Chronic kidney disease-associated pruritus (CKD-aP), long called uraemic pruritus, is itch caused by kidney failure rather than by a skin disease; the 2025 European S2k guideline on chronic pruritus describes it as frequent and difficult to treat, and cites Dialysis Outcomes and Practice Patterns Study data in which up to 30% of people on haemodialysis report it at moderate to severe intensity. The one Cochrane review of acupuncture for kidney disease symptoms, a 2016 review of acupuncture and related interventions for symptoms of CKD, found very low quality evidence of short-term effects of manual acupressure, used alongside usual care, on fatigue, depression, sleep and itch in people on haemodialysis. Cochrane's 2020 review of interventions for itch in advanced CKD left acupuncture out. Later reviews of needling, acupressure, ear acupressure and laser at points report lower itch scores, mostly from trials that compared the methods with conventional treatment or added them to it rather than testing them against a sham.
The Cochrane reviews
The 2016 review, by Kun Hyung Kim and colleagues, searched to January 2016 and included 24 randomised or quasi-randomised trials with 1,787 adults at CKD stage 3 to 5: 15 from mainland China, 7 from Taiwan and one each from Iran and Poland. The methods were manual acupuncture, acupressure, ear acupressure, transcutaneous electrical acupoint stimulation (current applied through skin pads at points), far-infrared radiation aimed at points, and indirect moxibustion. All trials were at high or unclear risk of bias for allocation concealment, and 17 measured outcomes for two months or less.
Against routine care, the review found that manual acupressure lowered depression scores by 4.3 points on the 63-point Beck Depression Inventory (3 trials, 128 people), fatigue by 1.2 points on the 10-point revised Piper Fatigue Scale (3 trials, 128 people) and sleep scores by 2.5 points on the 21-point Pittsburgh Sleep Quality Index (4 trials, 180 people); the review rated all three very low quality. Against sham acupressure, two trials of 137 people found no difference in sleep, and one trial of 70 people found none in fatigue or depression. The authors wrote that most trials comparing acupuncture-type methods with a sham found no difference between groups.
The itch trials were too few and too different to pool, so the review gave them no quality rating:
| Trial | Method | Comparison | People | Result as the review reports it |
|---|---|---|---|---|
| Che-Yi 2005 | Needling at one point | Sham needling 2 cm away | 40 | Itch 20 points lower on a 45-point score at 4 and 16 weeks |
| Hsu 2009 | Far-infrared at SP06 (Sanyinjiao) | Sham: plain adhesive tape | 41 | No difference at 8 weeks |
| Gao 2002 | Needling | Antihistamine with ointments | 68 | More responders with needling |
| Rui 2002 | Needling | Calcitriol | 150 | No difference at 16 weeks |
| Zhang 2011 | Needling added to haemodiafiltration | Haemodiafiltration alone | 30 | No difference at 12 weeks |
| Jedras 2003 | Acupressure | Control not specified | 60 | Lower itch scores at 6, 12 and 18 weeks |
The 2020 review, by Daniel Hercz, Simon Jiang and Angela Webster, searched to December 2019 and included 92 trials with 4,466 people at CKD stage 4 or 5. It set aside complementary methods such as acupuncture and massage on the ground that they could not easily be compared with the drug, topical, supplement, dialysis and light treatments it covered. It found high-certainty evidence that gabapentin and pregabalin reduced itch against placebo, and that kappa opioid agonists such as nalfurafine reduced it less.
A 2023 Cochrane review of interventions for fatigue in people on dialysis, by Patrizia Natale and colleagues, searched to October 2022 and included 94 studies with 8,191 people. Against placebo or control, acupressure may reduce fatigue in haemodialysis (6 studies, 459 people, standardised mean difference −0.64, 95% CI −1.03 to −0.25, I² 75%; low certainty), the same rating it gave exercise, aromatherapy and massage. A standardised mean difference (SMD) expresses the gap between groups in units of the spread of scores; I² measures how much the trials disagree beyond chance.
A 2019 Cochrane review of interventions for sleep in CKD, also by Natale and colleagues, searched to October 2018 and included 67 studies with 3,427 people. Against no acupressure, acupressure probably shortened the time taken to fall asleep and lengthened sleep (3 studies, 173 people; moderate certainty) and probably reduced fatigue (2 studies, 137 people; moderate certainty), while its effect on overall sleep quality was uncertain (very low certainty). The authors wrote that the effects of acupressure were not confirmed in the studies that used sham acupressure as the control.
Later reviews of itch
None of the reviews below is a Cochrane review. Most pool trials against sham or placebo with trials against drugs or dialysis alone; where a review kept them apart, the table says so.
| Review | Methods | Trials and people | Comparison | What the authors report | Certainty |
|---|---|---|---|---|---|
| Badiee Aval 2018 | Acupuncture, acupressure | 6 trials in 5 articles; 3 pooled | Not stated in the abstract | Itch 2 points lower on a visual analogue scale in the 3 acupressure trials | Not stated in the abstract |
| Yeam 2021 | 21 complementary treatments, among them acupuncture (5 trials) and acupressure (3) | 34 trials | Not stated in the abstract | Acupuncture, acupressure and topical capsaicin had the largest body of evidence for efficacy; acupuncture brought soreness, bleeding and haematoma | Not graded |
| Lu 2022, searched to September 2022 | Acupuncture, ear acupressure, point massage, injection, heat, patches, electrical stimulation | 40 trials, 2,735 people | Placebo and conventional treatment, pooled together | Visual analogue scale 1.6 points lower across 15 trials, with I² 86%; higher effective rates for acupuncture, ear acupressure and injection with massage | GRADE tool applied; no rating in the main text |
| Zhang 2023, searched to December 2021 | Acupuncture | 7 trials, 504 people | Conventional treatment, with subgroups for drugs and for dialysis alone | More responders than conventional treatment (risk ratio 1.28); no difference from drugs (1.20, 95% CI 0.98 to 1.47); none reported recurrence | Not stated in the abstract |
| Liu 2024 | Acupuncture, for kidney function and symptoms | 24 trials, 1,494 people; 6 trials of 226 people for itch | Sham or usual care, pooled | Itch SMD −2.20 (95% CI −3.84 to −0.57), I² 91%; the prediction interval crossed zero and the sample fell short of the size trial sequential analysis required | GRADE very low |
| Hsieh 2024, searched to September 2023 | Point stimulation without needles | 9 studies, 597 people | Not stated in the abstract | Itch effect size −1.30 (95% CI −1.67 to −0.93) | Not stated in the abstract |
| Lu 2024, network meta-analysis | Point stimulation methods compared with each other | 27 trials, 1,969 people | Conventional treatment and combinations | Acupuncture added to conventional treatment ranked first on visual analogue scale scores (mean difference −2.63) | Not stated in the abstract |
| He 2026, network meta-analysis, searched to December 2025 | 12 complementary methods, acupuncture among them | 29 trials, 1,968 people | Control groups; 9 high-risk trials excluded | Acupuncture SMD −2.12 against control; with the high-risk trials put back, the result was no longer significant | CINeMA low or very low for all but aromatherapy |
A network meta-analysis compares several treatments at once, including pairs no trial tested head to head. Liu and colleagues, at Longhua Hospital in Shanghai, judged every trial they included at high risk of bias, and noted that the trials run in China mostly reported positive results without detailed reporting. He and colleagues, at Sichuan University in Chengdu, rated herbal medicinal baths as the method whose effect held when the high-risk trials were added back. Lu 2022, by Ping-Hsun Lu and colleagues at Taipei Tzu Chi Hospital, is the review both the KDIGO and the European guidelines below cite.
Later reviews of fatigue and sleep
- Fatigue, acupressure, 2024. Chang and colleagues, searching to November 2022, pooled 8 trials with 725 people on haemodialysis and found less general fatigue with acupressure than in control groups (Hedges' g −0.78, 95% CI −1.09 to −0.48), with a larger effect when trials included the point Shenmen.
- Fatigue, acupressure, 2025. Tülüce and colleagues pooled 5 studies with 475 people, both randomised and non-randomised: Piper Fatigue Scale scores fell with acupressure, and visual analogue fatigue scores did not differ.
- Fatigue, all non-drug methods, 2026. A network meta-analysis by Li and colleagues, searching to December 2025, compared 8 interventions across 39 trials and 2,943 people. Point stimulation was associated with lower fatigue than usual care, ranked below brief behavioural intervention and mind-body therapy, with low or very low confidence.
- Insomnia, ear acupressure, 2021. Pei and colleagues pooled 8 trials with 618 people: after 8 weeks, sleep scores did not differ from estazolam, a sleeping drug, while narrative comparisons reported higher response rates than with sham ear acupressure and with mental health education.
- Sleep, acupressure, 2026. Wang and colleagues, at Chengdu University of Traditional Chinese Medicine, searched to March 2025 and included 27 studies with 2,037 people. Against a waiting list, acupressure lowered Pittsburgh scores by 3.5 points (moderate certainty); against medication the evidence was low to very low and showed little difference. None of the trials used a validated sham.
Trials with a sham
- Needling, 2005. Che-Yi and colleagues randomised 40 people on haemodialysis with itch that had not responded to other treatment. One group had needling on one side at
LI11(Quchi) three times a week for a month; the other had needling at a non-point 2 cm to the side of it. Itch scores went from 38.3 to 17.3 after treatment and 16.5 at 3 months in the point group, and from 38.3 to 37.5 and 37.1 in the sham group. Laboratory tests did not differ. - Acupressure for sleep, 2016. Arab and colleagues, in Iran, randomised 108 people on haemodialysis to true acupressure, placebo acupressure or no treatment, three times a week for 4 weeks during dialysis. Pittsburgh scores fell from 11.9 to 6.2 with true acupressure, from 11.3 to 10.6 with placebo and from 10.9 to 10.7 with no treatment.
- Laser acupuncture, 2026. Juan and colleagues, at Dalin Tzu Chi Hospital and China Medical University in Taiwan, randomised 60 people on haemodialysis to laser at
LI11,SP10(Xuehai) and Baichongwo (EX-LE3), or to sham laser, three times a week for 4 weeks, in a double-blind design. Scores on the 5-D itch scale were 6.9 points lower with laser than with sham (95% CI −8.4 to −5.4), and skin-related quality of life improved; no adverse events occurred.
Each of these is a single-centre trial of 108 people or fewer. Sham acupuncture sets out what a needle at a non-point, a placebo pressure and a switched-off laser can and cannot rule out, and Acupressure describes the method most of the dialysis trials used.
For low blood pressure during dialysis, a 2024 crossover pilot by Liu and colleagues at Keelung Chang Gung Memorial Hospital in Taiwan added electronic moxibustion, an infrared heating pad placed over CV04 (Guanyuan) for the second hour of dialysis, to 12 sessions for each of 32 people, and compared it with dialysis alone. Fatigue scores improved, while the number of hypotensive episodes and the fall in blood pressure did not change. Moxibustion describes the method.
What guidelines say
The KDIGO 2024 guideline on the evaluation and management of CKD, from Kidney Disease: Improving Global Outcomes and published in April 2024, includes a table of management strategies for common symptoms, attached to a practice point on symptom management. The table lists acupuncture for uraemic pruritus, citing Lu 2022, beside gabapentinoids, ultraviolet B and topical agents; acupuncture with exercise for depression, citing the 2016 Cochrane review; and complementary therapies such as acupuncture for pain. A 2023 KDIGO Controversies Conference report on symptoms in dialysis, a consensus statement rather than a guideline, cites the same Cochrane review for limited evidence of short-term benefit from manual acupressure for fatigue and depression, and names one treatment for itch, the drug difelikefalin.
The European S2k guideline on chronic pruritus, published in August 2025 by Elke Weisshaar and colleagues as an update of the 2019 edition, lists acupuncture at LI11, from Che-Yi 2005, among CKD-aP treatments with effects in controlled studies. Its section on physical treatments says the antipruritic evidence for acupuncture is much weaker than its evidence for pain, and its expert recommendation is that no recommendation can be made on physical treatments for chronic pruritus. A 2024 Spanish consensus document on CKD-aP in haemodialysis recommends general skin care, adequate dialysis and mineral control for mild itch, difelikefalin for moderate to severe itch and phototherapy for refractory itch, and does not mention acupuncture. NICE guideline NG107 on renal replacement therapy and conservative management, from October 2018, lists itching, fatigue and insomnia among the symptoms to recognise and ask about, and does not mention acupuncture. Clinical guidelines lists the guidelines AcuiQ tracks.
What the reviews could not settle
Whether needling or pressure at points differs from a sham for itch rests on two small single-centre trials, Che-Yi 2005 and Juan 2026, and the 2016 Cochrane review counted a third, Hsu 2009, that found no difference. The meta-analyses since pool sham-controlled trials with trials against drugs or dialysis alone, and the two that tested their own robustness, Liu 2024 and He 2026, found the result for acupuncture fragile: a prediction interval crossing zero in one, and loss of significance when high-risk trials were added back in the other. Most trials ran for weeks rather than months, and adverse events were rarely reported, which left the 2016 Cochrane authors unable to judge safety in people with CKD.
The Cochrane itch review, whose strongest evidence is for gabapentin and pregabalin, excluded acupuncture, so no Cochrane analysis sets the two side by side. For fatigue and sleep, the pooled acupressure comparisons were against waiting lists, usual care or medication, and the sham comparisons in the 2016 and 2019 Cochrane reviews did not confirm the effects. Cochrane has published no update of the 2016 review. A 2024 protocol by Gao and colleagues set out a systematic review of acupuncture for CKD-aP that would include sham, no-treatment and drug comparisons; AcuiQ found no published result from it in PubMed by October 2026. Atopic dermatitis and urticaria covers itch from skin disease, and Insomnia covers sleep trials outside dialysis.
AcuiQ's pages on uraemic pruritus, itch in dialysis, fatigue in haemodialysis, haemodialysis complications and chronic kidney disease list the protocols individual studies prescribed, each with its citation.