Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

Abstract

Background: Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. Methods: We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other nonopiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. Results: Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). Conclusions: In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.

Pain after Arteriovenous Access Creation

“…Concern about procedural pain can cause some patients to miss follow-up appointments for regular maintenance of the dialysis access 12 . A cohort study of Veterans Affairs Healthcare System patients demonstrated an increased risk of mortality for patients with pre-ESRD using chronic opiates or pregabalin/gabapentin; secondary analysis of this study also found that patients with ESRD receiving greater than one opiate prescription per year had associated higher mortality 13 . Considering ongoing opiate misuse within the United States and data affirming higher mortality with chronic opiate use, it is imperative to begin using methods to decrease opiate-based analgesia.…”

“…12 A cohort study of Veterans Affairs Healthcare System patients demonstrated an increased risk of mortality for patients with pre-ESRD using chronic opiates or pregabalin/gabapentin; secondary analysis of this study also found that patients with ESRD receiving greater than one opiate prescription per year had associated higher mortality. 13 Considering ongoing opiate misuse within the United States and data affirming higher mortality with chronic opiate use, it is imperative to begin using methods to decrease opiate-based analgesia. The results from this study demonstrate that use of RA for the creation of hemodialysis access results in fewer MMEs taken by patients postoperatively.…”