American Journal of Kidney Diseases

Pain Management in CKD: A Guide for Nephrology Providers

Published:November 20, 2016DOI:
      Although pain is one of the most commonly experienced symptoms by patients with chronic kidney disease, it is under-recognized, the severity is underestimated, and the treatment is inadequate. Pain management is one of the general primary palliative care competencies for medical providers. This review provides nephrology providers with basic skills for pain management. These skills include recognition of types of pain (nociceptive and neuropathic) syndromes and appropriate history-taking skills. Through this history, providers can identify clinical circumstances in which specialist referral is beneficial, including those who are at high risk for addiction, at risk for adverse effects to medications, and those with complicated care needs such as patients with a limited prognosis. Management of pain begins with the development of a shared treatment plan, identification of appropriate medications, and continual follow-up and assessment of efficacy and adverse effects. Through adequate pain management, providers can positively affect the health of individual patients and the performance of health care systems.

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        • Weisbord S.D.
        • Carmody S.S.
        • Bruns F.J.
        • et al.
        Symptom burden, quality of life, advance care planing and the potential value of palliative care in severely ill haemodialysis patients.
        Nephrol Dial Transplant. 2003; 18: 1345-1352
        • Davison S.N.
        Pain in hemodialysis patients: prevalence, cause, severity, and management.
        Am J Kidney Dis. 2003; 42: 1239-1247
        • Abdel-Kader K.
        • Unruh M.L.
        • Weisbord S.D.
        Symptom burden, depression, and quality of life in chronic and end-stage kidney disease.
        Clin J Am Soc Nephrol. 2009; 4: 1057-1064
        • Claxton R.N.
        • Blackhall L.
        • Weisbord S.D.
        • Holley J.L.
        Undertreatment of symptoms in patients on maintenance hemodialysis.
        J Pain Symptom Manage. 2010; 39: 211-218
        • Weisbord S.D.
        • Fried L.F.
        • Mor M.K.
        • et al.
        Renal provider recognition of symptoms in patients on maintenance hemodialysis.
        Clin J Am Soc Nephrol. 2007; 2: 960-967
        • Barakzoy A.S.
        • Moss A.H.
        Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease.
        J Am Soc Nephrol. 2006; 17: 3198-3203
        • Davison S.
        • Koncicki H.
        • Brennan F.
        Pain in chronic kidney disease: a scoping review.
        Semin Dial. 2014; 27: 188-204
        • Turk D.C.
        • Wilson H.D.
        • Cahana A.
        Treatment of chronic non-cancer pain.
        Lancet. 2011; 377: 2226-2235
        • Davison S.N.
        • Jhangri G.S.
        The impact of chronic pain on depression, sleep, and the desire to withdraw from dialysis in hemodialysis patients.
        J Pain Symptom Manage. 2005; 30: 465-473
        • Cohen S.D.
        • Patel S.S.
        • Khetpal P.
        • Peterson R.A.
        • Kimmel P.L.
        Pain, sleep disturbance, and quality of life in patients wtih chronic kidney disease.
        Clin J Am Soc Nephrol. 2007; 2: 919-925
        • Davison S.N.
        • Jhangri G.S.
        Impact of pain and symptom burden on the health-related quality of life of hemodialysis patients.
        J Pain Symptom Manage. 2010; 39: 477-485
        • Aitken E.
        • McLellan A.
        • Glen J.
        • Serpell M.
        • Mactier R.
        • Clancy M.
        Pain resulting from arteriovenous fistulae: prevalence and impact.
        Clin Nephrol. 2013; 80: 328-333
        • Weisbord S.D.
        • Mor M.K.
        • Sevick M.A.
        • et al.
        Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.
        Clin J Am Soc Nephrol. 2014; 9: 1594-1602
        • Green J.A.
        • Mor M.K.
        • Shields A.M.
        • et al.
        Renal provider perceptions and practice patterns regarding the management of pain, sexual dysfunction, and depression in hemodialysis patients.
        J Palliat Med. 2012; 15: 163-167
        • Cheatle M.D.
        Prescription opioid misuse, abuse, morbidity, and mortality: balancing effective pain management and safety.
        Pain Med. 2015; 16: S3-S8
        • Weisbord S.D.
        • Mor M.K.
        • Green J.A.
        • et al.
        Comparison of symptom management strategies for pain, erectile dysfunction, and depression in patients receiving chronic hemodialysis: a cluster randomized effectiveness trial.
        Clin J Am Soc Nephrol. 2013; 8: 90-99
        • Jensen T.S.
        • Baron R.
        • Haanpää M.
        • et al.
        A new definition of neuropathic pain.
        Pain. 2011; 152: 2204-2205
        • Barnard A.
        • Gwyther E.
        Pain management in palliative care.
        SA Fam Pract. 2006; 48: 30-33
        • Weiss S.C.
        • Emanuel L.L.
        • Fairclough D.L.
        • Emanuel E.J.
        Understanding the experience of pain in terminally ill patients.
        Lancet. 2001; 357: 1311-1315
        • Krashin D.
        • Murinova N.
        • Jumelle P.
        • Ballantyne J.
        Opioid risk assessment in palliative medicine.
        Expert Opin Drug Saf. 2015; 14: 1023-1033
        • Douglas C.
        • Murtagh F.
        • Chambers E.
        • Howse M.
        • Ellershaw J.
        Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group.
        Palliat Med. 2009; 23: 103-110
        • Murtagh F.E.
        • Addington-Hall J.
        • Edmonds P.
        • et al.
        Symptoms in the month before death for stage 5 chronic kidney disease patients managed without dialysis.
        J Pain Sympt Manage. 2010; 40: 342-352
        • Dowell D.
        • Haegerich T.M.
        • Chou R.
        CDC guideline for prescribing opioids for chronic pain—United States, 2016.
        JAMA. 2016; 315: 1624-1645
        • Koncicki H.M.
        • Brennan F.
        • Vinen K.
        • Davison S.N.
        An approach to pain management in end stage renal disease: considerations for general management and intradialytic symptoms.
        Semin Dial. 2015; 28: 384-391
        • Andrews P.A.
        • Sampson S.A.
        Topical non-steroidal drugs are systemically absorbed and may cause renal disease.
        Nephrol Dial Transplant. 1999; 14: 187-189
        • O'Callaghan C.A.
        • Andrews P.A.
        • Ogg C.S.
        Renal disease and use of topical non-steroidal anti-inflammatory drugs.
        Br Med J. 1994; 308: 110-111
        • Davison S.N.
        Chronic pain in end-stage renal disease.
        Adv Chronic Kidney Dis. 2005; 12: 326-334
        • Jankovic S.
        • Aleksic J.
        • Rakovic S.
        • et al.
        Nonsteroidal antiinflammatory drugs and risk of gastrointestinal bleeding among patients on hemodialysis.
        J Nephrol. 2009; 22: 502-507
        • Henrich W.L.
        • Agodoa L.E.
        • Barrett B.
        • et al.
        Analgesics and the kidney: summary and recommendations to the Scientific Advisory Board of the National Kidney Foundation from an Ad Hoc Committee of the National Kidney Foundation.
        Am J Kidney Dis. 1996; 27: 162-165
        • Kurella M.
        • Bennett W.
        • Chertow C.
        Analgesia in patients wtih ESRD: a review of available evidence.
        Am J Kidney Dis. 2003; 42: 217-228
        • Whelton A.
        Nephrotoxicity of nonsteroidal anti-inflammatory drugs: physiologic foundations and clinical implications.
        Am J Med. 1999; 106: 13S-24S
        • Johnson A.
        • Nguyen T.
        • Day R.
        Do nonsteroidal anti-inflammatory drugs affect blood pressure: a meta-analysis.
        Ann Intern Med. 1994; 121: 289-300
        • Pope J.
        • Anderson J.
        • Felson D.
        A meta-analysis of the effects of nonsteroidal anti-inflammatory drugs on blood pressure.
        Arch Intern Med. 1993; 153: 477-484
        • Koncicki H.M.
        Pain management in patients with renal impairment.
        in: Sachkheim K.A. Pain Management and Palliative Care: A Comprehensive Guide. Springer, New York, NY2015: 213-226
        • Lugo R.
        • Kern S.
        The pharmacokinetics of oxycodone.
        J Pain Palliat Care Pharmacother. 2004; 18: 17-30
        • Bennett W.M.
        • Aronoff G.R.
        • Morrison G.
        Drug prescribing in renal failure: dosing guidelines for adults.
        Am J Kidney Dis. 1983; 3: 155-193
        • Miller M.
        • Barber C.W.
        • Leatherman S.
        Prescription opioid duration of action and the risk of unintentional overdose—reply.
        JAMA Intern Med. 2015; 175: 1583
        • Filitz J.
        • Griessinger N.
        • Sittl R.
        • Likar R.
        • Schuttler J.
        • Koppert W.
        Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine.
        Eur J Pain. 2006; 10: 743-748
        • Mordarski S.
        Efficacy and safety of buprenorphine in patients receiving haemodialysis.
        J Appl Ther Res. 2009; 7: 46-51
        • Davison S.N.
        • Ferro C.J.
        Management of pain in chronic kidney disease.
        Progr Palliat Care. 2009; 17: 186-195
        • Mambelli E.
        • Barrella M.
        • Facchini M.G.
        • et al.
        The prevalence of peripheral neuropathy in hemodialysis patients.
        Clin Nephrol. 2012; 77: 468-475
        • Naylor H.
        • Raymond C.
        Treatment of neuropathic pain in patients with chronic kidney disease.
        CANNT J. 2011; 21: 34-38
        • Dworkin R.
        • O'Connor A.
        • Backonja M.
        • et al.
        Pharmacologic management of neuropathic pain: evidence-based recommendations.
        Pain. 2007; 132: 237-251
        • Innis J.
        Pain assessment and management for a dialysis patient with diabetic peripheral neuropathy.
        CANNT J. 2006; 16: 12-17
        • Biyik Z.
        • Solak Y.
        • Atalay H.
        • Gaipov A.
        • Guney F.
        • Turk S.
        Gabapentin versus pregabalin in improving sleep quality and depression in hemodialysis patients with peripheral neuropathy: a randomized rospective crossover trial.
        Int Urol Nephrol. 2013; 45: 831-837
        • Atalay H.
        • Solak Y.
        • Biyik Z.
        • Gaipov A.
        • Guney F.
        • Turk S.
        Cross-over, open-label trial of the effects of gabapentin versus pregabalin on painful peripheral neuropathy and health-related quality of life in haemodialysis patients.
        Clin Drug Investig. 2013; 33: 401-408
        • Ballantyne J.C.
        Chronic pain following treatment for cancer: the role of opioids.
        Oncologist. 2003; 8: 567-575
        • Ballantyne J.C.
        Opioid therapy in chronic pain.
        Phys Med Rehabil Clin North Am. 2015; 26: 201-218
        • Webster L.R.
        • Webster R.M.
        Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool.
        Pain Med. 2005; 6: 432-442
        • Dart R.C.
        • Surratt H.L.
        • Cicero T.J.
        • et al.
        Trends in opioid analgesic abuse and mortality in the United States.
        N Engl J Med. 2015; 372: 241-248
        • Delcher C.
        • Wagenaar A.C.
        • Goldberger B.A.
        • Cook R.L.
        • Maldonado-Molina M.M.
        Abrupt decline in oxycodone-caused mortality after implementation of Florida's Prescription Drug Monitoring Program.
        Drug Alcohol Depend. 2015; 150: 63-68
        • Webster L.R.
        Opioid-induced constipation.
        Pain Med. 2015; 16: S16-S21

      Linked Article

      • Opioid Overuse or NSAID Underuse? A Response to the Pain Guide
        American Journal of Kidney DiseasesVol. 69Issue 6
        • Preview
          Koncicki and colleagues1 offer a timely guide to pain management in chronic kidney disease (CKD). However, it relies heavily on the World Health Organization (WHO) pain ladder (originally created to guide the treatment of cancer pain), with the major adaptation to avoid nonsteroidal anti-inflammatory drugs (NSAIDs). The recent Centers for Disease Control and Prevention (CDC) guideline with its emphasis on avoiding opioids for chronic pain would have been a safer resource.
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