Chronic Kidney Disease
Functional impairment related to pain and its subjective experience may be exaggerated by underlying frailty, advanced age, and end-of-life issues. Pain and the collective symptom burden in CKD have tremendous negative impact on CKD patients’ HRQOL,8
similar.7 with overall
symptom burden accounting for up to 45 % of the variability in measured HRQOL. Pain alone accounted for up to 32 % of the variability in HRQOL.8
Depression among dialysis patients is often underdiagnosed and frequently co-exists with chronic pain.22,23
at least double those of the general population.23–28
dialysis patients with moderate to severe chronic pain, the prevalence of depression was significantly higher compared with those with mild or no pain (34.1 % versus 18.3 %, odds ratio [OR] 2.31, p=0.01).23
in an Italian study only 37 % of patients with moderate chronic pain received any form of analgesic medication, of which 88 % were anti-inflammatories.19 nephrology.29,33,34
pain);2,32 Sub-optimal pain management is not unique to
In patients with CKD, however, specific concerns include the following. Risks for drug toxicity may be compounded by reduced drug and metabolite clearance, intermittent removal by dialysis, and complex pharmacokinetics of the uremic milieu.35
Compared with the general
Prevalence rates of 20–50 % are Among a cohort of 87
The dyad of
chronic pain and depression is complex and incompletely understood. While pain itself may be the cause of depressive symptoms, pain may also be a symptom of depression. Regardless, concomitant depression and/or other symptoms can alter the experience of pain and represents a particular management challenge to clinical teams.29
This concept is
epitomized in the term ‘total pain’, which emphasizes the contribution of psychological, spiritual, and social factors to the experience of pain. The clinical implication is that healthcare providers need to address diagnosis and treat pain in conjunction with other psychosocial issues. At times this may require the particular expertise of specialist palliative care services.
Etiology of Pain in Advanced Chronic Kidney Disease
Pain in patients with advanced CKD tends to be progressive, is often multifactorial, and includes nociceptive, somatic, visceral, neuropathic, and complex regional pain syndromes.2
The cause of pain may stem from
comorbid conditions including diabetes, vascular disease, and arthritis or from the primary renal disease such as with polycystic kidney disease, multiple myeloma or nephrolithiasis. Pain may be due to CKD-related conditions including peripheral neuropathy, calcific uremic arteriolopathy (calciphylaxis), renal osteodystrophy, and dialysis-related amyloidosis, all of which may induce soft tissue and periarticular calcification, proximal myopathy, ruptured tendons, pseudo-gout or gout, carpal tunnel syndrome, bone deformities, pathological fractures, and tissue ischemia. Severe fibrosis of skin, joints, and internal organs from nephrogenic systemic fibrosis occurs rarely, associated with gadolinium exposure in patients with stage 5 CKD. Finally, dialysis therapies may result in steal syndromes distal to arteriovenous fistula, peritoneal fluid-induced abdominal distension and back pain, and chronic infections.
Pain Management in Chronic Kidney Disease Barriers to Effective Pain Relief
Despite the prevalence of pain and its effect on HRQOL, evidence suggests a lack of comprehensive pain management strategies in CKD facilities. A systematic review30
highlighted the limited and highly variable use of opioids in hemodialysis facilities. Prevalent opioid use ranged from 5 % to 36 %.30
Data derived from the Dialysis Outcomes Practice Patterns Study (DOPPS)31
indicated that opioids were prescribed for only 14.9 % of patients in American dialysis units in 2000, a decline from 18 % three years prior.4 No analgesics were prescribed for 74 % of patients reporting moderate to severe pain; only 17% of these patients received any form of opioid. Smaller North American cohort studies demonstrated analogous rates of opioid prescribing (21–37 % of patients with moderate to severe chronic
22 Pain Assessment
Pain assessment involves an organized history to elucidate the cause of pain, its location, quality, severity, and finally the impact on physical, social, and emotional functioning. It is important to form realistic pain management goals together with the patient; it may not be feasible to entirely alleviate pain.
Nociceptive and neuropathic pain syndromes are treated differently. Although pain in CKD patients is often of mixed type, elucidating which is predominant helps determine an appropriate management strategy. Generally, nociceptive pain responds well to opioids and neuropathic pain typically less so, often requiring opioid doses associated with unacceptable toxicity. Anticonvulsants and antidepressants may alleviate some symptoms of neuropathic pain. The DN4 questionnaire discriminates pain subtypes through a brief assessment of pain characteristics and signs of hypo- and hyperalgesia.42
Nociceptive pain stems from tissue damage and
secondary stimulation of sensory receptors. Pain is appreciated at the site of injury and typically reported as sharp, or knife-like. Visceral nociceptive pain related to capsular stretch or peritonitis may be described as dull and poorly localized. In contrast, neuropathic pain is described as burning or electric shocks and is typically associated with tingling and numbness. The etiology stems from nerve damage that increases excitation. Neuropathic pain may occur far from obvious tissue damage or in the absence of active damage, exemplified best by phantom limb pain.
If pain management is a priority, the routine use of pain assessment tools in CKD and dialysis clinics cannot be stressed enough. Simple bedside pain evaluation tools include visual analog, numerical rating, and verbal rating scales. Multidimensional assessment tools that incorporate HRQOL parameters include the McGill Pain Questionnaire (MPQ)9
and the Brief Pain Inventory (BPI).10 cross-cultural diverse patient populations.43
Both are validated among Global symptom
assessment tools developed initially for cancer patients have been adapted and validated for use with CKD patients including the widely used modified Edmonton Symptom Assessment System (mESAS), a visual 0–10 analog scale of 10 prevalent symptoms in CKD. The strength of the mESAS lies in its simplicity for patients and healthcare providers alike.6,44
The Dialysis Symptom Index (DSI) and the modified Patient US NEPHROLOGY
population polypharmacy, frequent medication adjustments and the number of comorbid illnesses increase risk for medication-related difficulties.36
The literature illustrates limited expertise among nephrologists in pain assessment and management.3,37,38
Finally, patient
under-reporting of pain may be compounded by poorly appreciated cognitive impairment. Cognitive deficits are apparent well before the transition to ESRD,39
by which time approximately 73 % have at least moderate cognitive impairment on formal neurocognitive testing despite no prior documentation.40
Even among young dialysis patients, over 67 % have been shown to have mild to moderate cognitive impairment.41
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