# Reduction of pruritus and depression using longitudinal patient-reported outcome measures in hemodialysis: a quality improvement project

## TL;DR

Using repeated patient reports in hemodialysis improved detection and treatment of itching and depression, enhancing care and patient-nurse agreement.

## Contribution

A quality improvement project using PROMs in a PDAS framework to systematically address CKD-aP and depression in HD patients.

## Key findings

- 32% of patients vs. 9% of nurses reported pruritus at baseline, with improved agreement after PROMs implementation.
- Difelikefalin reduced itch severity by 3 points (p < 0.001) in 16 patients, and psychiatric referrals reduced depression scores by 4.5 points (p = 0.015).
- Patient and nurse satisfaction with assessments increased from 38% to 67% and 55% to 75%, respectively.

## Abstract

Chronic kidney disease–associated pruritus (CKD-aP) and depression are common but often underrecognized and undertreated in hemodialysis (HD) patients, lowering quality of life and worsening outcomes.

To evaluate whether the systematic, repeated collection of patient-reported outcome measures (PROMs) integrated into a Plan-Do-Act-Study (PDAS) framework could enhance recognition of CKD-aP and depression and guide treatment.

127 adult patients receiving thrice-weekly in-center HD were included. PROMs were captured electronically at predefined phases.

During Adjustment phases, individualized symptom reports were reviewed by physicians, prompting initiation of difelikefalin for CKD-aP or referral to psychiatric care for depressive symptoms.

Changes in itch (Worst-Itch Numerical Rating Scale, WI-NRS) and depression (Patient Health Questionnaire-9, PHQ-9) and concordance between patients and nurses.

At baseline, 32% of patients versus 9% of nurses reported pruritus (κ = 0.18) and 27% versus 6% reported depression (κ = 0.19). Following PROM-guided interventions, 16 patients initiated difelikefalin (median WI-NRS reduction of 3 points, p < 0.001) and five were referred for psychiatric care (median PHQ-9 reduction of 4.5 points, p = 0.015). Patient–nurse agreement improved to κ = 0.66 for pruritus and κ = 0.65 for depression at study end. Ratings of assessment adequacy rose from 38% to 67% among patients and from 55% to 75% among nurses.

Routine, repeated PROMs markedly improved recognition of CKD-aP and depression, enabled targeted therapy with meaningful relief, and strengthened patient-staff alignment. This PDAS-based strategy supports KDIGO guidance and merits broader adoption to advance patient-centered dialysis care.

The online version contains supplementary material available at 10.1186/s41687-026-01003-6.