**7. Conclusion**

**6.9. Oral Activated Charcoal**

30 Updates in Hemodialysis

**6.10. Cholestyramine**

dialysis [128,129].

**6.12. Thalidomide**

**6.13. Nicergoline**

**6.14. Nicotinamide**

**6.11. Heparin**

accepted and utilized in clinical practice [127,128].

With the rationale of adsorbing an unidentified pruritogen, oral activated charcoal at the dose of 6 grams per day has been used for uremic pruritus. A double-blind crossover trial and a single-blind study have yielded impressive results [127,128]. This preparation is effective, inexpensive, and has a favorable side effect profile. However, this treatment has not yet been

The success of cholestyramine in treating PU is inconsistent. When administered at a dose of 5 grams twice a day, the gastrointestinal side effects are normally found. Moreover, the risk of acidosis must also be taken into consideration, particularly in patients who are not on

Patients on hemodialysis may develop pruritus when treated with porcine or bovine heparin. Pruritus is relieved promptly when another form of heparin is used, implying that these heparins act as allergens [9]. Paradoxically, administration of heparin at 75- 100 mg twice a day for 2-3 weeks can improve UP in some dialysis patients [130]. From the mechanism of action by inhibition of T-lymphocyte heparanase activity which is an important factor for Tcell migration to target tissues, low molecular weight heparin such as enoxaparin at low dose

Thalidomide is a relatively selective inhibitor of TNF-α production. The study indicated that thalidomide at 100 mg per day administered for 1 week can significantly reduce the intensity of pruritus by up to 80% in more than half of the subjects, suggesting a potential role for this

Nicergoline is a dopamine receptor agonist and a partial α-adrenergic blocker related to ergot alkaloids. A double-blind, placebo-controlled study that investigated the effect of 30 mg per day by mouth and 5 mg per day intravenously during dialysis, indicated relief of pruritus in most patients, and the effect lasted for 24- 48 h with improvement persistent in long-term therapy (30 mg per day) in most patients who responded to the initial treatment [133].

Nicotinamide is the pyridine-3-carboxylic acid amide of niacin, a component of the vitamin B complex. Namazi *et al*. suggested 3 mechanisms through which nicotinamide can be effective in treating UP: the anti-inflammatory effect through the inhibition of the expression of major

is effective in treating pruritus associated with lichen planus [2,131].

agent in the treatment of persistent UP [132].

UP is one of the most common and disabling symptoms for patients with ESRD. It is considered to be an inflammatory systemic disease rather than a local skin disorder. Biomarkers of inflammation are increased in patients with UP, and an imbalance of the endogenous opioi‐ dergic system might be involved in the complex pathogenesis of the disease. UP affects up to 90% of patients on dialysis and is associated with a high morbidity and mortality. Given the complexity of its pathogenesis and the lack of clear evidence regarding the efficacy of more conservative therapies, the only definitive treatment is kidney transplantation.

Antihistamines, which are the most widely used antipruritic agents, are ineffective for the treatment of hemodialysis-related pruritus. Safe and effective modalities, and those that should probably be considered as first-line treatment, are topical emollients. Other physical therapies and medications should be further investigated due to the inconsistent trial results. Without definitive treatment of the underlying disease, therapy for hemodialysis-related pruritus is often palliative at best, aiming to minimize the severity of pruritus and to improve the quality of life.

The standard of care remains to optimize the dialysis dose and to use biocompatible mem‐ branes, as well as the treatment of mineral abnormalities and anemia. The reasonable course for treating hemodialysis-related pruritus should be as follows:


Without definitive treatment of the underlying disease, therapy for hemodialysis-related pruritus is often palliative at best, aiming to minimize the severity of pruritus and to improve patients' quality of life.
