Background and objectives Uremic pruritus in patients on hemodialysis is associated with depression, lower quality of life, and mortality. We studied the prevalence, awareness, and treatment of pruritus to assess how well this important condition is currently managed internationally. Design, setting, participants, & measurements Data from 35,452 patients on hemodialysis in up to 17 countries from the Dialysis Outcomes and Practice Patterns Study were analyzed to describe pruritus prevalence from 1996 to 2015. Data from 6256 patients and 268 medical directors in 17 countries in 2012–2015 were analyzed to describe predictors, effects, medical directors’ awareness, and treatment of pruritus. Results Patients very much or extremely bothered by itching declined from 28% in 1996 to 18% in 2015. In 2012–2015, among patients nearly always or always bothered by itching, pruritus had a major effect on work and social life; 18% used no treatment for pruritus, and 17% did not report itching to health care staff. In total, 69% of medical directors underestimated the prevalence of pruritus in their unit. Managing high serum phosphorus and low Kt/V was ranked as the most important intervention, but no relationship was found between these factors and pruritus; 57% of medical directors used oral antihistamines for first-line chronic treatment of pruritus. Gabapentin was used by 45% as first-, second-, or third-line treatment. Nalfurafine was only used in Japan. Conclusions The prevalence of pruritus in people on hemodialysis is decreasing but remains underestimated. Large numbers of patients on hemodialysis with severe pruritus do not receive treatment. There is wide variation in the use of unlicensed medications for the treatment of pruritus. These data provide a benchmark for initiatives to improve the management of uremic pruritus. Multimedia This article contains multimedia at https://vimeo.com/49458473 This article contains multimedia at vimeo.com/49455976

Intradialytic cycling (IDC), delivered during haemodialysis (HD), has the potential to improve many health issues. This systematic review and meta-analysis examine the evidence on the effects of IDC on exercise capacity, quality of life (QoL), physical function and cardiovascular health. Twenty-four databases were searched alongside Internet and hand searching, and consultation with experts. Eligibility criteria were cluster randomized, randomized and quasi-randomized controlled trials (RCTs) of IDC versus usual care in prevalent adult HD patients. Primary outcome measures were exercise capacity (VO₂ peak and field tests) and QoL. Secondary measures were cardiac and physical function. Thirteen RCTs were eligible. Eight provided data for use in meta-analyses, which indicated no significant change in VO₂ peak (mean difference, MD 1.19 mL/kg/min, 95% confidence interval −1.15 to 3.52, P = 0.3), physical (mean change, MC 1.97, −8.27 to 12.22, P = 0.7) or mental component (MC 3.37, −7.94 to 14.68, P = 0.6) summary scores of the Medical Outcomes Short Form 36, pulse wave velocity (MD −0.57 m/s, −1.55 to 0.41, P = 0.4), systolic (MD −2.28 mmHg, −14.46 to 9.90, P = 0.7) or diastolic blood pressure (MD 2.25 mmHg, −3.01 to 7.50, P = 0.4) following IDC. IDC, however, leads to an improvement in performance on the 6-min walk test (MD 87.84 m, 39.60–136.09, P = 0.0004). All included studies were considered to have high risk of bias. There is insufficient evidence demonstrating whether cycling exercise during HD improves patient outcomes. High-quality, adequately powered RCTs of IDC are required.

Patients with chronic kidney disease (CKD) exhibit reduced exercise capacity, poor physical function and symptoms of fatigue. The mechanisms that contribute to this are not clearly defined but may involve reductions in mitochondrial function, mass and biogenesis. Here we report on the effect of non‐dialysis dependent CKD (NDD‐CKD) on mitochondrial mass and basal expression of transcription factors involved in mitochondrial biogenesis compared to a healthy control cohort (HC). In addition, we sought to investigate the effect of a 12‐week exercise‐training programme on these aspects of mitochondrial dysfunction in a NDD‐CKD cohort.For the comparison between NDD‐CKD and HC populations, skeletal muscle biopsies were collected from the vastus lateralis (VL) of n=16 non‐dialysis dependent CKD patient’s stage 3b‐5 (NDD‐CKD) and n=16 healthy controls matched for age, gender and physical activity (HC). To investigate the effect of exercise training, VL biopsies were collected from n=17 NDD‐CKD patients before and after a 12‐week exercise intervention that was comprised of aerobic exercise (AE) or a combination of aerobic exercise and resistance training (CE). Mitochondrial mass was analysed by citrate synthase activity and mitochondrial protein content by Porin expression, whilst the expression of transcription factors involved in mitochondrial biogenesis were quantified by real‐time qPCR. NDD‐CKD patients exhibited a significant reduction in mitochondrial mass when compared to HC, coupled to a reduction in PGC‐1α, NRF‐1, Nrf2, TFam, mfn2 and SOD1/2 gene expression. 12‐weeks of exercise training resulted in a significant increase in PGC‐1α expression in both groups, with no further changes seen across indicators of mitochondrial biogenesis. No significant changes in mitochondrial mass were observed in response to either exercise programme. NDD‐CKD patients exhibit reduced skeletal muscle mitochondrial mass and gene expression of transcription factors involved in mitochondrial biogenesis compared to HC. These reductions were not restored following 12‐weeks of exercise training implying exercise resistance in this cohort. The reasons for this lack of improvement are currently unknown and require further investigation, as reversing the dysregulation of these processes in NDD‐CKD may provide a therapeutic opportunity to improve muscle fatigue and dysfunction in this population.