A Common Cause of Pruritus in Dialysis Patients

The informative review of pruritus in chronic kidney disease (CKD) patients by Patel et al addresses a persistent, perplexing problem.1 The plethora of possible causes and solutions suggests a multifactorial etiology, but their paper failed to mention what I believe is a common cause of pruritus, much more common than the liver or endocrine disorders they cite. I have observed, in dialysis patients, the frequent association of pruritus with iron deficiency and the relief of pruritus with correction of iron deficiency. In 1988, I reported the first such cases.2 Earlier reports had described the association of pruritus and iron deficiency in non-CKD patients.3, 4, 5, 6 In the predialysis era, pruritus was reported in only 16% of CKD patients7 but was present in 78% to 85% of patients in the pre-erythropoietin dialysis era,8, 9 possibly reflecting an increased prevalence of iron deficiency which accompanied hemodialysis therapy. With the advent of erythropoietin therapy, iron deficiency has received greater attention, with iron measurement and parenteral iron administration now being routine. It is possible that any decrease in pruritus in recent years1 may reflect more routine use of parenteral iron and less iron deficiency in CKD patients.

Iron deficiency may be the most common readily treatable cause of significant pruritus in dialysis patients and should be recognized as a possible cause of pruritus in any patient, with or without CKD. Iron deficiency must be corrected before attributing pruritus solely to CKD.