Successful Use of Difelikefalin in Severe Chronic Kidney Disease–Associated Pruritus in a Patient With Complex Etiological Contributors: A Case Report

Introduction: Chronic kidney disease–associated pruritus (CKD‐aP) is a frequently experienced, unpleasant skin condition. Difelikefalin, an agonist of the kappa opioid receptor, is indicated for the treatment of moderate‐to‐severe CKD‐aP in adult patients on hemodialysis. Reports of the effectiveness of difelikefalin in complex patient cases encountered in routine clinical practice are rare.

Case Presentation: The presented patient had a complex interplay of morbidities, most notably diabetes mellitus type 2, tertiary hyperparathyroidism, end‐stage renal disease (ESRD), and CKD‐associated mineral bone disease (CKD‐MBD), all of which are associated with the development and severity of CKD‐aP. The patient’s CKD‐aP was resistant to H ₁ ‐receptor antagonists and gabapentin and showed no improvement after parathyroidectomy. Treatment with difelikefalin rapidly and sustainably improved symptoms, with a brief recurrence of itching toward the end of each long interdialytic interval. Apart from a short episode of vertigo at the initiation of treatment, no adverse events were observed over the long duration of treatment (currently more than 2.5 years).

Conclusion: In a patient with longstanding conditions and multiple comorbidities, difelikefalin showed sustained effectiveness against H ₁ ‐receptor antagonist– and gabapentin–resistant CKD‐aP. Difelikefalin was well tolerated over the long term.