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Wachterman MW, Sinha A, Leveille T, Waikar SS, Widera E, Romero K, Bokhour B. Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease. J Am Geriatr Soc 2024; 72:2060-2069. [PMID: 38777614 PMCID: PMC11226377 DOI: 10.1111/jgs.18936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. METHODS Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. RESULTS With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. CONCLUSIONS Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Sushrut S Waikar
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Eric Widera
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
| | - Kai Romero
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
- By the Bay Health, San Francisco, California, USA
| | - Barbara Bokhour
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- Center for Healthcare Organization and Implementation of Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts, USA
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Mohsen M, Feldberg J, Abbaticchio A, Jassal SV, Battistella M. Development and Validation of a Treatment Algorithm for Osteoarthritis Pain Management in Patients With End-Stage Kidney Disease Undergoing Hemodialysis. Can J Kidney Health Dis 2024; 11:20543581241249365. [PMID: 38746016 PMCID: PMC11092542 DOI: 10.1177/20543581241249365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/14/2024] [Indexed: 05/16/2024] Open
Abstract
Background Although osteoarthritis is common in the hemodialysis population and leads to poor health outcomes, pain management is challenged by the absence of clinical guidance. A treatment algorithm was developed and validated to aid hemodialysis clinicians in managing osteoarthritis pain. Objective The objective was to develop and validate a treatment algorithm for managing osteoarthritis pain in patients undergoing hemodialysis. Design A validation study was conducted based on Lynn's method for content validation. Setting To develop and validate a treatment algorithm, interviews were conducted virtually by the primary researcher with clinicians from various institutions across the Greater Toronto and Hamilton Area in Ontario. Patients The treatment algorithm was developed and validated for the management of osteoarthritis pain in patients on hemodialysis. Patients were not involved in the development or validation of the tool. Measurements The algorithm was measured for content and face validity. Content validity was measured by calculating the content validity index of each component (I-CVI) of the algorithm and the overall scale validity index (S-CVI). Face validity was assessed by calculating the percentage of positive responses to the face validity statements. Methods A draft algorithm was developed based on literature searches and expert opinion and validated by interviewing nephrology and pain management clinicians. Through consecutive rounds of 1:1 interviews, content and face validity were assessed by asking participants to rate the relevance of each component of the algorithm and indicate their level of agreeability with a series of statements. Following each round, the I-CVI of the algorithm as well as the S-CVI was calculated and the percentage of positive responses to the statements was determined. The research team revised the algorithm in response to the findings. The final algorithm provides a stepwise approach to the non-pharmacologic and pharmacologic management of pain, including topical, oral, and opioid use. Results A total of 18 clinicians from 7 institutions across the Greater Toronto and Hamilton Area were interviewed (10 pharmacists, 5 nurse practitioners, and 3 physicians). The average S-CVI of the algorithm across all 3 rounds was 0.93. At least 78% of participants provided positive responses to the face validity statements. Limitations An algorithm was developed based on input from clinicians working in the province of Ontario, limiting the generalizability of the algorithm across provinces. In addition, the algorithm did not include the perspectives of primary care providers or patients/caregivers. Conclusions An algorithm for the management of osteoarthritis pain in the hemodialysis population was developed and validated through expert review to standardize practices and encourage clinicians to use evidence-based treatments and address the psychosocial symptoms of pain. As the algorithm possesses a high degree of content and face validity, it may improve osteoarthritis pain management among patients undergoing hemodialysis. Future research will assess the implementation of the algorithm across hemodialysis settings.
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Affiliation(s)
- Mai Mohsen
- Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
- Department of Nephrology, Toronto General Hospital – University Health Network, ON, Canada
| | - Jordanne Feldberg
- Department of Nephrology, Toronto General Hospital – University Health Network, ON, Canada
| | - Angelina Abbaticchio
- Department of Nephrology, Toronto General Hospital – University Health Network, ON, Canada
| | - S. Vanita Jassal
- Department of Nephrology, Toronto General Hospital – University Health Network, ON, Canada
- Department of Medicine, University of Toronto, ON, Canada
| | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
- Department of Nephrology, Toronto General Hospital – University Health Network, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
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Sridharan K. Assessment of drug utilization and potentially inappropriate medications in hemodialysis patients with end-stage renal dysfunction: A study in a tertiary care hospital in Bahrain. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:131-141. [PMID: 38393922 DOI: 10.3233/jrs-230004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND Patients undergoing dialysis pose therapeutic challenges in terms of polypharmacy, administration of potentially inappropriate drugs, and drugs with the potential risk of toxicity. OBJECTIVE This study evaluated the use of drugs, potentially inappropriate medicines (PIM), drugs with risk of Torsades de Pointes (TdP), and the complexity of the prescribed regimen using the medication regimen complexity index scale in patients undergoing hemodialysis. METHODS A retrospective cohort study was carried out amongst patients receiving hemodialysis. Drugs were classified into one of four classes: (i) drugs used in managing renal complications, (ii) cardiovascular drugs, (iii) anti-diabetic drugs, (iv) drugs for symptomatic management, and (v) others. Drugs were considered as PIM according to the Can-SOLVE CKD working group from a network of Canadian nephrology health professionals. The study adhered to the CredibleMeds classification of drugs with known, possible, and conditional risk of TdP and the complexity of prescribed medicines was evaluated based on the pre-validated medication regimen complexity index scale based on form/route, frequency of dosing, and requirement of special instructions. RESULTS Sixty-three participants were included in the study (49 males and 14 females) with the median (range) age of 45 (21-66) years. Cardiovascular drugs followed by drugs used for managing renal complications were the most common classes administered. Notably, 12 (19.1%) patients received one of the non-steroidal anti-inflammatory drugs, 21 (33.3%) received a proton pump inhibitor, three (4.8%) received pregabalin, two (3.2%) received opioid drugs, and one (1.6%) was administered celecoxib. Atorvastatin, furosemide, omeprazole, and allopurinol were the most common PIM drugs administered to the study participants followed by others. Drugs used for symptomatic management had significantly more PIM compared to other classes (p < 0.0001). Six (9.5%) patients received drugs with known TdP risk, one with possible TdP risk, and 61 with conditional risk. Median (range) medical regimen complexity index score was 26.5 (2-62.5). CONCLUSION A huge burden of drug therapy was observed in the hemodialysis patients in terms of higher proportions of PIM, complex medical regimen, and prescription of drugs with risk of TdP. Implementation of clinical decision support tools enhancing rational prescription and identification of drugs with TdP risk, introducing antimicrobial stewardship, and stepwise deprescription of the drugs with the least benefit-risk ratio are warranted.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Manama, Kingdom of Bahrain E-mail:
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Barakji J, Korang SK, Feinberg JB, Maagaard M, Mathiesen O, Gluud C, Jakobsen JC. Tramadol for chronic pain in adults: protocol for a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. Syst Rev 2023; 12:145. [PMID: 37608394 PMCID: PMC10463795 DOI: 10.1186/s13643-023-02307-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Chronic pain in adults is a frequent clinical symptom with a significant impact on patient well-being. Therefore, sufficient pain management is of utmost importance. While tramadol is a commonly used pain medication, the quality of evidence supporting its use has been questioned considering the observed adverse events. Our objective will be to assess the benefits and harms of tramadol compared with placebo or no intervention for chronic pain. METHODS/DESIGN We will conduct a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis to assess the beneficial and harmful effects of tramadol in any dose, formulation, or duration. We will accept placebo or no intervention as control interventions. We will include adult participants with any type of chronic pain, including cancer-related pain. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and BIOSIS for relevant literature. We will follow the recommendations by Cochrane and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors ('bias') and random errors ('play of chance') will be assessed. The certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION Although tramadol is often being used to manage chronic pain conditions, the beneficial and harmful effects of this intervention are unknown. The present review will systematically assess the current evidence on the benefits and harms of tramadol versus placebo or no intervention to inform clinical practice and future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019140334.
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Affiliation(s)
- J Barakji
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
| | - S K Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - J B Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Medical Department, Cardiology Section, Holbaek University Hospital, Holbaek, Denmark
| | - M Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - O Mathiesen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - C Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - J C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
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Barakji J, Korang SK, Feinberg J, Maagaard M, Mathiesen O, Gluud C, Jakobsen JC. Cannabinoids versus placebo for pain: A systematic review with meta-analysis and Trial Sequential Analysis. PLoS One 2023; 18:e0267420. [PMID: 36716312 PMCID: PMC9886264 DOI: 10.1371/journal.pone.0267420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/16/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To assess the benefits and harms of cannabinoids in participants with pain. DESIGN Systematic review of randomised clinical trials with meta-analysis, Trial Sequential Analysis, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES The Cochrane Library, MEDLINE, Embase, Science Citation Index, and BIOSIS. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Published and unpublished randomised clinical trials comparing cannabinoids versus placebo in participants with any type of pain. MAIN OUTCOME MEASURES All-cause mortality, pain, adverse events, quality of life, cannabinoid dependence, psychosis, and quality of sleep. RESULTS We included 65 randomised placebo-controlled clinical trials enrolling 7017 participants. Fifty-nine of the trials and all outcome results were at high risk of bias. Meta-analysis and Trial Sequential Analysis showed no evidence of a difference between cannabinoids versus placebo on all-cause mortality (RR 1.20; 98% CI 0.85 to 1.67; P = 0.22). Meta-analyses and Trial Sequential Analysis showed that cannabinoids neither reduced acute pain (mean difference numerical rating scale (NRS) 0.52; 98% CI -0.40 to 1.43; P = 0.19) or cancer pain (mean difference NRS -0.13; 98% CI -0.33 to 0.06; P = 0.1) nor improved quality of life (mean difference -1.38; 98% CI -11.81 to 9.04; P = 0.33). Meta-analyses and Trial Sequential Analysis showed that cannabinoids reduced chronic pain (mean difference NRS -0.43; 98% CI -0.72 to -0.15; P = 0.0004) and improved quality of sleep (mean difference -0.42; 95% CI -0.65 to -0.20; P = 0.0003). However, both effect sizes were below our predefined minimal important differences. Meta-analysis and Trial Sequential Analysis indicated that cannabinoids increased the risk of non-serious adverse events (RR 1.20; 95% CI 1.15 to 1.25; P < 0.001) but not serious adverse events (RR 1.18; 98% CI 0.95 to 1.45; P = 0.07). None of the included trials reported on cannabinoid dependence or psychosis. CONCLUSIONS Cannabinoids reduced chronic pain and improved quality of sleep, but the effect sizes are of questionable importance. Cannabinoids had no effects on acute pain or cancer pain and increased the risks of non-serious adverse events. The harmful effects of cannabinoids for pain seem to outweigh the potential benefits.
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Affiliation(s)
- Jehad Barakji
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Medical Department, Cardiology Section, Holbaek University Hospital, Holbaek, Denmark
| | - Mathias Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
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Comorbidity phenotypes and risk of mortality in patients with osteoarthritis in the UK: a latent class analysis. Arthritis Res Ther 2022; 24:231. [PMID: 36229868 PMCID: PMC9559033 DOI: 10.1186/s13075-022-02909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteoarthritis (OA) is a common chronic condition but its association with other chronic conditions and mortality is largely unknown. This study aimed to use latent class analysis (LCA) of 30 comorbidities in patients with OA and matched controls without OA to identify clusters of comorbidities and examine the associations between the clusters, opioid use, and mortality. METHODS A matched cohort analysis of patients derived from the IQVIA Medical Research Data (IMRD-UK) database between 2000 and 2019. 418,329 patients with newly diagnosed OA were matched to 243,170 patients without OA to identify comorbidity phenotypes. Further analysis investigated the effect of opioid use on mortality in individuals with OA and their matched controls. RESULTS The median (interquartile range (IQR)) number of comorbidities was 2 (1-4) and 1 (0-3) in the OA and control groups respectively. LCA identified six comorbidity phenotypes in individuals with and without OA. Clusters with a high prevalence of comorbidities were characterised by hypertension, circulatory, and metabolic diseases. We identified a comorbidity cluster with the aforementioned comorbidities plus a high prevalence of chronic kidney disease, which was associated with twice the hazard of mortality in hand OA with a hazard ratio (HR) (95% CI) of 2.53 (2.05-3.13) compared to the hazard observed in hip/knee OA subtype 1.33 (1.24-1.42). The impact of opioid use in the first 12 months on hazards of mortality was significantly greater for weak opioids and strong opioids across all groups HR (95% CI) ranging from 1.11 (1.07-11.6) to 1.80 (1.69-1.92)). There was however no evidence of association between NSAID use and altered risk of mortality. CONCLUSION This study identified six comorbidity clusters in individuals with OA and matched controls within this cohort. Opioid use and comorbidity clusters were differentially associated with the risk of mortality. The analyses may help shape the development of future interventions or health services that take into account the impact of these comorbidity clusters.
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Lambourg E, Colvin L, Guthrie G, Walker H, Bell S. Analgesic use and associated adverse events in patients with chronic kidney disease: a systematic review and meta-analysis. Br J Anaesth 2021; 128:546-561. [PMID: 34763813 DOI: 10.1016/j.bja.2021.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Treating pain in the context of chronic kidney disease (CKD) is challenging because of altered pharmacokinetics and pharmacodynamics, with an increased risk of toxicity and drug adverse events in this population. The aims of this systematic review and meta-analysis were to assess the prevalence of analgesic use and establish the risk of analgesics-related adverse events, in patients with CKD. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Medline, Embase, CINAHL, and CENTRAL were searched until January 2021. Random-effects meta-analyses and meta-regression were conducted to pool and summarise prevalence data and measures of association between analgesic use and adverse events. RESULTS Sixty-two studies relevant to the prevalence of analgesic use and 33 to analgesic-related adverse events were included, combining data on 2.3 and 3 million individuals, respectively. Pooled analyses found that 41% (95% confidence interval [CI], 35-48) of the CKD population regularly use analgesia. The annual period prevalence was estimated at 50% for opioids and 21% for nonsteroidal anti-inflammatory drugs (NSAID). Overall, 20% and 7% of patients with CKD are on chronic opioid or NSAID therapy, respectively. Opioid use was associated with an increased risk of death (1.61; 95% CI, 1.12-2.31; n= 7, I2= 91%), hospitalisation (1.38; 95% CI, 1.32-1.45; n=2, I2=0%), and fractures (1.51; 95% CI, 1.16-1.96; n=3, I2=54%). CONCLUSION High levels of analgesic consumption and related serious adverse outcomes were found in patients with CKD. Consideration needs to be given to how these patients are assessed and managed in order to minimise harms and improve outcomes. CLINICAL TRIAL REGISTRATION CRD42019156491 (PROSPERO).
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Affiliation(s)
- Emilie Lambourg
- Division of Population Health and Genomics, Medical Research Institute, University of Dundee, Dundee, UK
| | - Lesley Colvin
- Division of Population Health and Genomics, Medical Research Institute, University of Dundee, Dundee, UK
| | | | - Heather Walker
- Division of Population Health and Genomics, Medical Research Institute, University of Dundee, Dundee, UK; Renal Unit, Ninewells Hospital, Dundee, UK
| | - Samira Bell
- Division of Population Health and Genomics, Medical Research Institute, University of Dundee, Dundee, UK; Renal Unit, Ninewells Hospital, Dundee, UK.
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Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature. Dermatol Surg 2021; 47:454-461. [PMID: 33625143 DOI: 10.1097/dss.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.
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Filchenko IA, Korostovtseva LS, Tereshchenko NM, Tsed AN, Sviryaev YV. [Self-reported sleep and wake disorders in patients with ostheoarthrosis and end-stage renal disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:80-91. [PMID: 34078865 DOI: 10.17116/jnevro202112104280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to assess subjective sleep and wake disorders (SWD) in patients with osteoarthritis and comorbid end-stage renal disease (ESRD) receiving hemodialysis (ESRD-HD) compared to patients with osteoarthritis and without chronic kidney disease (CKD) as well as to clarify of the association of subjective sleep characteristics with the levels of anxiety and depression and pain, general health score and laboratory parameters in these cohorts. MATERIAL AND METHODS This pilot case-control study included the patients with stage III hip osteoarthritis with ESRD-HD (n=19) and without CKD (n=19) aged 18-85 years. The patients received the consultations of orthopedic surgeon and internal medicine specialist with anthropometry and clinical and biochemical blood tests. Subjective SWD were assessed with Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Insomnia Severity Index (ISI), diagnostic criteria for restless legs syndrome (RLS) and Berlin questionnaire. Anxiety and depression were assessed with Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI). Subjective general health and osteoarthritis-related pain were assessed with visual analog scales (VAS). RESULTS Compared to the patients with osteoarthritis and without CKD, the patients with osteoarthritis and ESRD-HD had a lower VAS score for general health (50.00 (40.00-75.00) points and 80.00 (70.00-80.00) points, p=0.014), a higher PSQI (12.0 (8.5-14.5) points and 8.0 (6.0-11.0) points, p=0.046), a higher incidence of RLS (59% and 16.8%, p=0.017) and a lower level of anxiety according to HADS (0.0 (0.0-3.0) points and 3.0 (2.0-5.5) points, p=0.025). The correlation and regression analysis showed the association of PSQI score with VAS score for general health (b= -1.7 points, p=0.002 with adjustment for age, sex and ESRD-HD), as well as the association of SWD with laboratory markers (PSQI score with creatinine level, FSS with eosinophil count, RLS with creatinine, urea and potassium levels). CONCLUSION The results of our study demonstrated the high incidence of SWD in patients with osteoarthritis. These SWD have complex pathogenesis and require specific approach in patients with osteoarthritis and ESRD-HD.
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Affiliation(s)
- I A Filchenko
- Sechenov Institute of Evolutionary Physiology and Biochemistry of RAS, St. Petersburg, Russia
| | | | - N M Tereshchenko
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A N Tsed
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - Yu V Sviryaev
- Sechenov Institute of Evolutionary Physiology and Biochemistry of RAS, St. Petersburg, Russia.,Almazov National Medical Research Centre, St. Petersburg, Russia
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Langreck C, Wauson E, Nerland D, Lamb B, Folkerts T, Winter L, Lu E, Tague S, McCarson KE, Ploski JE, Banasr M, Duman RS, Roland MM, Babich V, Di Sole F, Duric V. Hippocampal mitogen-activated protein kinase phosphatase-1 regulates behavioral and systemic effects of chronic corticosterone administration. Biochem Pharmacol 2021; 190:114617. [PMID: 34023293 DOI: 10.1016/j.bcp.2021.114617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022]
Abstract
Clinical reports indicate a bidirectional relationship between mental illness and chronic systemic diseases. However, brain mechanisms linking chronic stress and development of mood disorders to accompanying peripheral organ dysfunction are still not well characterized in animal models. In the current study, we investigated whether activation of hippocampal mitogen-activated protein kinase phosphatase-1 (MKP-1), a key factor in depression pathophysiology, also acts as a mediator of systemic effects of stress. First, we demonstrated that treatment with the glucocorticoid receptor (GR) agonist dexamethasone or acute restraint stress (ARS) significantly increased Mkp-1 mRNA levels within the rat hippocampus. Conversely, administration of the GR antagonist mifepristone 30 min before ARS produced a partial blockade of Mkp-1 upregulation, suggesting that stress activates MKP-1, at least in part, through upstream GR signaling. Chronic corticosterone (CORT) administration evoked comparable increases in hippocampal MKP-1 protein levels and produced a robust increase in behavioral emotionality. In addition to behavioral deficits, chronic CORT treatment also produced systemic pathophysiological effects. Elevated levels of renal inflammation protein markers (NGAL and IL18) were observed suggesting tissue damage and early kidney impairment. In a rescue experiment, the effects of CORT on development of depressive-like behaviors and increased NGAL and IL18 protein levels in the kidney were blocked by CRISPR-mediated knockdown of hippocampal Mkp-1 prior to CORT exposure. In sum, these findings further demonstrate that MKP-1 is necessary for development of enhanced behavioral emotionality, while also suggesting a role in stress mechanisms linking brain dysfunction and systemic illness such as kidney disease.
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Affiliation(s)
- Cory Langreck
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States; Department of Pharmacology, Columbia University, New York, NY 10032, United States
| | - Eric Wauson
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Dakota Nerland
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Brad Lamb
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Tyler Folkerts
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Lori Winter
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Eileen Lu
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Sarah Tague
- Smith Intellectual & Developmental Disabilities Research Center, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Kenneth E McCarson
- Smith Intellectual & Developmental Disabilities Research Center, University of Kansas Medical Center, Kansas City, KS 66160, United States; Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Jonathan E Ploski
- School of Behavioral and Brain Sciences and Department of Molecular and Cell Biology, The University of Texas at Dallas, Dallas, TX 75080, United States
| | - Mounira Banasr
- Campbell Family Mental Health Research Institute of CAMH, Toronto, Canada; Department of Psychiatry, Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Ronald S Duman
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06508, United States
| | - Miranda M Roland
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Victor Babich
- School of Liberal Arts and Sciences, Mercy College of Health Sciences, Des Moines, IA 50312, United States
| | - Francesca Di Sole
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States
| | - Vanja Duric
- Department of Physiology and Pharmacology, Des Moines University, Des Moines, IA 50312, United States.
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11
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Hayward S, Hole B, Denholm R, Duncan P, Morris JE, Fraser SDS, Payne RA, Roderick P, Chesnaye NC, Wanner C, Drechsler C, Postorino M, Porto G, Szymczak M, Evans M, Dekker FW, Jager KJ, Caskey FJ. International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study. Nephrol Dial Transplant 2021; 36:503-511. [PMID: 32543669 DOI: 10.1093/ndt/gfaa064] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. METHODS The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. RESULTS Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021]. CONCLUSIONS Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.
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Affiliation(s)
- Samantha Hayward
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Barnaby Hole
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Rachel Denholm
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Bristol Medical School, University of Bristol, Bristol, UK
| | - James E Morris
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Rupert A Payne
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Christiane Drechsler
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Maurizio Postorino
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Gaetana Porto
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Marie Evans
- Department of Clinical Sciences Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
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12
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Cowan A, Garg AX. Controlling pain in dialysis care: a choice among undesirable options. Nephrol Dial Transplant 2021; 36:749-751. [PMID: 33156907 DOI: 10.1093/ndt/gfaa256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andrea Cowan
- Division of Nephrology, Western University, London, ON, Canada
| | - Amit X Garg
- Division of Nephrology, Western University, London, ON, Canada
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Comerci G, Marr L, Finlay E. End Stage Chronic Pain (ESCP): Naming Complex Suffering in the Opioid Crisis Era. Am J Hosp Palliat Care 2020; 38:1078-1082. [PMID: 33124436 DOI: 10.1177/1049909120969623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The "opioid crisis" stemming from overprescribing of prescription opioids describes an iatrogenic situation which has resulted in a rise in opioid use disorder (OUD) and overdose deaths. Many of these patients suffer from chronic non-cancer pain syndromes (CNCP) who have been injudiciously treated with opioids. Some patients with CNCP are treated successfully with opioids in accordance with modern guidelines. There is a very complex, small group of patients with CNCP who require higher than recommended dosages of opioids when other modalities and treatments have failed. We describe such a patient and believe that there is a subset of patients with unremitting suffering from chronic pain which we have called end-stage chronic pain (ESCP). These patients, despite receiving expert chronic pain care, often require high doses of opioids and suffer a dramatic decline in quality of life (QOL), function and an increase in their suffering when their opioids are tapered or discontinued. We have responded to the treatment of this group of patients by critically examining our approach to the use of opioids for their pain and attempting to reconcile high dose opioids in the setting of the Center for Disease Control (CDC) guidelines. We describe a patient with severe chronic pain from congenital spinal disease who experienced increased pain and suffering when his opioids were tapered. We will discuss our approach to this patient and in doing so discuss the concept of ESCP and proposed criteria for the use of high dose opioids in such patients.
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Affiliation(s)
- George Comerci
- 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Lisa Marr
- Division of Palliative Care, 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Esme Finlay
- Division of Palliative Care, 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
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14
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Chung KM, Ho CH, Chen YC, Hsu CC, Chiu CC, Lin HJ, Wang JJ, Huang CC. Chronic Pain Increases the Risk for Major Adverse Cardiac and Cerebrovascular Events: A Nationwide Population-Based Study in Asia. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:1985-1990. [PMID: 32377670 DOI: 10.1093/pm/pnaa107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Chronic pain (CP) may increase the risk for major adverse cardiac and cerebrovascular events (MACCEs); however, this issue is still unclear in the Asian population. We conducted this study to delineate it. DESIGN From the Taiwan National Health Insurance Research Database, we identified 17,614 participants (<65 years) with CP and matched them by age and sex at a 1:2 ratio to participants without CP, who made up the comparison cohort. Several causes of CP and its underlying comorbidities were also analyzed. OUTCOME MEASURE A comparison of MACCE occurring in the two cohorts was performed via follow-up until 2015. RESULTS The mean age (SD) was 50.2 (11.5) years and 50.4 (11.7) years in participants with and without CP, respectively. In both cohorts, the percentage of female participants was 55.5%. Common causes of CP were spinal disorders (23.9%), osteoarthritis (12.4%), headaches (11.0%), gout (10.2%), malignancy (6.2%), and osteoporosis (4.5%). After adjusting for hypertension, diabetes, chronic obstructive pulmonary disease, renal diseases, hyperlipidemia, liver diseases, dementia, and depression, participants with CP had a higher risk for MACCE than those without CP (adjusted hazard ratio [AHR] = 1.3, 95% confidence interval [CI] = 1.3 - 1.4). After conducting subgroup analyses, an increased risk was also found for all-cause mortality (AHR = 1.4, 95% CI = 1.1 - 1.8), acute myocardial infarction (AHR = 1.2, 95% CI = 1.0 - 1.4), and stroke (AHR = 1.3, 95% CI = 1.3 - 1.4). CONCLUSIONS CP is associated with increased occurrence of MACCE. Early detection and interventions for CP are suggested.
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Affiliation(s)
- Kun-Ming Chung
- Division of General Internal Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Recreation and Health Care Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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15
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Curseen KA, Taj J, Grant Q. Pain Management in Patients with Serious Illness. Med Clin North Am 2020; 104:415-438. [PMID: 32312407 DOI: 10.1016/j.mcna.2020.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Managing pain in patients with serious illness can be complex. However, pain is often a prominent symptom in patients with malignant and nonmalignant serious illness and providers have to be adept at balancing effective pain management and safety. Clinicians should start with a standard pain assessment that lays important groundwork for developing a tailored multimodal approach to pain management. It is important to identify physical causes of pain and also existential causes. Opioids are not always appropriate but are still an important tool for managing pain. Basic opioid management and safe practices are essential when managing this population.
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Affiliation(s)
- Kimberly Angelia Curseen
- Internal Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA.
| | - Jabeen Taj
- Hospice and Palliative Medicine, Cardiac Palliative Care, Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory University Hospital, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
| | - Quintesia Grant
- Palliative and Supportive Care, Grady Memorial Hospital, Harbor Grace Hospice, Atlanta, GA, USA; Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
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Abstract
PURPOSE OF REVIEW Strong epidemiological and pathologic evidence associates NSAIDs with kidney disease, both acute and chronic. Hence, the usage of NSAIDs has decreased in patients with, or at risk for, chronic kidney disease (CKD). Coupled with this has been a rise in use of opioids and other non-NSAID alternatives, which do come with significant, and underrecognized, risk of nonrenal adverse events. We review the literature to understand if this shift is appropriate or deleterious. RECENT FINDINGS NSAIDs do have a low but tangible risk in causing acute kidney injury, electrolyte imbalances, and increasing blood pressure. However, their role in causing progressive kidney disease is due to long-term usage in high cumulative dosages, and the use of NSAIDs in combination with other agents. Alternatives such as opioids, tramadol, gabapentin and baclofen have weak evidence to support their use and strong evidence to show their harm in patients with CKD. SUMMARY Tradeoffs are inherent in using active pharmaceuticals, and NSAIDs are no exception. Balancing potential benefits with possible adverse effects around pain management should be a part of every conversation for patients with kidney disease.
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17
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Owsiany MT, Hawley CE, Triantafylidis LK, Paik JM. Opioid Management in Older Adults with Chronic Kidney Disease: A Review. Am J Med 2019; 132:1386-1393. [PMID: 31295441 PMCID: PMC6917891 DOI: 10.1016/j.amjmed.2019.06.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/11/2022]
Abstract
Chronic pain, a common comorbidity of chronic kidney disease, is consistently under-recognized and difficult to treat in older adults with nondialysis chronic kidney disease. Given the decreased kidney function associated with aging and chronic kidney disease, these patients are at increased risk for drug accumulation and adverse events. Emerging research has demonstrated the efficacy of opioids in chronic kidney disease patients, but research specifically focusing on older, nondialysis chronic kidney disease patients is scarce. The primary objective of this review is to determine which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients. We discuss the limited existing evidence on opioid prescription in older, nondialysis chronic kidney disease patients and provide recommendations for the management of oral and transdermal opioids in this patient population. Specifically, transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring; and tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events. Because older adults with nondialysis chronic kidney disease are at increased risk for adverse events, vigilant monitoring of opioid prescription is critical. Lastly, collaboration among an interprofessional clinical team can ensure safe prescription of opioids in older adults with nondialysis chronic kidney disease.
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Affiliation(s)
| | - Chelsea E Hawley
- New England Geriatric Research, Education and Clinical Center; Pharmacy Department, VA Boston Healthcare System, Mass
| | | | - Julie M Paik
- New England Geriatric Research, Education and Clinical Center; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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18
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Barakji JA, Korang SK, Feinberg J, Maagard M, Gluud C, Mathiesen O, Jakobsen JC. Cannabinoids versus placebo or no intervention for pain: protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2019; 9:e031574. [PMID: 31676655 PMCID: PMC6830650 DOI: 10.1136/bmjopen-2019-031574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/07/2019] [Accepted: 10/04/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Pain is a frequent clinical symptom with significant impact on the patient's well-being. Therefore, adequate pain management is of utmost importance. While cannabinoids have become a more popular alternative to traditional types of pain medication among patients, the quality of evidence supporting the use of cannabinoids has been questioned. The beneficial and harmful effects of cannabinoids in patients with pain is unknown. Accordingly, we aim to assess the efficacy, tolerability and safety of cannabinoids (herbal, plant-derived extracts and synthetic) compared with placebo or no intervention for any type of pain. METHODS AND ANALYSES We will conduct a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis to assess the beneficial and harmful effects of cannabinoids in any dose, formulation and duration. We will accept placebo or no treatment as control interventions. We will include participants with any type of pain (acute and chronic pain, cancer-related pain, headache, neuropathic pain or any other types of pain). We will systematically search The Cochrane Library, MEDLINE, Embase, Science Citation Index and BIOSIS for relevant literature. We will follow the recommendations by Cochrane and the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The risk of systematic errors (bias) and random errors (play of chance) will be assessed. The overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Ethical approval is not a requirement since no primary data will be collected. The findings of this systematic review will be submitted for peer-reviewed publication and disseminated in national and international conferences. DISCUSSION Although cannabinoids are now being used to manage different pain conditions, the evidence for the clinical effects are unclear. The present review will systematically assess the current evidence for the benefits and harms of cannabinoids to inform practice and future research.
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Affiliation(s)
- Jehad Ahmad Barakji
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Center for Clinical Intervention Research, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Center for Clinical Intervention Research, Copenhagen, Denmark
- Pediatric Department, Holbaek Hospital, Holbaek, Denmark
| | | | - Mathias Maagard
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Center for Clinical Intervention Research, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Center for Clinical Intervention Research, Copenhagen, Denmark
| | | | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Rigshospitalet, Department 7812, Center for Clinical Intervention Research, Copenhagen, Denmark
- Cardiology Department, Holbaek Hospital, Holbaek, Denmark
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20
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Aitken E, McColl G, Kingsmore D. The Role of Qutenza® (Topical Capsaicin 8%) in Treating Neuropathic Pain from Critical Ischemia in Patients with End-Stage Renal Disease: An Observational Cohort Study. PAIN MEDICINE 2018; 18:330-340. [PMID: 28204726 DOI: 10.1093/pm/pnw139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Current treatment strategies for painful critical ischemia in patients with end-stage renal disease (ESRD) are suboptimal. A drug that is non-renally excreted has minimal systemic absorption and does not require dose adjustment in renal failure is attractive. The aim of this study was to evaluate the safety and efficacy of Qutenza® (topical capsaicin 8%) for chronic neuropathic pain from critical ischemia in patients with ESRD. Design and Setting A prospective cohort study was conducted in a single-center, university teaching hospital. Patients Twenty patients with ESRD were treated with Qutenza® for neuropathic pain from critical limb ischemia. Methods Patients were followed-up at 1, 6 and 12 weeks post-treatment. The primary end point was the difference in visual analog scale (VAS) between baseline and week 12. Secondary end points were Brief Pain Inventory questionnaire (BPI) scores, quality of life assessment (EQ-5D) and patient global impression of change (PGIC). Safety and tolerability data were also collected. The trial was prospectively registered with clinical trials databases (EudraCT: 2012-001586-32; NCT01704313). Results There was significant reduction in VAS from baseline to week 12 (-20+/-7%; P = 0.02). There was a significant reduction in all seven domains of the BPI. Quality of life also improved at 12 weeks following treatment in two of the EQ-5D domains (mobility and pain). Qutenza® was well tolerated with no significant side effects in this patient cohort, which included 20% diabetics. Conclusions In this small, observational study Qutenza® treatment has been shown to be effective and well-tolerated to treat neuropathic pain from critical ischemia in patients with ESRD.
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Affiliation(s)
- Emma Aitken
- Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - Gillian McColl
- Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - David Kingsmore
- Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
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21
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Chan KY, Yap DY, Yip T, Sham MK, Lui SL, Chan TM. Palliative Care Consultation in Advanced Chronic Kidney Disease with Pain. J Palliat Med 2018; 21:809-814. [DOI: 10.1089/jpm.2017.0505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kwok Ying Chan
- Palliative Medical Unit, Grantham Hospital, Aberdeen, Hong Kong
| | - Desmond Y.H. Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Terence Yip
- Department of Medicine, Renal Unit, Tung Wah Hospital, Sheung Wan, Hong Kong
| | - Mau Kwong Sham
- Palliative Medical Unit, Grantham Hospital, Aberdeen, Hong Kong
| | - Sing Leung Lui
- Department of Medicine, Renal Unit, Tung Wah Hospital, Sheung Wan, Hong Kong
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
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22
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Raina R, Krishnappa V, Gupta M. Management of pain in end-stage renal disease patients: Short review. Hemodial Int 2017; 22:290-296. [DOI: 10.1111/hdi.12622] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/02/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rupesh Raina
- Department of Nephrology; Cleveland Clinic Akron General/Akron Nephrology Associates; Akron Ohio USA
| | - Vinod Krishnappa
- Department of Nephrology; Cleveland Clinic Akron General/Akron Nephrology Associates; Akron Ohio USA
| | - Mona Gupta
- Department of Hospice and Palliative Medicine; University Hospitals Cleveland Medical Center; Cleveland Ohio USA
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Nagar VR, Birthi P, Salles S, Sloan PA. Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review. PAIN MEDICINE 2017; 18:1416-1449. [DOI: 10.1093/pm/pnw238] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Koncicki HM, Unruh M, Schell JO. Pain Management in CKD: A Guide for Nephrology Providers. Am J Kidney Dis 2017; 69:451-460. [DOI: 10.1053/j.ajkd.2016.08.039] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/09/2016] [Indexed: 02/05/2023]
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Koncicki HM, Brennan F, Vinen K, Davison SN. An Approach to Pain Management in End Stage Renal Disease: Considerations for General Management and Intradialytic Symptoms. Semin Dial 2015; 28:384-91. [PMID: 25864854 DOI: 10.1111/sdi.12372] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The prevalence and severity of symptoms in patients with advanced chronic kidney disease is higher than those of the general population and comparable to those with other chronic and serious medical conditions. Despite the prevalence and severity in this population, symptoms continue to be under-recognized and inadequately managed. The recognition of specific intradialytic pain syndromes such as pain related to arteriovenous access, headaches, muscle cramps or generalized pain by providers may aid in improving patient compliance and quality of life. The approach to pain management in end stage renal disease patients follows that of the general population with specific considerations regarding clearance and potential side effects guiding selection of agents. Overall, evidence is limited regarding the pharmacology of many medications in this population.
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Affiliation(s)
- Holly M Koncicki
- Division of Kidney Diseases & Hypertension, Department of Internal Medicine, Hofstra North Shore-LIJ School of Medicine, Great Neck, New York
| | - Frank Brennan
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Katie Vinen
- Department of Renal Medicine, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sara N Davison
- Division of Nephrology & Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Gallieni M, Cancarini G. Drugs in the elderly with chronic kidney disease: beware of potentially inappropriate medications. Nephrol Dial Transplant 2014; 30:342-4. [PMID: 24923769 DOI: 10.1093/ndt/gfu191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Maurizio Gallieni
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo, Milan, Italy
| | - Giovanni Cancarini
- Department of Nephrology, A.O. Spedali Civili Brescia and Università di Brescia, Brescia, Italy
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Davison SN, Koncicki H, Brennan F. Pain in Chronic Kidney Disease: A Scoping Review. Semin Dial 2014; 27:188-204. [DOI: 10.1111/sdi.12196] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Sara N. Davison
- Division of Nephrology & Immunology; Department of Medicine; University of Alberta; Edmonton Alberta Canada
| | - Holly Koncicki
- Department of Geriatrics and Palliative Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York City New York
| | - Frank Brennan
- Department of Palliative Care; St George Hospital; Sydney New South Wales Australia
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Murphy E, Germain MJ, Cairns H, Higginson IJ, Murtagh FEM. International variation in classification of dialysis withdrawal: a systematic review. Nephrol Dial Transplant 2013; 29:625-35. [PMID: 24293659 DOI: 10.1093/ndt/gft458] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with end-stage renal disease (ESRD), the rate of deaths preceded by dialysis withdrawal is high. However, rates vary across studies and national renal registries. This study aimed to (i) determine how dialysis withdrawal mortality is defined in the literature and (ii) whether mortality rates preceded by dialysis withdrawal change over time. METHODS MEDLINE (1946 to March 2012) and EMBASE (1980 to March 2012) databases were searched. We included epidemiological studies that reported data permitting calculation of crude (unadjusted) mortality rates preceded by dialysis withdrawal. Definitions of dialysis withdrawal were also extracted. Crude mortality rates and 95% confidence intervals were calculated using OpenEpi software. Non-English language studies were excluded. RESULTS Twenty-three eligible studies were identified; these included 14 527 885 dialysis patients at risk from six countries. Crude mortality rates preceded by dialysis withdrawal ranged from 3 to 50.2 per 1000 person-years. Seven different definitions of dialysis withdrawal were identified, with no assessment of validity. Crude mortality rates preceded by withdrawal have increased over time across the study period 1966 (3 per 1000 person-years) to 2010 (48.6 per 1000 person-years), although these rates are difficult to interpret because of differences in classification. In the USA crude mortality rates preceded by dialysis withdrawal are higher in the older population and have increased over time in the age group 65+ years. In this age group, the crude mortality rate preceded by dialysis withdrawal was 89.4 per 1000 person-years (2008-10) compared with 26.1 per 1000 person-years in the age group 50-64 years (2008-10). CONCLUSION Mortality rates preceded by dialysis withdrawal over time should be interpreted with caution because of differences in classification. Types of dialysis withdrawal need more careful elucidation, and we propose a unified classification of dialysis withdrawal based on trajectories and causal criteria.
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Affiliation(s)
- Emma Murphy
- NIHR GSTFT/KCL Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Barrantes F, Luan FL, Kommareddi M, Alazem K, Yaqub T, Roth RS, Sung RS, Cibrik DM, Song P, Samaniego M. A history of chronic opioid usage prior to kidney transplantation may be associated with increased mortality risk. Kidney Int 2013; 84:390-6. [DOI: 10.1038/ki.2013.136] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/30/2013] [Accepted: 02/07/2013] [Indexed: 12/20/2022]
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Palkovits M, Šebeková K, Klenovics KS, Kebis A, Fazeli G, Bahner U, Heidland A. Neuronal activation in the central nervous system of rats in the initial stage of chronic kidney disease-modulatory effects of losartan and moxonidine. PLoS One 2013; 8:e66543. [PMID: 23818940 PMCID: PMC3688530 DOI: 10.1371/journal.pone.0066543] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 04/18/2013] [Indexed: 11/19/2022] Open
Abstract
The effect of mild chronic renal failure (CRF) induced by 4/6-nephrectomy (4/6NX) on central neuronal activations was investigated by c-Fos immunohistochemistry staining and compared to sham-operated rats. In the 4/6 NX rats also the effect of the angiotensin receptor blocker, losartan, and the central sympatholyticum moxonidine was studied for two months. In serial brain sections Fos-immunoreactive neurons were localized and classified semiquantitatively. In 37 brain areas/nuclei several neurons with different functional properties were strongly affected in 4/6NX. It elicited a moderate to high Fos-activity in areas responsible for the monoaminergic innervation of the cerebral cortex, the limbic system, the thalamus and hypothalamus (e.g. noradrenergic neurons of the locus coeruleus, serotonergic neurons in dorsal raphe, histaminergic neurons in the tuberomamillary nucleus). Other monoaminergic cell groups (A5 noradrenaline, C1 adrenaline, medullary raphe serotonin neurons) and neurons in the hypothalamic paraventricular nucleus (innervating the sympathetic preganglionic neurons and affecting the peripheral sympathetic outflow) did not show Fos-activity. Stress- and pain-sensitive cortical/subcortical areas, neurons in the limbic system, the hypothalamus and the circumventricular organs were also affected by 4/6NX. Administration of losartan and more strongly moxonidine modulated most effects and particularly inhibited Fos-activity in locus coeruleus neurons. In conclusion, 4/6NX elicits high activity in central sympathetic, stress- and pain-related brain areas as well as in the limbic system, which can be ameliorated by losartan and particularly by moxonidine. These changes indicate a high sensitivity of CNS in initial stages of CKD which could be causative in clinical disturbances.
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Affiliation(s)
- Miklós Palkovits
- Neuromorphological and Neuroendocrine Research Laboratory, Semmelweis University and the Hungarian Academy of Sciences, Budapest, Hungary
| | - Katarína Šebeková
- Institute of Molecular Biomedicine, Medical Faculty, Comenius University, Bratislava, Slovakia
| | | | - Anton Kebis
- Laboratory of Organ Perfusion of Slovak Center of Organ Transplantation, Slovak Medical University, Bratislava, Slovakia
| | - Gholamreza Fazeli
- Institute of Pharmacology and Toxicology, University of Wuerzburg, Wuerzburg, Germany
| | | | - August Heidland
- Department of Internal Medicine, University of Wuerzburg and KfH-Kidney Centre, Wuerzburg, Germany
- * E-mail:
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Abstract
SUMMARY Cancer and noncancer pain can usually be managed according to the WHO analgesic ladder and, in many countries, morphine remains the first-line opioid of choice for chronic severe pain. There have been many advances in the use of opioids for moderate-to-severe pain control in recent years. Consequently, the position of morphine as the gold standard became gradually more questioned, mostly because of serious adverse effects and the availability of different opioids and new formulations. The place of morphine as the first-line option is based on reasons of familiarity, availability or cost rather than medical advantages. In recent years, a number of systematic reviews failed to demonstrate superiority of morphine over other opioids in terms of efficacy or tolerability. Moreover, some strong opioids have shown improved tolerability or convenience. Currently, morphine might still be considered as a reference drug for equivalent dosing, but not for strategic healthcare decisions, as it has not demonstrated clinical or pharmacological superiority over other opioids. Therefore, there is a lack of evidence to sustain the role of morphine as the gold standard in the treatment of chronic severe pain.
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Affiliation(s)
- Rafael Gálvez
- Pain Unit, Hospital Virgen de las Nieves, Avenida de las Fuerzas Armadas, 2. 18014, Granada, Spain
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Abstract
Palliative care begins with establishing goals of care based on estimated prognosis in end-stage renal disease (ESRD). Patients with ESRD are increasingly characterized by older age and multiple comorbid illnesses, and have a mortality rate 8 times higher than the general Medicare population. Dialysis patients are appropriate for palliative care because of their high mortality rate and high symptom burden. More patients and families are choosing not to start or withdraw dialysis for multiple reasons, particularly in patients older than 60 years. Advance directives and resuscitation directives are important in ensuring compassionate and goal-directed palliative care of ESRD patients. Drug toxicities are avoidable by using appropriate drugs at the correct doses and dosing intervals.
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Affiliation(s)
- Ronald Werb
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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Kafkia T, Chamney M, Drinkwater A, Pegoraro M, Sedgewick J. Pain in chronic kidney disease: prevalence, cause and management. J Ren Care 2011; 37:114-22. [PMID: 21561548 DOI: 10.1111/j.1755-6686.2011.00234.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pain is an unpleasant sensory and emotional experience and is the most common symptom experienced by renal patients. It can be caused by primary co-morbid diseases, renal replacement therapies, medication or treatment side effects, and its intensity varies from moderate to severe. Pain management in renal patients is difficult, since the distance between pain relief and toxicity is very small. This paper will provide an algorithm for pain management proposed using paracetamol, nonsteroid anti-inflamatory drugs (NSAIDs), mild and stronger opioids as well as complementary techniques. Quality of Life (QoL) and overall enhancement of the patient experience through better pain management are also discussed. To improve pain management it is essential that nurses recognise that they have direct responsibilities related to pain assessment and tailoring of opioid analgesics and better and more detailed education.
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Mariotti MC, Rocha de Carvalho JG. Improving quality of life in hemodialysis: impact of an occupational therapy program. Scand J Occup Ther 2010; 18:172-9. [DOI: 10.3109/11038128.2010.488271] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Williams AF, Manias E. Perceptions of pain control by consumers with chronic kidney disease. ACTA ACUST UNITED AC 2009. [DOI: 10.1111/j.1752-9824.2009.01022.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Heiwe S, Bjuke M. “An Evil Heritage”: Interview Study of Pain and Autosomal Dominant Polycystic Kidney Disease. Pain Manag Nurs 2009; 10:134-41. [DOI: 10.1016/j.pmn.2009.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 02/18/2009] [Accepted: 03/05/2009] [Indexed: 11/28/2022]
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Golan E, Haggiag I, Os P, Bernheim J. Calcium, parathyroid hormone, and vitamin D: major determinants of chronic pain in hemodialysis patients. Clin J Am Soc Nephrol 2009; 4:1374-80. [PMID: 19578003 DOI: 10.2215/cjn.00680109] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain is a frequent complaint of hemodialysis (HD) patients, yet information regarding its causes and frequency is relatively scarce. The aim of this study was to evaluate the frequency and possible causes of chronic pain in patients who are on long-term HD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We prospectively enrolled 100 patients who were undergoing maintenance HD for at least 3 mo. Pain was evaluated using the Brief Pain Inventory. Data collected on each participant included age, gender, ethnic origin, body mass index, smoking habits, time on dialysis, type of blood access, comorbidities, and biochemical and hematologic parameters. RESULTS The average age was 64.5 yr; the average time on dialysis 40.4 mo. Forty-five patients were male. Thirty-one participants were of Arabic origin. Fifty-three patients had diabetes, 36 of whom had diabetic retinopathy. Although 51 patients experienced chronic pain, only 19.6% described the pain as severe. Musculoskeletal pain, neuropathic pain, and headache were the most prevalent forms of pain. The presence of diabetic retinopathy and neuropathy (but not diabetes per se) and levels of intact parathyroid hormone, calcium, and calcitriol (but not 25-hydroxyvitamin D(3)) differed significantly between those who experienced chronic pain and those who did not. On a logistic regression model, higher serum calcium levels and intact parathyroid hormone levels >250 pg/ml were independently associated with chronic pain, as well as the presence of diabetic retinopathy. Calcitriol had a marginal effect. CONCLUSIONS Disturbed mineral metabolism is strongly associated with chronic pain in long-term HD patients, along with microangiopathy.
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Affiliation(s)
- Eliezer Golan
- Department of Nephrology and Hypertension, Meir Medical Center, 59 Tchernichovsky Street, Kfar Saba 44281, Israel.
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Manias E, Williams A. Managing pain in chronic kidney disease: patient participation in decision-making. J Adv Nurs 2008; 61:201-10. [DOI: 10.1111/j.1365-2648.2007.04488.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Germain M, Cohen LM. Renal Supportive Care: View from Across the Pond: The United States Perspective. J Palliat Med 2007; 10:1241-4. [DOI: 10.1089/jpm.2006.0252] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael Germain
- Division of Nephrology, Baystate Medical Center, Springfield, Massachusetts
| | - Lewis M. Cohen
- Psychiatric Consultation Service, Baystate Medical Center, Springfield, Massachusetts
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40
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Manias E, Williams A. Communication between patients with chronic kidney disease and nurses about managing pain in the acute hospital setting. J Clin Nurs 2007; 16:358-67. [DOI: 10.1111/j.1365-2702.2007.02075.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Williams A, Manias E. A structured literature review of pain assessment and management of patients with chronic kidney disease. J Clin Nurs 2007; 17:69-81. [PMID: 17608633 DOI: 10.1111/j.1365-2702.2007.01994.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES This paper reviews the literature concerning nurses' assessment and management of pain in adult patients with chronic kidney disease, and proposes implications for clinical practice to support the control of pain in these patients. BACKGROUND Chronic kidney disease is a worldwide public health concern with increasing incidence and prevalence, poor patient outcomes and high cost. Patients with kidney disease often experience pain. Optimal pain assessment and management are key clinical activities; however, inadequate pain control by health professionals persists. Renal failure compounds this problem because of the small margin between pain relief and toxicity, and the patient's concomitant health problems. CONCLUSIONS The literature review uses 93 articles that were published in medical- and other health-related journals, including 12 medical and pharmaceutical studies specifically relating to pain control in adults with kidney disease. Very little research has been conducted on pain in patients with kidney disease prior to requiring dialysis or kidney transplantation for survival. However, past research showed pain is common and analgesics are underprescribed in patients on dialysis in end-stage kidney disease. The review indicates that an interest in nephrotoxicity and analgesic-induced morbidity dominates over an interest in pain relief in patients with kidney disease. Most analgesics are excreted renally or by the liver, and the use of simple analgesics such as paracetamol is cautioned. RELEVANCE TO CLINICAL PRACTICE Findings from the literature review highlight specific difficulties relating to effective pain control in patients with chronic kidney disease. Research is required to identify and overcome barriers to effective pain management, including the development of specific tools to facilitate interventions that optimize analgesic outcomes in patients with chronic kidney disease.
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Affiliation(s)
- Allison Williams
- School of Nursing, The University of Melbourne, Carlton, Australia.
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Germain MJ, Cohen LM, Davison SN. Withholding and Withdrawal from Dialysis: What We Know About How Our Patients Die. Semin Dial 2007; 20:195-9. [PMID: 17555480 DOI: 10.1111/j.1525-139x.2007.00273.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Withholding and withdrawal of dialysis has been a reality since dialysis was invented. Only in the past 20 years has it been formally studied, and we still have a great deal to learn. The nephrology community has slowly come to accept that, for some of our patients, not having dialysis is a better option than continuing or initiating therapy. The principles of palliative care throughout the disease trajectory and hospice care at end of life are germane to this population due to its high symptom burden and mortality rate. We review what is currently known concerning patients who choose to withhold or withdraw from dialysis, and the current barriers (and solutions) to providing them with optimal palliative care.
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Affiliation(s)
- Michael J Germain
- Division of Nephrology, Department of Medicine, Tufts University, Boston, Massachusetts, USA.
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Barakzoy AS, Moss AH. Efficacy of the World Health Organization Analgesic Ladder to Treat Pain in End-Stage Renal Disease. J Am Soc Nephrol 2006; 17:3198-203. [PMID: 16988057 DOI: 10.1681/asn.2006050477] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pain is the one of the most common symptoms experienced by patients with ESRD; it impairs their quality of life and is undertreated. Most pain clinicians believe that the pain management approach of the World Health Organization (WHO) three-step analgesic ladder is applicable to the treatment of patients with ESRD, but this approach has not been validated for them. A cohort of 45 hemodialysis patients were assessed for type and severity of pain using the Short-Form McGill Pain Questionnaire and then treated during a 4-wk period according to the WHO analgesic ladder. Mean age was 65 +/- 12.5 yr, and 22 (49%) patients had diabetic nephropathy as the cause of ESRD. Initial pain was rated severe by 34 (76%) patients. There was no difference in initial pain rating by gender, age, race, or type of pain. Forty percent of patients reported nociceptive pain, 31% neuropathic, and 29% both. Adequate analgesia was achieved in 43 (96%) of 45 patients. The mean pain score decreased from 7.8 +/- 1.2 to 1.6 +/- 1.3 (P < 0.001). Patients who were 65 yr and older had higher posttreatment scores than those who were younger than 65 (2.1 +/- 1.4 versus 0.94 +/- 0.93; P = 0.002) and more medication adverse effects. It is concluded that the use of the WHO three-step analgesic ladder leads to effective pain relief in hemodialysis patients. Older patients will need more careful pain management to achieve the same results as younger patients. Further studies are needed to confirm these results in a larger, more diverse dialysis population.
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Affiliation(s)
- Ahmad S Barakzoy
- Section of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia 26506-9022, USA
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Davison SN, Jhangri GS, Holley JL, Moss AH. Nephrologists' reported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol 2006; 1:1256-62. [PMID: 17699356 DOI: 10.2215/cjn.02040606] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nephrologists commonly engage in end-of-life decision-making with patients with ESRD and their families. The purpose of this study was to determine the perceived preparedness of nephrologists to make end-of-life decisions and to determine factors that are associated with the highest level of perceived preparedness. The nephrologist members of the Renal Physicians Association (RPA) and the Canadian Society of Nephrology were invited to participate in an online survey of their end-of-life decision-making practices. A total of 39% of 360 respondents perceived themselves as very well prepared to make end-of-life decisions. Age >46 yr, six or more patients withdrawn from dialysis in the preceding year, and awareness of the RPA/American Society of Nephrology (ASN) guideline on dialysis decision-making were independently associated with the highest level of self-reported preparedness. Nephrologists who reported being very well prepared were more likely to use time-limited trials of dialysis and stop dialysis of a patient with permanent and severe dementia. Compared with Americans, Canadian nephrologists reported being equally prepared to make end-of-life decisions, stopped dialysis of a higher number of patients, referred fewer to hospice, and were more likely to stop dialysis of a patient with severe dementia. Nephrologists who have been in practice longer and are knowledgeable of the RPA/ASN guideline report greater preparedness to make end-of-life decisions and report doing so more often in accordance with guideline recommendations. To improve nephrologists' comfort with end-of-life decision-making, fellowship programs should teach the recommendations in the RPA/ASN guideline and position statement.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, University of Alberta, Edmonton, Alberta, Canada.
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46
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Rousseau PC. Recent Literature. J Palliat Med 2006. [DOI: 10.1089/jpm.2006.9.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paul C. Rousseau
- Department of Geriatrics and Extended Care, VA Medical Center, Phoenix, AZ 85012
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