The predominant symptom among patients with late-stage kidney disease is recurrent acute pain. Although pain related to chronic kidney disease (CKD) has a complex etiology, it predisposes patients to depressive disorder, poor quality of life, and lower survival rates (Davison, Koncicki, & Brennan, 2014). The latest statistics indicate that pain prevalence stands at 40-60% and 60-70% in CKD patients under dialysis or hemofiltration and those with late-stage kidney disease, respectively (Nahin, 2015).
The pain level is highest at 100% in hospitalized renal patients with musculoskeletal pain being the chief complaint (Davison et al., 2014). Pain can be either neuropathic, i.e., pain resulting from lesions affecting the somatic system, or nociceptive, i.e., inflammatory reactions that have somatic or visceral origins (Davison et al., 2014). Patients describe nociceptive pain as a “dull, throbbing, and cramping” feeling and neuropathic pain as a “tingling, numbing, burning, and stabbing” sensation (Davison et al., 2014, p. 194).
Most analgesics used with other patients are not recommended for CKD pain management due to poor renal clearance. Common pharmacological options for pain management include opioids and non-opioid agents, e.g., NSAIDs, while non-pharmacological interventions include heat therapy, exercise, and cryotherapy (Johnson, Paley, Howe, & Sluka, 2015). The pharmacokinetics of drugs – distribution and clearance – are altered in CKD patients due to renal failure or dysfunction. The choice of analgesics requires knowledge of its etiology, severity, and pathophysiology. The aim is to reduce analgesic-induced renal complications and effects of drug accumulation resulting from poor excretion.
The aim of this paper to analyze literature on oral or intravenous pharmacological treatments and adjunctive non-pharmacological interventions recommended for optimal pain management in hospitalized CKD patients. The PICO question used is; in CKD patients (P), how do pharmacological interventions alone (I) compare with non-pharmacological options as adjuncts (C) in managing pain, shown by reduced pain intensity (O) based on validated instruments?
A literature search was done for the PICO question in three databases: PubMed, CINAHL, and MEDLINE. The MeSH terms used in the search included ‘pain’ ‘analgesics’, ‘CKD pain management’, and ‘non-pharmacological pain interventions’. The inclusion criteria included RCTs, clinical trials, systematic reviews, and studies published 2012-present. The five studies included in the final analysis met the inclusion criteria and focused on pain management interventions for patients with CKD.
Problems in CKD Pain Management
Pain management through pharmacological methods increases the risk of further renal deterioration due to the effects of the drugs. NSAIDs are linked to reduced kidney function in patients with CKD (Pham et al., 2017). Changes in drug pharmacokinetics and poor renal clearance lead to drug accumulation. Therefore, appropriate analgesic selection and dose adjustment is crucial in preventing drug-induced comorbidities. The stage of CKD, the nature of the drug, its metabolite, and hemodialysis determine the drug metabolism in the liver (Pham et al., 2017).
Pain is a common problem among CDK patients. Chronic pain may be the effect of renal impairment or due to anticoagulant administration during hemodialysis. Pain in dialysis patients is an outcome of epidural hematoma related to analgesic use. Medication side effects may be avoided through peripheral nerve blocks, which involve epidural anesthesia to manage pain in end-stage renal disease (ESRD) that requires dialysis (Pham et al., 2017).
Pain etiology in ESRD is linked to conditions like diabetic neuropathy, co-morbidity, dialysis-related muscle cramps, catheters or needles used in hemodialysis, and syndromes like renal osteodystrophy (Twafic & Bellingham, 2015). Therefore, important considerations in selecting effective pain relief interventions include the pharmacokinetics of drugs and the status of the dialysis equipment.
In CKD-stage 1, the kidney function is not impaired. The recommended pain management plan at this stage includes analgesic administration through a peripheral nerve blockage (Pham et al., 2017). The recommended first-line analgesics include acetaminophen and NSAIDs, which can effectively reduce mild to moderate pain and minimize the need for opioids (Pham et al., 2017). Besides NSAIDs, other analgesic adjuncts, which yield optimal pain control at a lower opioid dose, are tramadol and gabapentin.
At stage 2, renal function is slightly impaired. However, renal clearance is unaffected, which excludes dose adjustment requirements. Pham et al. (2017) state that patient monitoring in stage 2 is critical to prevent the progression of renal impairment related to anesthetic use. In some cases, stepping down the dosage requirements may be necessary to prevent bleeding or hypotension. NSAIDs also affect renal circulation through the inhibition of prostaglandins involved in arteriolar vasodilation (Pham et al., 2017). Prolonged NSAID administration to CDK patients with other comorbidities should be avoided because of the risk of hypotension.
Analgesic recommendations in pain management in CDK stage 3 and 4 patients entail avoiding NSAIDs, dose adjustments, and close patient observation to detect adverse effects (Pham et al., 2017). In advanced cases, opioids can be used, but after a careful consideration of their pharmacological profile to ensure safety. They must not produce toxic metabolites that cause further kidney damage or neurotoxicity, which increases pain. Examples of such drugs include Alfentanil, Fentanyl, and morphine.
Besides medications, adjunctive non-pharmacological therapies exist for pain management. Topical thermal therapy and TENS have a local analgesic effect when used with patients experiencing nociceptive pain (Johnson et al., 2015). Thus, heat therapy or cryotherapy should be explored as adjunctive options for pain relief in CKD patients. Topical thermal therapy works by lowering local metabolism and inflammatory reactions, resulting in a short-lived pain sensation. It also suppresses local muscle spasm associated with acute pain.
Another non-pharmacological intervention is the transcutaneous electrical stimulation (TENS) technique. A review by Johnson et al. (2015) found that TENS lowers pain sensation through neurosensory changes in the PNS and spinal cord. It is an efficacious intervention for postsurgical pain and musculoskeletal pain. Other interventions with variable levels of effectiveness include ultrasound therapy, exercise, and cognitive behavioral therapy.
Analysis and Synthesis
Effective pain management in CDK patients requires knowledge of the pharmacokinetics and pharmacodynamics of the analgesics and their metabolites. A range of safe non-opioid and opioid pain regimens exist for this patient group. The review shows that pain medication prescriptions should take into consideration the properties of the pharmacological agent and the efficacy of the dialysis protocol in use (Davison et al., 2014).
Nonopioid options, including NSAIDs, are effective therapies for low to moderate pain. However, they increase the risk of dose-dependent kidney failure, bleeding, and hypotension (Twafic & Bellingham, 2015). Safe nonopioid drugs are recommended for pain management in CDK stage 1 and 2, where renal clearance and excretion is not impaired.
Opioid use in the CDK population is problematic. The nurse is required to balance between optimal pain management and opioid-related adverse effects like hypotension and toxicity (Pham et al., 2017). For this reason, the recommended practice is to give a lower initial dose, step it up gradually, and extend the dosing interval to avoid these side effects. For CDK patients in stage 3 and 4, NSAIDs administration is avoided because of related adverse effects (Pham et al., 2017). Instead, adjuvant medications, such as tramadol and gabapentin, can be administered to achieve optimal pain control. These drugs can also help minimize opioid doses and treat neuropathic etiologies of pain (Twafic & Bellingham, 2015).
From the review, non-pharmacological interventions are important therapeutic options that do not involve metabolite accumulation or dosage adjustment requirements. They are effective in nociceptive pain control by reducing the pain duration (Johnson et al., 2015). Such interventions may be effective in treating pain syndromes related to drug-induced inflammatory responses in CDK patients. Therefore, NSAIDs and opioid analgesics at appropriate doses are effective treatments for neuropathic pain conditions, while topical thermal therapy is efficacious in nociceptive pain control in dialysis patients.
Pain is the chief complaint among patients with chronic kidney disease. Specifically, people with pre-CDK symptoms and those undergoing hemodialysis report higher pain scores than the general population. Ineffective pain control in CDK patients increases the risk of depressive disorders and lowers patient outcomes and survival rates. Nevertheless, optimal pain management in this population is problematic because of possible drug-related complications. Further, in dialysis patients, renal insufficiency leads to poor clearance and drug accumulation.
A mastery of the pharmacokinetics of the pharmacological agents is critical in achieving adequate pain control, while minimizing drug side effects. The nonopioid options, e.g., NSAIDs are recommended for pain control in CDK stage 1 and 2. Advanced CDK requires opioids, which, if used in high doses, can cause dependence and metabolite accumulation. On the other hand, non-pharmacological interventions, such as topical thermal therapy, can reduce nociceptive pain control, albeit with limited effectiveness.
Therefore, non-pharmacological interventions could be used as adjuncts with low-dose opioid and nonopioid drugs to achieve adequate pain control in CDK patients and minimize adverse complications.
Davison, S. N., Koncicki, H., & Brennan, F. (2014). Pain in chronic kidney disease: A scoping review. Seminars in Dialysis, 27(2), 188–204. Web.
Johnson, M. I., Paley, C. A, Howe, T. E., & Sluka, K. A. (2015). Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database of Systematic Reviews, 6, 1-9. Web.
Nahin, R. L. (2015). Estimates of pain prevalence and severity in adults: United States, 2012. The Journal of Pain, 16(8), 769-780. Web.
Pham, P. C., Khaing, K., Sievers, T. M., Pham, P. M., Miller, J. M., Pham, S. V.,…Pham, P. T. (2017). 2017 update on pain management in patients with chronic kidney disease. Clinical Kidney Journal, 10(5), 688–697. https://doi.org/10.1093/ckj/sfx080
Twafic, Q. A., & Bellingham, G. (2015). Postoperative pain management in patients with chronic kidney disease. Journal of Anaesthesiology, Clinical and Pharmacology, 31(1), 6-13. Web.