Skip to main content
  • Research article
  • Open access
  • Published:

Sleep disturbance among Malaysian patients with end-stage renal disease with pruritus

Abstract

Background

Chronic kidney disease-associated pruritus (CKD-aP) is a well-recognized, frequent and compromising complication among patients on hemodialysis. Despite advancement in basic medical sciences, CKD-aP is still a major complication and a challenge for both physicians and patients to manage. The aim of this study was to estimate the prevalence of CKD-aP among hemodialysis patients in Malaysia, to determine the impact of CKD-aP on sleep quality and any factors associated with CKD-aP.

Method

A multi-centered, cross-sectional study design was conducted from February 2017 to September 2017 at a tertiary hospital and its affiliated dialysis centers, in Kuala Lumpur, Malaysia. Included were patients > 18 years of age who were undergoing hemodialysis and could understand Malay. Participants were asked to fill the Malay 5D-itch scale and the Malay Pittsburgh sleep quality index (PSQI) upon recruitment.

Results

A total of 334/334 patients were recruited (response rate = 100%). The majority were male (59.6%) and Chinese (61.7%). A total of 61.3% had pruritus, of which most patients (63.4%) reported that their pruritus was mild. More than half (54.1%) reported that they slept > 6 h, and 93.2% experienced no sleep disturbances during the night. However; the overall PSQI median score [IQR] was 6.0 [5.0–9.0]. No significant association was found between demographic and clinical characteristics of patients with the severity of pruritus. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.

Conclusion

In Malaysia, the prevalence of CKD-aP was 61.3%, of which the majority reported that their pruritus was mild. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.

Peer Review reports

Background

Chronic kidney disease associated-pruritus (CKD-aP) is a well-recognized, frequent and compromising complication among patients on hemodialysis. Treating CKD-P is a huge challenge [1, 2]. Treatment is difficult due to the refractory nature of the disease [3]. The absence of suitable and effective treatments for CKD-aP management has resulted in poor sleep among hemodialysis patients [3]. The prevalence of CKD-aP varies from country to country. This may be due to advancement in basic health and medical sciences in developed countries versus developing countries [4]. The prevalence of CKD-aP has decreased from 90% [5] in the 1970s to 22–55% in the modern era [6,7,8].

The pathophysiology of CKD-aP is not completely clear [1] and is believed to be multifactorial, resulting from the integration of multiple factors’ including demographics, neuropathic and psychogenic factors [9]. During hemodialysis, numerous cytokines including interleukin-1 are released following contact with plasma and the dialysis membranes [10]. Interleukin-1 has been suggested to stimulate the release of possible pruritogenic substances [11]. It is also suggested that in hemodialysis patients, accumulation of non-dialyzable middle molecules stimulate free nerve endings contributing to pruritus [11].

CKD-aP usually begins about six months after the start of dialysis [12], and studies have shown a significant positive relationship between pruritus and the duration of hemodialysis [13]. Pruritus can present as either an acute or chronic condition [7], either generalized or localized; and may last from a few months to in some cases more than one year [14]. The onset of pruritus, its duration, and its intensity can change over time, and itch has been reported to worsen at night [15]. The body parts affected are the back, limbs, chest, and head [15].

Pruritus is an undesirable situation that aggravates itchiness and negatively affects patients’ sleep as well as the quality of life [16, 17] as it causes nocturnal awakenings and creates difficulty in falling asleep [18, 19]. A higher mortality risk is also observed in those with poor sleep quality [20]. Moderate to extreme CKD-aP had 15–21% higher mortality compared to those without pruritus [15]. Therefore, the aim of this study was to estimate the prevalence of CKD-aP among hemodialysis patients in Malaysia, to determine the impact of CKD-aP on sleep quality and any factors associated with CKD-aP.

Methods

A cross-sectional, multi-centered study was conducted from February to September 2017 at a tertiary hospital and its affiliated dialysis centers in Kuala Lumpur, Malaysia.

Participants

Patients ≥18 years of age who were undergoing hemodialysis and could understand Malay were recruited. Excluded were patients with pruritus due to other conditions such as liver disease, systemic lupus erythematosus (SLE).

Sample size

Sample size was calculated using the Cochran formula [21]. Our pilot study found that the prevalence of CKD-aP was 68% [22]. Hence, the sample size required was 334 (with a 95% level of confidence and 80% power).

Instruments used

Baseline demographic questionnaire

This questionnaire was used to collect demographic data such as socioeconomic status, disease duration, dialysis duration, and existing comorbidities conditions.

The Malay 5D-itch scale (MD-IS)

The validated Malay 5D-itch scale (MD-IS) [22] was used to assess CKD-aP. The Malay 5D-itch scale has five domains, addressing the duration, degree, direction, disability, and distribution of itching. All items of the four domains (duration, degree, direction, disability) were measured on a five-point Likert scale (where 1 represented the lowest degree of pruritus, and 5 represented the highest degree). The distribution domain was measured in a different manner. If two body parts were affected, the score given was 1; 3–5 body parts affected was scored as 2, 6–10 body parts were scored as 3, 11–13 body parts were scored as 4, and 14–16 body parts were scored as 5. The overall score of the MD-IS was calculated by summing all five domains; a score below 5 indicates no pruritus; whilst a score of 25 indicates severe pruritus [22]. M5D-IS score of 5–10 indicates mild pruritus, a score of 11–19 indicated moderate pruritus and 20–25 shows severe pruritus.

The Malay Pittsburgh sleep quality index (PSQI)

The validated Malay Pittsburgh sleep quality index (PSQI) [23] is an instrument that measures self-rated sleep quality over the past one month. It consists of 19 items, which is combined with seven component scores such as subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Sleep duration was rated on a 4-point Likert scale of less than 5 h to more than 7 h; sleep efficiency was rated by the number of hours asleep divided by the total number of hours in bed. The use of sleep medication and poor daytime dysfunction were rated on a 4-point Likert scale (“not during the past month, less than once per week, once or twice per week, three or more times per week”). Sleep disturbance was assessed by nine questions which focused on waking up in the middle of the night or early in the morning, getting up to go to the toilet, difficulty breathing properly, coughing or snoring loudly, being too cold, being too hot, having nightmares, experiencing pain, or other reasons for disturbed sleep and each question was rated on 4-point Likert scale (“not during the past month, less than once per week, once or twice per week, three or more times per week”). Subjective sleep was evaluated with one question on a 4-point Likert scale from very good to very bad. The seven components were each scored from 0 (no difficulty) to 3 (severe difficulty) [24, 25]. The overall score was combined by summing up the scores of these seven components that ranged from 0 to 21 [26]. PSQI score ≥ 5 were classified as bad sleepers and PSQI < 5 classified were as good sleepers [26].

Procedure

Patients were approached while they were undergoing hemodialysis. The objective of the study was explained. Written informed consent was obtained from those who agreed to participate. Participants were then asked to fill in the baseline demographic form, the Malay 5D-itch scale and the Pittsburgh sleep quality index (PSQI).

Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences version 20.0 (SPSS Inc., Chicago, IL). Normality was assessed using the Kolmogorov–Smirnov test. As normality could not be assumed, non-parametric tests were used. Categorical variables were presented as number and frequency, while continuous variables were presented as either mean or standard deviation or median and interquartile ranges (IQR). To determine the factors associated with pruritus, patients were categorized to 1) mild pruritus and 2) moderate to severe pruritus. Any association between variables which had a p-value < 0.25 were then included in the logistic regression analysis, where a p-value< 0.05 was considered significant.

Results

A total of 334/334 patients were recruited (response rate = 100%). The flow on how patients were recruited is shown in Fig. 1. The majority were male (59.6%) and Chinese (61.7%). Significantly more Malays had pruritus (p = 0.014). The duration of having CKD and duration in months receiving dialysis were significantly higher in patients with pruritus. Hypertension (n = 142), diabetes mellitus (n = 85), and hyperlipidemia (n = 30) were the most common co-morbidities observed in CKD patients with pruritus (Table 1).

Fig. 1
figure 1

Flow diagram of patient recruitment and eligibility for further assessment

Table 1 Demographics and clinical characteristic of Participants (n = 334)

Prevalence and the characteristic of CKD-aP

Of the 334 patients recruited, 205 (61.3%) reported that they had CKD-aP based on the total score of the M5D-itch scale (Table 2). Most patients n = 182 (88.1%) reported that they experienced pruritus for < 6 h a day and 130 (63.4%) patients reported that their intensity of itching over the past 2 weeks was mild, the remaining participants reported that the intensity of itching was moderate [16 (7.8%)] and severe [6 (2.9%)] (Table 2). The majority [133 (64.9%)] reported that their pruritus has completely resolved. Nearly half [100 (48.8%)] quoted pruritus as a reason for the difficulty in falling asleep. The majority of participants (> 77.0%) also reported that pruritus did not affect their leisure, housework or work/school. Back, forearm, abdomen, lower leg, and thighs, were parts of the body most affected by pruritus. Most patients [177 (86.3%)] had mild pruritus (based on the overall total score of M5D itch scale score of 5–25) as shown in Table 2. All patients (205%?) were dialyzed using high-flux dialyzers. The membranes used in these dialyzers were of the polyarylsulfone family. Seven (3.4%) patients were prescribed antihistamines, 4 (1.9%) were prescribed steroids, and 2 (0.9%) were prescribed gabapentinoids.

Table 2 Responses obtained by patients regarding CKD-aP using the Malay 5D itch scale s (n = 205)

More than half (54.1%) of patients reported that they slept > 6 h, 191 (93.2%) experienced no sleep disturbances during the night. Majority of the patients [107 (52.2%)] of the patients were having mild difficulty score in sleep latency, whereas 144 (70.2%) had mild difficulty in day time dysfunction, 85 (41.5%) reported that their sleep efficiency was 85% and 141 (68.8%) reported that their sleep quality ranged from fairly to very good, 202 (98.5%) of our patients never used sleep medications. The overall PSQI median score [IQR] was 6.0 [5.0–9.0] (Table 3).

Table 3 Responses obtained by patients regarding their sleep quality using the Malay Pittsburgh Sleep Quality Index (PSQI) (n = 205)

The intensity of pruritus was significantly associated with poorer sleep quality (Spearman’s rho = 0.408, p = < 0.001). Patients with moderate to severe pruritus were found to be 5.47 times more likely to exhibit bad sleep as compared to those with mild or no pruritus. No significant association was found between demographic and clinical characteristics of patients with the severity of pruritus.

Discussion

The prevalence of CKD-aP was high, of which the majority of patients reported that it was mild in severity. The intensity of pruritus was significantly associated with poorer sleep quality.

The prevalence of CKD-aP in our study was 61.3%, which was similar to previous studies in Malaysia which reported rates of 58.6% [27] and 64.2% [28]; Turkey (53.4 and 85.4%) [29, 30] and74% in Pakistan [31]. The possible reasons for the variation in the prevalence of CKD-aP among different studies may be due to the study design, cohort studied (sample size, different study population), ethnicity (i.e. the individual’s tolerance or threshold for itch) or instruments used to assess CKD-aP [4, 32]. Moreover, the assessment of pruritus is also subjective one as it is based on perception, which is influenced by cultural, educational and socio-economic status [32]. Patients with depressive symptoms were reported to have 1.3 to 1.7 times higher risk of developing severe pruritus compared to those without depression [15, 33]. Patients with increased pruritus severity were also found to be more likely to miss hemodialysis sessions. Missed hemodialysis sessions have been associated with increased all-cause, cardiac-related, and infection-related hospitalizations and mortality [34].

The prevalence of CKD-aP in our study was 61.3%. However, the majority (86.3%) reported that their pruritus was mild. Our findings differed from previous studies which reported prevalence rates of mild pruritus as 48.8% in Japan [35], 22.2% in Egypt [36], and 41.7% in Saudi Arabia [37]. In our setting, only high-flux dialyzers were used, and studies have shown that high-flux dialyzers efficiently remove average-sized molecules associated with the aggravation of pruritus better than low-flux dialyzers [38]. However, some studies reported a high prevalence of CKD-aP even when patients were on high flux dialyzers: 62.6% in Taiwan [39], 53.4% in Turkey [30], 72.9% in Japan [38], 74.3% in Israel [40]. This may be due to the different type of dialyzer membranes used. Patients on dialyzers which uses polysulphone membranes experienced more pruritus than those using haemophane or cuprophane membranes [13, 41]. Some pruritogenic substances may be activated or released in greater amounts after blood contact with polysulphone membranes compared to other materials [42]. Use of high-flux polyacrylonitrile membrane has been reported to alleviate the severity of pruritus [43]. Hemodialysis with the target of Kt/V ≥ 1.5 (K = dialyzer clearance of urea, t = dialysis time, V = volume of distribution of urea, approximately equal to patient’s total body water) [44], as well as the use of high-flux dialyzer, may play a role in reducing the severity of uremic pruritus [44,45,46]. A search of published literature found that other factors that were found to be associated with CKD-aP were elevated blood urea nitrogen (BUN) [38, 47, 48]; crystal deposition of calcium and phosphate on skin (due to hypercalcemia and hyperphosphatemia) [49]; high aluminum level [50]; secondary hyperparathyroidism [47]; erythropoietin deficiency, high ferritin level, lower transferrin [30] and xerosis [51]. However, we did not found any associations in our study.

In our study, 48.8% of patients reported occasional delays in falling asleep, followed by 9.8% with frequent delays in falling asleep affected due to CKD-aP. Our findings were similar with other studies, where more than 45% [15], 59.1% [52] and 70% [38] of patients suffering from moderate to severe CKD-aP were observed to have poor sleep quality. Patients with moderate to severe pruritus were found to be 5.47 times more likely to exhibit bad sleep as compared to patients with mild pruritus, which was lower than a previous study which reported an odds ratio of 8.4 times for poor sleep [1]. A possible reason may be due to the fact that the majority of our patients reported having mild pruritus as opposed to having moderate or severe pruritus [53].

A limitation of our study was that the data collected was not generalizable, as it was only collected from dialysis centers based in Kuala Lumpur. We also did not have an (age and sex-matched) control group for our population. However, the strength of our study was that we had a very good response rate.

Conclusion

In Malaysia, the prevalence of CKD-aP was 61.3%, of which the pruritus experienced was mild. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.

Abbreviations

5D-IS:

5D itching scale

CI:

Confidence interval

CKD:

Chronic kidney disease

MUHREC:

Monash University Human Research and Ethics Committee

PSQI:

Pittsburgh sleep quality index

References

  1. Shirazian S, Aina O, Park Y, Chowdhury N, Leger K, Hou L, Miyawaki N, Mathur VS. Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges. Int J Nephrol Renov Dis. 2017;10:11.

    Article  Google Scholar 

  2. Simonsen E, Komenda P, Lerner B, Askin N, Bohm C, Shaw J, Tangri N, Rigatto C. Treatment of uremic pruritus: a systematic review. Am J Kidney Dis. 2017;70:638–55.

    Article  CAS  Google Scholar 

  3. Lopes GB, Nogueira FCP, de Souza MR, Penalva MA, de Amorim JL, Pisoni RL, Robinson BM, Lopes AA. Assessment of the psychological burden associated with pruritus in hemodialysis patients using the kidney disease quality of life short form. Qual Life Res. 2012;21:603–12.

    Article  Google Scholar 

  4. Hu X, Sang Y, Yang M, Chen X, Tang W. Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: a meta-analysis of cross-sectional studies. Medicine. 2018;97:e10633.

    Article  Google Scholar 

  5. Young A Jr, Sweeney E, David D, Cheigh J, Hochgelerenl E, Sakai S, Stenzel K, Rubin A. Dermatologic evaluation of pruritus in patients on hemodialysis. New York state journal of medicine. 1973;73:2670.

    PubMed  Google Scholar 

  6. Khan MU, Hassali MAA, Ahmad A, Elkalmi RM, Zaidi STR, Dhingra S. Perceptions and practices of community pharmacists towards antimicrobial stewardship in the state of Selangor, Malaysia. PloS one. 2016;11:e0149623.

    Article  Google Scholar 

  7. Narita I, Iguchi S, Omori K, Gejyo F. Uremic pruritus in chronic hemodialysis patients. Journal of nephrology. 2008;21:161–5.

    PubMed  Google Scholar 

  8. Kim KH, Lee MS, Choi S-M, Ernst E. Acupuncture for treating uremic pruritus in patients with end-stage renal disease: a systematic review. J Pain Symptom Manag. 2010;40:117–25.

    Article  Google Scholar 

  9. Yosipovitch G. Pruritus. Curr Probl Dermatol. 2003;15:143–64.

    Article  Google Scholar 

  10. Pereira B, Dinarello C. Production of cytokines and cytokine inhibitory proteins in patients on dialysis. Nephrol Dial Transplant. 1994;9:60–71.

    PubMed  Google Scholar 

  11. Falodun L, Ogunbiyi A, George A, Salako B. Uremic pruritus in patients with end stage renal disease, in Ibadan, Nigeria. Tropical Journal of Nephrology. 2017;3:111–3.

    Google Scholar 

  12. Robertson KE, Mueller BA. Uremic pruritus. Am J Health Syst Pharm. 1996;53:2159–70.

    Article  CAS  Google Scholar 

  13. Szepietowski JC, Sikora M, Kusztal M, Salomon J, Magott M, Szepietowski T. Uremic pruritus: a clinical study of maintenance hemodialysis patients. J Dermatol. 2002;29:621–7.

    Article  Google Scholar 

  14. Robinson-Bostom L, DiGiovanna JJ. Cutaneous manifestations of end-stage renal disease. J Am Acad Dermatol. 2000;43:975–86.

    Article  CAS  Google Scholar 

  15. Pisoni RL, Wikström B, Elder SJ, Akizawa T, Asano Y, Keen ML, Saran R, Mendelssohn DC, Young EW, Port FK. Pruritus in haemodialysis patients: international results from the Dialysis outcomes and practice patterns study (DOPPS). Nephrology Dialysis Transplantation. 2006;21:3495–505.

    Article  Google Scholar 

  16. Erturk IE, Arican O, Omurlu IK, Sut N. Effect of the pruritus on the quality of life: a preliminary study. Ann Dermatol. 2012;24:406–12.

    Article  Google Scholar 

  17. Berger TG, Steinhoff M. Pruritus and renal failure. In: Seminars in cutaneous medicine and surgery. NIH Public Access; 2011: p. 99.

  18. Yosipovitch G, Zucker I, Boner G, Gafter U, Shapira Y, David M. A questionnaire for the assessment of pruritus: validation in uremic patients. Acta Derm Venereol. 2001;81:108–11.

    Article  CAS  Google Scholar 

  19. Zucker I, Yosipovitch G, David M, Gafter U, Boner G. Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: uremic pruritus is still a major problem for patients with end-stage renal disease. J Am Acad Dermatol. 2003;49:842–6.

    Article  Google Scholar 

  20. Ibrahim MK, Elshahid AR, El Baz TZ, Elazab RM, Elhoseiny SA, Elsaie ML. Impact of Uraemic pruritus on quality of life among end stage renal disease patients on Dialysis. J Clin Diagn Res. 2016;10:WC01.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Daniel W: Biostatistics: A Foundation for analysis in the health sciences, 7th edR Wiley. N Y 1999.

  22. Rehman IU, Wu DB-C, Lai P, Mei S, Palanisamy UD, Lim SK, Khan TM. Translation of the 5D itching scale from english to Malay, and its validation among patients with chronic kidney disease in Malaysia. Frontiers in medicine. 2017;4:189.

    Article  Google Scholar 

  23. Zahari Z, Siong LC, Musa N, Mohd Yasin MA, Choon TS, Mohamad N, Ismail R. Demographic profiles and sleep quality among patients on methadone maintenance therapy (MMT) in Malaysia. Pak J Pharm Sci. 2016;29(1):239–46.

    CAS  PubMed  Google Scholar 

  24. Li Y, Zhang S, Zhu J, Du X, Huang F. Sleep disturbances are associated with increased pain, disease activity, depression, and anxiety in ankylosing spondylitis: a case-control study. Arthritis research & therapy. 2012;14:R215.

    Article  Google Scholar 

  25. Buysse DJ, Reynolds CF III, Monk TH, Hoch CC, Yeager AL, Kupfer DJ. Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh sleep quality index (PSQI). Sleep. 1991;14:331–8.

    CAS  PubMed  Google Scholar 

  26. Buysse DJ, Reynolds CF III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213.

    Article  CAS  Google Scholar 

  27. Ying SC, Krishnan M. Interpretation Of Quality Of Life Outcomes Amongst End Stage Renal Disease Patients In Selected Hospitals Of Malaysia. Int J Pharm Sci Res. 2014;5:60.

    Google Scholar 

  28. Ibrahim N, Chiew-Tong NK, Desa A. Symptoms and health-related quality of life in patients with heamodialysis and continuous ambulatory peritoneal dialysis. Research Journal of Medical Sciences. 2011;5:252–6.

    Article  Google Scholar 

  29. Kavurmacı M. Prevalence of uremic itching in patients undergoing hemodialysis. Hemodial Int. 2015;19:531–5.

    Article  Google Scholar 

  30. Ozen N, Cinar FI, Askin D, Mut D. Uremic pruritus and associated factors in hemodialysis patients: a multi-center study. Kidney research and clinical practice. 2018;37:138.

    Article  Google Scholar 

  31. Rehman IU, Munib S, Ramadas A, Khan TM. Prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in Pakistan. PLoS One. 2018;13:e0207758.

    Article  Google Scholar 

  32. Jamal ASP. Pruritus among end-stage renal failure patients on hemodialysis. Saudi J Kidney Dis Transplant. 2000;11(2):181–5.

    CAS  Google Scholar 

  33. Lopes AA, Albert JM, Young EW, Satayathum S, Pisoni RL, Andreucci VE, Mapes DL, Mason NA, Fukuhara S, Wikström B. Screening for depression in hemodialysis patients: associations with diagnosis, treatment, and outcomes in the DOPPS. Kidney Int. 2004;66:2047–53.

    Article  Google Scholar 

  34. Foley RN, Gilbertson DT, Murray T, Collins AJ. Long interdialytic interval and mortality among patients receiving hemodialysis. N Engl J Med. 2011;365:1099–107.

    Article  CAS  Google Scholar 

  35. Takahashi N, Yoshizawa T, Okubo A, Kumagai J, Kawanishi H, Tsuchiya S, Moriishi M, Masaki T, Ebata T. Usefulness of the Japanese version of the 5-D itch scale for rating pruritus experienced by patients undergoing hemodialysis. Renal Replacement Therapy. 2018;4:26.

    Article  Google Scholar 

  36. Nofal E, Farag F, Nofal A, Eldesouky F, Alkot R, Abdelkhalik Z. Gabapentin: a promising therapy for uremic pruritus in hemodialysis patients: a randomized-controlled trial and review of literature. J Dermatol Treat. 2016;27:515–9.

    Article  CAS  Google Scholar 

  37. Khan TM, Al-Haider I, Syed Sulaiman SA, Hassali MA. Linguistic validation of the 5D itching scale to Arabic in patients with end-stage kidney disease. Journal of renal care. 2013;39:222–7.

    Article  Google Scholar 

  38. Narita I, Alchi B, Omori K, Sato F, Ajiro J, Saga D, Kondo D, Skatsume M, Maruyama S, Kazama J. Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients. Kidney Int. 2006;69:1626–32.

    Article  CAS  Google Scholar 

  39. Chiu Y-L, Chen H-Y, Chuang Y-F, Hsu S-P, Lai C-F, Pai M-F, Yang S-Y, Peng Y-S. Association of uraemic pruritus with inflammation and hepatitis infection in haemodialysis patients. Nephrology Dialysis Transplantation. 2008;23:3685–9.

    Article  CAS  Google Scholar 

  40. Dyachenko P, Shustak A, Rozenman D. Hemodialysis-related pruritus and associated cutaneous manifestations. Int J Dermatol. 2006;45:664–7.

    Article  Google Scholar 

  41. Patel TS, Freedman BI, Yosipovitch G. An update on pruritus associated with CKD. Am J Kidney Dis. 2007;50:11–20.

    Article  Google Scholar 

  42. Szepietowski JC, Salomon J. Uremic pruritus: still an important clinical problem. J Am Acad Dermatol. 2004;51:842–3.

    Article  Google Scholar 

  43. Aucella F, Vigilante M. Gesuete a: the effect of polymethylmethacrylate dialysis membranes on uraemic pruritus. NDT plus. 2010;3:i8–i11.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. Ko M-J, Wu H-Y, Chen H-Y, Chiu Y-L, Hsu S-P, Pai M-F, Lai C-F, Lu H-M, Huang S-C, Yang S-Y. Uremic pruritus, dialysis adequacy, and metabolic profiles in hemodialysis patients: a prospective 5-year cohort study. PLoS One. 2013;8:e71404.

    Article  CAS  Google Scholar 

  45. Hui B, Min Z, Yin C, Long G. Effect of high-flux dialysis membrane on uremic pruritus and solute clearance of maintenance hemodialysis patients. J Clin Rehabil Tissue Eng Res. 2011;29. http://en.cnki.com.cn/Article_en/CJFDTOTAL-XDKF201129057.htm.

  46. Jiang X, Ji F, Chen Z-W, Huang Q-L. Comparison of high-flux hemodialysis with hemodialysis filtration in treatment of uraemic pruritus: a randomized controlled trial. Int Urol Nephrol. 2016;48:1533–41.

    Article  CAS  Google Scholar 

  47. Dar NR, Akhter A. Clinical characteristics of uremic pruritus in patients undergoing haemodialysis. J Coll Physicians Surg Pak. 2006;16:94–6.

    PubMed  Google Scholar 

  48. Keithi-Reddy S, Patel T, Armstrong A, Singh A. Uremic pruritus. Kidney Int. 2007;72:373–7.

    Article  CAS  Google Scholar 

  49. Kurban MS, Boueiz A, Kibbi A-G. Cutaneous manifestations of chronic kidney disease. Clin Dermatol. 2008;26:255–64.

    Article  Google Scholar 

  50. Hsu C-W, Weng C-H, Chan M-J, Lin-Tan D-T, Yen T-H, Huang W-H. Association between serum aluminum level and uremic pruritus in hemodialysis patients. Sci Rep. 2018;8:17251.

    Article  Google Scholar 

  51. Aramwit P, Supasyndh O: Uremic Pruritus; Its Prevalence, Pathophysiology and Management. In Updates in Hemodialysis. InTech; 2015.

  52. Tessari G, Dalle CV, Loschiavo C, Tessitore N, Rugiu C, Lupo A, Girolomoni G. The impact of pruritus on the quality of life of patients undergoing dialysis: a single Centre cohort study. Journal of nephrology. 2009;22:241–8.

    CAS  PubMed  Google Scholar 

  53. Weiss M, Mettang T, Tschulena U, Passlick-Deetjen J, Weisshaar E. Prevalence of chronic itch and associated factors in haemodialysis patients: a representative cross-sectional study. Acta Derm Venereol. 2015;95:816–21.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We are thankful to Dr. Saleem Perwaiz Iqbal (Monash University Malaysia) for his help in statistical analysis.

Funding

None.

Availability of data and materials

The datasets used and/or analyzed during the current study is available from the corresponding author on reasonable request.

Author information

Authors and Affiliations

Authors

Contributions

Conceived and design: IR, TMK. Data Collection: IR, SKL, PSML. Analyzed the data: IR, TMK. Interpretation of data/result: IR, TMK, PSML. Read and approved the final version: TMK, LHL, and PSML. All authors approved the submission of the final manuscript.

Corresponding authors

Correspondence to Inayat Ur Rehman or Tahir Mehmood Khan.

Ethics declarations

Ethics approval and consent to participate

Ethics approval obtained from Monash University Human Research and Ethics Committee (MUHREC Approval No: CF16/1766–2,016,000,890); University of Malaya Medical Center (MREC ID No: 20161230–4722). A written informed consent was obtained from the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rehman, I.U., Lai, P.S.M., Lim, S.K. et al. Sleep disturbance among Malaysian patients with end-stage renal disease with pruritus. BMC Nephrol 20, 102 (2019). https://doi.org/10.1186/s12882-019-1294-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12882-019-1294-1

Keywords