screened. Twelve patients had severe pruritus and were prescribed DFK. Of these patients, 9 responded with a reduction by at least 3 points on their WI-NRS and 4 patients had a complete response (Figure). In some patients, these changes correlated with an improvement in the quality of life as measured by SADS. Safety profile was acceptable. Two patients discontinued treatment due to adverse events of gait disturbance and fatigue in one and somnolence/mental status change in the other. A third patient discontinued treatment due to diagnosis of bullous pemphigus. Discussion: Our protocol has helped us identify patients with CKD-aP in our hemodialysis center and has allowed to improve patient quality of life. Our experience represents well the feasibility to incorporate framework for screening and diagnosis as well as a treatment algorithm of CKD-aP published in a recent Canadian narrative review.