Effect of Sambucus ebulus topical preparation on uremic pruritus

Uremic pruritus or chronic kidney disease-associated pruritus (CKD-aP) is a common and distressing symptom in patients with end stage renal disease (ESRD) and receiving either peritoneal dialysis or hemodialysis. Although prevalence of pruritus has declined recently by improved hemodialysis techniques, this symptom remains a major and frequent problem in these patients; and more than 40% of patients undergoing hemodialysis suffer from it (1). The most common areas affected are the back, arms, legs and face (2, 3). In general Itching was characterized as worse during dialysis, immediately after that and at night than during the day. These prurituses in combination with other symptoms decreases quality of life and make patient depressed (4). The pathogenesis of uremic pruritus is obscure, Its believed that multi substances cause this problem and it is not dependent on just one factor; some of these risk factors are, parathormone, histamine, divalent ions such as calcium, phosphorus and magnesium, male gender, high pre-dialysis level of BUN, high levels of b2microglobulin and dialysis filter (1,4,5).There is not any definite treatment; and No drugs have been approved for this problem by the U.S. Food and Drug Administration. Some common treatments such as antihistamine, topical steroids, emollients, and phototherapy (UVB) are available but have not been investigated rigorously (4). Sambucus ebulus (Caprifoliaceae) or Dwarf elder is grown naturally in southern and central Europe and southwest of Asia especially Iran and Iraq. It is known as „Palemʼ or „Aghtii‟ in Iran and distributed in Northern coast of Caspian Sea like Mazandaran province (6). Flavonoids, phenols, steroids, tannins, sambunigrin, glycosides, cardiac glycosides, caffeic acid derivatives, chlorogenic acid, ursolic acid, ebulitins, ebulin and volatile substances of these species were previously reported (6-8). In traditional medicine, extracts of different parts of the herb like leaves, rhizome, root and fruitsused in treating some inflammatory cases such as, bee and nettle bites, arthritis and sore-throat, burns and infectious wounds, edema, eczema, urticaria, hemorrhoids, rheumatism (6,7,9). In other studies some effects of S. ebulus were investigated Anti-inflammatory and antinociceptive (10), antioxidant (11,12) anticancer (13) and antibacterial (14) effects. Since there is no specific treatment, moreover because of current treatments issues and according to effects and properties of S. Abstract Uremic pruritus is a common and distressing symptom that affects more than 40% of patients undergoing hemodialysis. Several medications as well as topical preparation have been used for relief this condition. Sambucus ebulus has been shown antiinflammatory and wound healing effects. In this research, the antipruritic effect of S. ebulus fruit extract was evaluated on patients with uremic pruritus. S. ebulus fruits were collected from Sari suburb, Iran. Fruits were dried at room temperature and several fractions of extract were prepared. After formulating suitable gel (2%) a randomized, single blind, placebo-controlled clinical trial was performed in 78 patients (40 patients received S. ebulus topical gel 2% and 38 patients received placebo gel) for 8 weeks and the changes in hyperuremic induced pruritus severity were evaluated. Sixty one patients completed the study. The Pruritus severity index was reduced in both groups after 8 weeks‟ treatment. S. ebulus topical gel showed more effect than placebo, but this difference was not statistically significant. The results showed that S. ebulus topical gel can reduce uremic pruritus severity, and more study with higher extract concentration or more cases is proposed.