Dr. Preet very grateful for his contribution.

The question should need to be clarified, that  is to say : has the itching present during all the  days, or this itching is appearing only during the dialysis session? It should also to be pointed out t if this itching compared associated to a sudden or recent modification of the ratio calcium/phosphate or or associated to a programmed reduction of the total water, and particularly in this case, it could be of interest to know if the itching appears during the hemodialysis, because in many cases the itching could simply du to a relatively  excessive dehydration , this not necessarily associated to the instability of blood pressure. This event could  usefully be investigated by a bioimpedance analysis .

Yes Doctor , I appreciate your help, the itching appears during the hemodialysis, It is also resistant to the usual medication. Thanks

Pruritus is a major issue in dialysis patients and ignored by many treating physicians.  

Clearly, the whole skin seems to be affected and evidence of active inflammation has been documented likely related to some unidentified toxins.

Recent article on KI by Mettang and Kremer nicely reviewed the available data. The management of uremic pruritus is limited though I have summarized in the link below a potential approach.

http://renalfellow.blogspot.com/2015/04/uremic-pruritis-algorithm-for-management.html

Dear Dr Rodriguez, thank you for your kind reply. There is non doubt that according to what said and shown by Dr Rella, the itching is a very common  symptom of the uremic disease, even in a not irrelevant number of patients the present dialysis strategies and techniques, as hemodiafiitration and hemofiltration on line obtained the reduction of this problem. It is certainly possible that in a patient suffering habitually the itching by uremia ,this could be triggered by the hemodialysis  session, because the relative skin dehydration. But your quoted case seems to be different because the itching appears ONLY during the treatment, being usually  absent ,if  I have correctly understood. Consequently I thought that possibly the itching is triggered by the further loss of water in patient probably suffering of a marginal dehydration , this driving to an increasing of the skin  dryness during the treatment, a condition able to induce very frequently insistent itching episodes also in healthy persons. This condition, as mentioned in the first reply. could be appreciated by defining the amount of the body water according to the different location respect to the total body water, as intracellular and extracellular water, this quite sufficiently available using the multi-frequency bioimpedance, particularly performing this text before the dialysis starting and  after the itching appearance. and comparing the eventual difference of the body water. It is to point out that the noted difference could be only apparent, due only to the modified skin transmittance to the different skin dryness conditions, but also in this case the difference could all the same shows that the mutation could be responsible of the itching.. Obviously my suggestions have to be considered only as a working hypothesis, because  in Medicine all is hypothesis until a certain proof     

Dr Giancarlo, I thank you very much for your kindness for your reply.

Be sure your patient is not allergic to the agent being used to clean the skin with before getting cannulated.  Also check if they have an allergy to the tape being used to secure the needles and lines.

After eradication of other causes try intensive hemodialysis, emulients, gabapentin, tacrolimus-ointment, naltrexon, kappa opioid agonist (nalfurafine), consultation to dermatology. Sometimes low dose short term steroid treatment may be effective. 

Dr. Gultekin, I very much like your answer.

Itching that occurs ONLY during hemodialysis may also be due to an allergy to some part of the dialysis circuit, including the fibers of the dialyzer, the potting material, or possibly the ethylene chloride gas used to sterilize a new dialyzer (though this more typically causes headaches and other symptoms).  Are dialyzers reused, or is it a new one each time?  If a new dialyzer is used, are the symptoms any better or worse?  Running an extra bag of saline through the dialyzer or switching brands may be worth trying.

The causes of itching added by Dori Shatell could undoubtedly be a possibility, but at present the new used not cellulosic  fibers  are considered free of this undesired effect. I can't add comments on the effects due to the reuse  of the dialyzer, because absolutely forbidden in Italy, and in any case never utilized in my center. An adequate elevated saline washing of the dialyzer , that is to say of all the dialyzing system, is without doubts a very  advisable method.

I also know of at least one patient who is allergic to chromium in the dialysis needles.  Unfortunately, there are no chromium-free options in the US, and she really suffers.

If the problem is limited to hemodialysis then our esteemed colleagues have provided useful suggestions. I would suggest to ensure higher kt/v target. This again will be a daunting task as such patients do not tolerate and sign off early. Additional possibilities to consider will be histamine / mast cell disorders. Look for dermatographism and response to H2 receptor blocker in combination with H1 blocker. Wishing you success in managing this difficult case!

It is not often but please keep in mind  that it might be heparin side effect

I think that the itching in hemodialyzed patients is linked to many different causes, probably some times different within the patents, as well shown in the past interventions.  It  seems to me that it could be interesting to compare the incidence of itching between the above mentioned patients and the patents undergoing a successful peritoneal dialysis treatment (PD). In my experience this very nagging event has  really very  low incidence in PD. Taking into account the most fundamental difference of  molecules and  water removal  between the two treatments, undoubtedly PD patients do not undergo the risk of excessive dehydration during the treatment, a very possible cause of itching,  having eventually the risk of over hydration, and many substances considered possible causes  of itching attain a better  removal with PD than HD. This seems more  shown taking into account that also the current techniques of HDF and on line HF show better general results than standard HD, including itching  incidence. The further difference, between PD and extracorporeal treatments, and I think more important ,  is that PD is a continuous or in case of APD, sub continuous  treatment. versus the standard three treatments / week of HD. strategies