Pain Management in Pediatric Chronic Kidney Disease

Abstract

Pain is a common problem in children with chronic kidney disease (CKD); however, limited data exist regarding its management. Although most pain is managed pharmacologically, in some instances non-pharmacologic management can aid in safely ameliorating discomfort. Because of the accumulation of toxic metabolites, many common pain medications have adverse effects on kidney function or altered pharmacokinetics in the setting of CKD. Decreased clearance impacts safe dosing of analgesics. The pain management of patients on renal replacement therapy requires an understanding of drug clearance due to the different modalities of dialysis. This educational review highlights pain medications that are safe, albeit often with adjusted dosing, as well as drugs best avoided in the management of pediatric kidney disease. Acetaminophen should be used as a first-line therapy for pain management in children with CKD. Opioids may be added to control moderate to severe pain. Although data are currently lacking, buprenorphine holds promise as a potentially useful drug for the treatment of pain in pediatric patients with CKD. The addition of adjuvant pain medications and non-pharmacologic therapies maybe also be helpful. Despite these options, pain often remains difficult to treat in children with CKD.

<p>Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists</p>

“… 46 Therefore, an analgesic approach with morphine or codeine is not specifically recommended in patients with renal impairment. Based on this first evaluation, it is evident that the WHO analgesic ladder needs to be adapted for CKD patients, 9 , 44 since morphine and codeine are not recommended for subjects with GFR value lower than 60 mL/min per 1.73 m2, 34 , 41 , 47 and should not be used at all in ESRD subjects. 28 , 48 , 49 …”

“… 44 , 54 Currently the use of tramadol for pain management in children younger than 12 years is contraindicated. 9 In contrast, elderly patients with GFR > 30 mL/min per 1.73 m 2 can assume tramadol and do not need dosage adjustments, 55 even though those >75 years old should not exceed the dosage of 300 mg; whereas patients with a creatinine clearance <30 mL/min should be treated using the dose of 50–100 mg tramadol, increasing dosing interval with a maximum daily dose of 200 mg. 7 , 55 HD significantly removes tramadol, thus its administration should be given after each HD session. 7 , 56 Two case reports have been published on tramadol-induced respiratory depression in HD patients, both caused by accidental overdoses.…”

“…Finally, insufficient evidence exists on the safety and efficacy of opioids in pediatric CKD patients. 9 In general, most opioids are only prescribed off-label in the pediatric setting and approved molecules vary in Europe and in the US. In patients, younger than 12 years old, codeine prescription has been recently restricted by FDA and EMA; while tramadol is currently contraindicated only in the US, while in Europe it is approved by EMA in children older than 1 year.…”

“…5 – 8 Nevertheless, the incidence of CKD in children is not negligible. 9 The top causes of pediatric CKD are generally represented by congenital abnormalities of kidneys and urinary tract, 10 , 11 even though recent evidence have also identified obesity as a relevant risk factor for CKD development in adolescents. 12 , 13 Moreover, among cancer patients, renal impairment is quite common and is related to the cancer treatments and/or to the disease itself.…”

“… 7 When pain intensity requires a strong analgesic, opioids are indicated in the pharmacological recommendations for pain management in CKD adults, as a part of the analgesic therapeutic plan. 7 , 9 , 28 However, in these specific patients, opioids may not exhibit the same safety profile as in the general population; therefore, there is still a lack of clinical consensus about their appropriate use in CKD subjects. Moreover, most of non-pain specialists may be unfamiliar with this kind of drugs and pain specialists are only occasionally involved in the management of these patients.…”