⚠️ Important Disclaimer

Clinical Assessment

• 66-year-old male
• CKD on Maintenance Hemodialysis (MHD) x 6 months
• T2DM + HCV positive
• Presenting with: pulling/stretching sensation in abdomen + pain + sleep disturbance at night

1. Uremic pruritus (CKD-associated pruritus) - the "stretching/pulling" sensation on skin is a common description Indian patients use for uremic itch; affects 25-73% of HD patients; worse at night
2. Restless Legs Syndrome (RLS) - prevalence ~68% in renal failure; characterized by uncomfortable leg/abdominal sensations, worse at rest/night
3. Abdominal wall muscle cramps - common in diabetic dialysis patients due to electrolyte flux during HD
4. Diabetic neuropathic component - dysesthetic pain aggravated at night
5. Rule out: Constipation (common in dialysis patients on phosphate binders), ascites, mesenteric ischemia (less likely)

Prescription

Rx | Patient: 66 yr Male | CKD on MHD | T2DM | HCV+

1. Pregabalin - for uremic pruritus + neuropathic pain + RLS

• Why post-HD only? Pregabalin is dialyzable; give after each session. Between sessions, if needed, 25 mg OD at bedtime on non-dialysis days (with caution; start low).
• Titrate to 50 mg/post-HD after 2 weeks if inadequate response and well tolerated
• Monitor: Sedation, dizziness, fall risk (especially at 66 yrs)

2. Topical Emollient - immediate symptom relief for pruritus/dry skin

Emollients should be applied within 3 minutes after bathing/sponging for maximum effect.

3. For Nocturnal Sleep Disturbance

• Note: Antihistamines are NOT effective for uremic pruritus through the histamine pathway, but their sedative effect can help with sleep-onset difficulty. Use short-term (1-2 weeks) only.
• Avoid in severe sedation risk.

4. Bowel Care / Abdominal Cramp Component

5. Calcium + Vitamin D (if not already prescribed)

• Calcitriol 0.25 mcg OD: Rocaltrol (Roche) / Calcirol (Cadila) - if PTH elevated
• Calcium carbonate 500 mg with meals as phosphate binder: Shelcal 500 / Calcitas

6. Diabetic Neuropathy Management

What NOT to Prescribe in this Patient

HCV Note (Important)

• Referral to hepatologist for DAA therapy (e.g., Glecaprevir/Pibrentasvir - Maviret - safe in all GFR stages including dialysis)
• Standard isolation precautions during HD (dedicated machine if available per hospital policy)
• Liver function monitoring

Summary Fast-Relief Plan

Follow-up

• Review at 2 weeks - reassess itch VAS score, sleep quality
• Check serum calcium, phosphate, PTH, parathyroid status
• If pruritus persists despite above: consider Gabapentin 100 mg post-HD 3x/week (alternative) or refer for Difelikefalin if available in India (under access programs)
• Refer to hepatology for HCV treatment planning

Disclaimer: This is clinical decision-support for a registered medical professional. All prescriptions must be issued, verified, and signed by a licensed practitioner. Drug doses in CKD/MHD patients must be individualized based on dialysis adequacy (Kt/V), residual renal function, lab values, and patient tolerance.

Clinical Prescription: CKD on MHD, 66-year Male, T2DM, HCV+

Step 1: Symptom Interpretation

Step 2: Check and Optimise Dialysis Adequacy

• Kt/V ≥ 1.2 (poor dialysis is a major driver of pruritus)
• Serum Ca, PO4, PTH - treat hyperparathyroidism if present (worsens itch)
• Serum ferritin - iron deficiency worsens RLS; target ferritin 200-500 ng/mL in HD

Step 3: Prescription

Drug 1 - Pregabalin (First-line for CKD-aP + RLS + Neuropathic Pain)

Reference: Dermatology 5e (Elsevier): "Pregabalin (25-75 mg po post-hemodialysis)" - Grade 1 evidence for CKD-aP. Bradley & Daroff Neurology: alpha-2-delta ligands (gabapentin/pregabalin) are first-line for RLS in renal failure patients.

Drug 2 - Topical Emollient (Fastest Symptom Relief - Start Today)

Drug 3 - Hydroxyzine (Short-term Sleep Aid)

Drug 4 - Bowel Regularity (for Abdominal Tightness/Bloating)

Drug 5 - Methylcobalamin (Neuropathy Support)

Drug 6 - Calcium + PTH Management (If Not Already Prescribed)

Step 4: Summary Prescription Sheet

Rx - CKD/MHD Patient, 66M, T2DM, HCV+
Date: ___________

1. Tab Pregalin 25 mg (Pregabalin) - 1 tab after each dialysis (Mon/Wed/Fri or TTS)
                                   - 1 tab HS on non-dialysis days
   [Titrate to 50 mg post-HD after 2 weeks if needed]

2. Calmurid / Moisturex Soft Cream - Apply to abdomen + limbs BD-TDS, especially at HS

3. Tab Atarax 10 mg (Hydroxyzine) - 1 tab HS for 2 weeks only

4. Duphalac Syrup 15 mL (Lactulose) - Twice daily; adjust for stool frequency

5. Tab Mecobal 1500 mcg (Methylcobalamin) - 1 tab OD with food

6. Tab Shelcal 500 (Calcium Carbonate) - 1 tab with each meal TDS
   Cap Rocaltrol 0.25 mcg (Calcitriol) - 1 cap OD [adjust per PTH]

Step 5: What to AVOID in This Patient

Step 6: HCV Management (Separate Referral)

• Glecaprevir/Pibrentasvir (Maviret - AbbVie) - 3 tablets once daily x 8-12 weeks - safe in all GFR including dialysis, no dose adjustment
• Sofosbuvir-based regimens (Hepcinat, Ledifos) - avoid in eGFR <30; sofosbuvir metabolite accumulates
• Also ensure: Dedicated dialysis machine or strict isolation precautions per hospital policy; HCV RNA and LFT monitoring

Expected Timeline of Relief

Follow-up Plan

• 1 week: Assess itch VAS (0-10), sleep quality, sedation, fall risk
• 2 weeks: Titrate Pregabalin to 50 mg post-HD if needed; taper Atarax
• 1 month: Check Ca, PO4, PTH, serum ferritin, LFTs (HCV)
• If itch persists at 6 weeks: Add Montelukast 10 mg OD (Montair - Cipla) or refer for UVB phototherapy