Pain management in polycystic kidney disease

Abstract

Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be "cured," an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.

Management of Pain in Autosomal Dominant Polycystic Kidney Disease and Anatomy of Renal Innervation

“…3 Chronic pain due to cyst formation may also present as a persistent discomfort localized to a small area that is aggravated by standing or walking. 6 Many patients also experience a sudden onset of pain while performing physical activities. 4 Renal mechanosensory nerves, which respond to changes in pressure, and renal chemosensory nerves, which respond to ischemia or alterations of the renal interstitial fluid, have been identified in the kidney.…”

“…5 Pain presentation based on cyst size can be variable as some patients with smaller cysts can experience severe pain, while other patients with larger cysts remain pain free. 6 Renal associated pain in ADPKD can present in various ways, making it difficult to clinically confirm its etiology. Clinical findings often need to be correlated to diagnostic images to confirm the source of the pain.…”

“…An observation was made that patients with ADPKD have lumbodorsal muscle hypertrophy, giving further evidence of mechanical changes that can occur in patients with ADPKD. 6 …”

“…5 Compression on the stomach and duodenum can result in decreased appetite and abdominal fullness, leading to a risk of malnutrition. 5,6 Chronic Liver Pain in ADPKD Hepatic cysts in ADPKD can be identified in up to 94% of patients ages 35-46 years through magnetic resonance imaging. The cyst volume and incidence increases with age as the disease progresses.…”

“…Compared to pain from renal cysts, liver cysts can cause pain that is more severe and resistant to conservative, medical, and surgical intervention. 6 …”