Pruritus in ESRD After Three Years on Thrice-Weekly Maintenance Hemodialysis: An Unusual and Unexpected Etiology

Introduction: Pruritus is a symptom of uremia and during maintenance hemodialysis could result from inadequate dialysis and/or concomittant hyperphosphatemia, drug reaction or other causes of pruritus. Case Description: In August 2021, a 72-yo hypertensive diabetic male patient started hemodialysis for uremic symptoms via a tunneled hemodialysis catheter. The AV fistula was created 3 months earlier and was cannulated sometime in 2022. He was on hydromorphone for chronic pain from osteoarthritis and had spinal fusion in mid-2023, requiring more hydromorphone. There was a history of treated scabies in 2011. He had difficulty controlling hyperphosphatemia despite phosphorus binders (TUMs and later, Sevelamer) and regular hemodialysis. He had complained of intermittent itching localized to the right foot, right leg and the right hand, in November 2023. This was ascribed to either increased hydromorphone use after spinal fusion, hyperphosphatemia or dry skin. He was advised to use moisturizers and to be more compliant with the phosphorus binders. In August 2024, the patient complained during hemodialysis rounds of worsening generalized and now mostly night-time itching. This was despite generally improved phosphorus control and regular hemodialysis treatments, with adequate Kt/v. His bedtime antihistamine was switched without any improvement. In September 2024, the patient discovered bedbugs in his bed. He was immediately isolated for his hemodialysis treatments, and it took the combined efforts of the nurses, the social worker and the front office over several weeks, with multiple phone calls and consultations, to eventually activate enough public health resources to eradicate the bedbug problem in the patient’s home using extermination Terminix services. He now feels great. Discussion: It is imperative to consider bed bugs as another cause of pruritus in ESRD patients, especially if it’s nocturnal. The importance of a detailed history including the patient's home environment may help bridge the potential diagnostic challenges posed by such patients. Furthermore, the risk of transmission to other patients within the hemodialysis facility would represent a nightmare experience. Finally, the US Public Health System shuld be a lot more agile, responsive and proactive in tackling such cases.