Pain Management in CKD: A Guide for Nephrology Providers

Koncicki, Holly M.; Unruh, Mark; Schell, Jane O.

doi:10.1053/j.ajkd.2016.08.039

Cited by 66 publications

(84 citation statements)

References 47 publications

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“…In particular, both are metabolized to morphine-6-glucuronide, which is more potent than morphine itself, equilibrates slowly across the blood-brain barrier, and may result in prolonged sedation (4,43,45). Guidelines recommend that hydrocodone, oxycodone, and tramadol be used with caution given that their pharmacokinetic profile has not been well established in the setting of kidney failure (4,8,9,46,47). Fentanyl and methadone are thought to be relatively safe, because they are converted to inactive metabolites, but they require management and careful monitoring by experienced practitioners (44,48).…”

Section: Discussionmentioning

confidence: 99%

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Ishida

McCulloch

Steinman

et al. 2018

CJASN

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Background and objectives Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.Design, setting, participants, & measurements Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (.60 mg, #60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).Results The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.Conclusions Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

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Section: Discussionmentioning

confidence: 99%

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Ishida

McCulloch

Steinman

et al. 2018

CJASN

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“…Assessment of pain for its severity, location, character, and duration is the initial step in the management. Multidisciplinary approach using assessment tools and personal interviews aid proper and thorough workup for pain . Eliciting history thoroughly gives complete information with regards to pain and a mnemonic described by Barnard et al “PQRST” aids this process where P stands for precipitating/alleviating factors, Q for quality of pain, R for radiation of pain, S for site and severity of pain, and T for timing/onset of pain, constant/intermittent pain .…”

Section: Pain Assessment In Esrdmentioning

confidence: 99%

“…This follows a pain specialist/palliative care consultation, patient and family counseling, discussion about treatment options and correction of reversible causes . Finally, decision has to be made whether patient requires nonpharmacological or pharmacological management …”

Section: Management Of Pain In Esrdmentioning

confidence: 99%

“…This method has been validated for use in ESRD patients and guide nephrologists in the introduction and acceleration of analgesia (Figure ) . The initial step is to start with non‐opioid drug and then to escalate to the next level with addition of weak opioid in step 2 and strong opioid in step 3 if optimal pain control is not achieved . Adjuvant medication can be added at any stage wherever necessary…”

Section: Management Of Pain In Esrdmentioning

confidence: 99%

“…Use of NSAID's in ESRD population has not been extensively investigated and the available data is insufficient. However, acetaminophen is the non‐opioid drug of choice and NSAID's can be used in ESRD patients with close monitoring for side effects such as gastrointestinal bleeding, uncontrolled hypertension, and hyperkalemia . Neuropathic pains can be effectively treated with gabapentin, pregabalin, and tricyclic antidepressants .…”

Section: Management Of Pain In Esrdmentioning

confidence: 99%

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Management of pain in end‐stage renal disease patients: Short review

Raina

Krishnappa

Gupta

2017

Hemodialysis International

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Pain management in end stage renal disease (ESRD) patients is a complex and challenging task to accomplish, and effective pain and symptom control improves quality of life. Pain is prevalent in more than 50% of hemodialysis patients and up to 75% of these patients are treated ineffectively due to its poor recognition by providers. A good history for PQRST factors and intensity assessment using visual analog scale are the initial steps in the management of pain followed by involvement of palliative care, patient and family counseling, discussion of treatment options, and correction of reversible causes. First line should be conservative management such as exercise, massage, heat/cold therapy, acupuncture, meditation, distraction, music therapy, and cognitive behavioral therapy. Analgesics are introduced according to WHO guidelines (by the mouth, by the clock, by the ladder, for the individual, and attention to detail) using three-step analgesic ladder model. Neuropathic pain can be controlled by gabapentin and pregabalin. Substitution/addition of opioid analgesics are indicated if pain control is not optimal. Commonly used opioids in ESRD patients are tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Methadone, fentanyl, and buprenorphine are the ideal analgesics in ESRD. However, complex pain syndrome requires multidrug analgesic regimen comprising opioids, non-opioids, and adjuvant medication, which should be individualized to the patient to achieve adequate pain control.

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Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes

et al. 2020

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IMPORTANCE Pain is a common symptom among patients with kidney disease. However, little is known about use of analgesics among patients aged 65 years or older with chronic kidney disease (CKD) who do not receive dialysis treatment. OBJECTIVE To assess national trends and geographic variations in use of opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults with and without CKD in the US (2006-2015) and examine associations between use of opioids and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the 5% Medicare claims data (2005-2015) to select 10 retrospective annual cohorts of Medicare Part D beneficiaries aged 65 years and older from 2006 to 2015 and a retrospective longitudinal cohort. Data were analyzed in August 2019. EXPOSURES CKD status and other comorbidities identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. MAIN OUTCOMES AND MEASURES Analgesic use was measured by overall use (proportion of ever used opioids/NSAIDs), long-term use (prescribed >90 days), and cumulative use (total annual days' supply). Patient outcomes included progression to end-stage kidney disease (ESKD) and all-cause mortality. RESULTS A total of 6 260 454 beneficiaries (9.6% identified with CKD by claims) were selected in the annual cohorts and 649 339 beneficiaries (8.3% identified with CKD) were selected in the longitudinal cohort. There was significant growth in opioid use (31.2%-42.4%) and NSAID use (10.7%-16.6%) among patients aged 65 years and older with CKD from 2006 to 2015. Long-term use of opioids increased during 2006 to 2014 (25.8%-36.7%) but decreased through 2015 at 35.6%, while long-term use of NSAIDs remained stable. Opioid use was higher in patients with CKD, particularly CKD stages 4 to 5

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Pain Management in CKD: A Guide for Nephrology Providers

Cited by 66 publications

References 47 publications

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Management of pain in end‐stage renal disease patients: Short review

Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes

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