Novel treatment protocol for ameliorating refractory, chronic pain in patients with autosomal dominant polycystic kidney disease

Abstract

Autosomal dominant polycystic kidney disease (ADPKD) patients can suffer from chronic pain that can be refractory to conventional treatment, resulting in a wish for nephrectomy. This study aimed to evaluate the effect of a multidisciplinary treatment protocol with sequential nerve blocks on pain relief in ADPKD patients with refractory chronic pain. As a first step a diagnostic, temporary celiac plexus block with local anesthetics was performed. If substantial pain relief was obtained, the assumption was that pain was relayed via the celiac plexus and major splanchnic nerves. When pain recurred, patients were then scheduled for a major splanchnic nerve block with radiofrequency ablation. In cases with no pain relief, it was assumed that pain was relayed via the aortico-renal plexus, and catheter-based renal denervation was performed. Sixty patients were referred, of which 44 were eligible. In 36 patients the diagnostic celiac plexus block resulted in substantial pain relief with a change in the median visual analogue scale (VAS) score pre-post intervention of 50/100. Of these patients, 23 received a major splanchnic nerve block because pain recurred, with a change in median VAS pre-post block of 53/100. In 8 patients without pain relief after the diagnostic block, renal denervation was performed in 5, with a borderline significant change in the median VAS pre-post intervention of 20/100. After a median follow-up of 12 months, 81.8% of the patients experienced a sustained improvement in pain intensity, indicating that our treatment protocol is effective in obtaining pain relief in ADPKD patients with refractory chronic pain.

Multidisciplinary management of chronic refractory pain in autosomal dominant polycystic kidney disease

“…If pain relief is observed after the splanchnic RFA block but recurred after a significant period of time, a splanchnic block is repeated. If no substantial pain relief is seen after the diagnostic celiac plexus or splanchnic nerve block, patients underwent catheter-based renal denervation [ 11 , 14 , 15 ]. Of note, renal denervation was not available for patients from 2016 to 2021 because ablation catheters were no longer available due to the disappointing results of the Simplicity trials [ 18 ].…”

“…In our polycystic kidney disease (PKD) expertise center, a novel multidisciplinary treatment protocol was introduced in 2013 in which we aim to spare kidney function by avoiding or postponing nephrectomy by applying sequential nerve blocks (Fig. 1 ) [ 8 , 11 ].…”

“…Our initial results with this protocol were promising. In 2017 we reported that after a median follow-up of 12 months, 81.8% of the 44 patients who received nerve blocks experienced a sustained improvement in pain intensity, indicating that our treatment protocol was effective in providing pain relief in ADPKD patients with chronic refractory pain [ 11 ]. However, not all patients were eligible to undergo a nerve block.…”

The mechanism of Autosomal Dominant Polycystic Kidney Disease (ADPKD)

“…Under this situation, analgesics can be adapted, including acetaminophen and opioid. If the glomerular filtration rate (GFR) of the patient is normal, short-term nonsteroidal anti-inflammatory drugs can be used [8]. Traction of the renal pedicle, oppression of structure nearby, or abnormal activation of the sensory or autonomic nervous system can lead to chronic pain.…”

European ADPKD Forum multidisciplinary position statement on autosomal dominant polycystic kidney disease care

“…involving radiologists, physical therapists and pain specialists [ 1 ]. A multidisciplinary, stepwise protocol in the Netherlands has recently shown promising results [ 48 ].…”