Dr Mehwish Asif1, Miss Elizabeth Josland1, Miss Alison Smyth1, Dr. Kelly Chenlei Li1,2
1Renal department, St george hospital, Kogarah, Australia, 2UNSW Medicine and Health., , Australia
Biography:
Biography of Author
My name is Mehwish Asif, and I am a Basic Physician Trainee at St George Hospital. I am deeply passionate about medicine, with a particular interest in nephrology. With every step in my training, I aim to grow both professionally and personally, continually learning and striving to make a meaningful impact in the lives of my patients.
Background:
Chronic kidney disease-associated pruritus (CKDaP) affects up to 60–70% of patients with advanced kidney disease, including those managed conservatively. It significantly impairs sleep, mood, and quality of life. The pathophysiology is multifactorial, involving altered opioid receptor activity, systemic inflammation, and metabolic dysregulation. Treatment options are limited. Difelikefalin, a selective peripherally acting kappa-opioid receptor agonist, is approved for CKDaP in haemodialysis, but its efficacy in conservative kidney management (CKM) is unknown.
Case Presentation:
An 86-year-old woman with stage 5 diabetic kidney disease managed with CKM experienced severe, prolonged, treatment-resistant pruritus. Prior therapies including emollients, capsaicin, pregabalin, mirtazapine, turmeric, phototherapy, and subcutaneous lignocaine provided no relief. Baseline itch was 10/10 on Worst Itch Numerical Rating Scale (WI-NRS), 5/5 across all 5D Pruritus Scale domains, and overwhelming itch and sleep disturbance were reported on iPOS-Renal.
She commenced intravenous difelikefalin 0.5 mcg/kg weekly. By week 3, WI-NRS improved to 2/10, with complete symptom resolution (WI-NRS 0/10) by week 4. 5D scores decreased to ≤2 in all domains, with sustained sleep improvement through week 12. No adverse effects were reported.
Discussion:
This case supports emerging evidence that difelikefalin may be effective and well-tolerated in non-haemodialysis CKD patients. Given the shared pruritus mechanisms in kidney failure, extrapolation from haemodialysis data is reasonable. Weekly dosing proved practical, efficacious, and safe. Larger studies are needed to evaluate efficacy, safety, and optimal dosing in CKM patients.
Conclusion:
Difelikefalin may offer rapid, sustained relief of CKDaP in CKM patients. Broader access and formal evaluation are needed to support its use in this under-treated group.