Opioid Prescription, Morbidity, and Mortality in US Transplant Recipients

Postoperative pain management after abdominal transplantations

PURPOSE OF REVIEW

The aim of this review article is to present current recommendations as well as knowledge gaps and controversies pertaining to commonly utilized postoperative pain management after solid organ transplantation in the abdominal cavity.

RECENT FINDINGS

Postsurgical pain has been identified as one of the major challenges in recovery and treatment after solid organ transplants. Many perioperative interventions and management strategies are available for reducing and managing postoperative pain. Management should be tailored to the individual needs, taking an interdisciplinary and holistic approach and following enhanced recovery after surgery guidelines. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures.

SUMMARY

The optimal pain management regimen has not yet been definitively established, and current scientific evidence does not yet support the endorsement of a certain analgesic approach. This objective necessitates the need for high-quality randomized controlled trials.

Effects of intraoperative liposomal bupivacaine on postoperative opioid usage in kidney transplant recipients

This study retrospectively evaluated the use of intraoperative locally infiltrated peri-incisional liposomal bupivacaine in kidney transplant recipients with the primary outcome of oral morphine equivalent reduction during the transplant admission. Secondary outcomes included pain scores, time to first bowel movement and length of stay. Postoperative morphine equivalents were significantly lower in the liposomal bupivacaine group <24 hours (50% reduction, p < 0.05) and 24-48 hours (56.5% reduction, p < 0.05). When accounting for analgesic medication choices, liposomal bupivacaine did not result in a significant reduction in opioid use within 48 hours postoperatively with the exception of a 51% (p = 0.02) median reduction in fentanyl patient-controlled analgesia morphine equivalents <24 hours postoperatively. Morphine equivalence reductions >48 hours, differences in pain scores, time to first bowel movement or length of stay did not reach significance. Intraoperative liposomal bupivacaine reduced kidney transplant recipient's postoperative opioid requirements, but this benefit did not reliably extend past 24 hours postoperatively.

Opioid Prescriptions for US Patients Undergoing Long-Term Dialysis or with Kidney Transplant from 2011 to 2020

Key Points

Background

Pain is important for patients with kidney failure, but opioid medication prescriptions are associated with morbidity and mortality. The Centers for Disease Control and Prevention issued opioid prescription guidelines in 2016 and 2022, associated with dramatically decreased prescription rates in the United States. It is critical to know whether nationwide opioid prescription rates for patients with kidney failure have decreased.

Methods

We analyzed the United States Renal Data System database from 2011 to 2020 to describe trends in the proportion of patients with ESKD who received one or more, or long-term, opioid prescriptions, examined factors associated with long-term opioid prescriptions, and evaluated associations of all-cause death with short-term or long-term opioid prescriptions.

Results

From 2011 to 2022, the percentage of patients with kidney failure (dialysis and kidney transplant) who received at least one or more, or who had received long-term, opioid medication prescriptions decreased steadily, from 60% to 42%, and from 23% to 13%, respectively (both P for trend < 0.001). The largest reductions in prescription rates were for hydrocodone and oxycodone. Similar trends existed for dialysis and kidney transplant patients. Women, the poor, and those in rural settings were more likely to receive long-term opioid prescriptions. Prescription rates were highest in White patients and those aged 45–64 years. Short-term and long-term opioid medication prescriptions were associated with higher mortality in both dialysis and kidney transplant patients.

Conclusions

The opioid prescription rates of patients with ESKD decreased between 2011 and 2020. Higher mortality risk was associated with both short-term and long-term opioid prescriptions. Mortality risk was monotonically associated with morphine milligram equivalents in patients with kidney failure who received long-term opioid prescriptions.

Anterior quadratus lumborum block for analgesia after living-donor renal transplantation: a double-blinded randomized controlled trial

INTRODUCTION

Limited non-opioid analgesic options are available for managing postoperative pain after renal transplantation. We aimed to investigate whether the unilateral anterior quadratus lumborum (QL) block would reduce postoperative opioid consumption after living-donor renal transplantation in the context of multimodal analgesia.

METHODS

Eighty-eight adult patients undergoing living-donor renal transplantation were randomly allocated to receive the unilateral anterior QL block (30 mL of ropivacaine 0.375%) or sham block (normal saline) on the operated side before emergence from anesthesia. All patients received standard multimodal analgesia, including the scheduled administration of acetaminophen and fentanyl via intravenous patient-controlled analgesia. The primary outcome was the total opioid consumption during the first 24 hours after transplantation. The secondary outcomes included pain scores, time to first opioid administration, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulation, and length of hospital stay.

RESULTS

The total opioid consumption in the first 24 hours after transplantation did not differ significantly between the intervention and control groups (median (IQR), 160.5 (78-249.8) vs 187.5 (93-309) oral morphine milligram equivalent; median difference (95% CI), -27 (-78 to 24), p=0.29). No differences were observed in the secondary outcomes.

CONCLUSIONS

The anterior QL block did not reduce opioid consumption in patients receiving multimodal analgesia after living-donor renal transplantation. Our findings do not support the routine administration of the anterior QL block in this surgical population.

TRIAL REGISTRATION NUMBER

NCT04908761.

Opioids and the kidney: two sides of the same coin

Renal dysfunction, including acute renal failure (ARF) and chronic kidney disease (CKD), continues to present significant health challenges, with renal ischemia-reperfusion injury (IRI) being a pivotal factor in their development and progression. This condition, notably impacting kidney transplantation outcomes, underscores the urgent need for innovative therapeutic interventions. The role of opioid agonists in this context, however, remains a subject of considerable debate. Current reviews tend to offer limited perspectives, focusing predominantly on either the protective or detrimental effects of opioids in isolation. Our review addresses this gap through a thorough and comprehensive evaluation of the existing literature, providing a balanced examination of the dualistic nature of opioids' influence on renal health. We delve into both the nephroprotective and nephrotoxic aspects of opioids, dissecting the complex interactions and paradoxical effects that embody the "two sides of the same coin" phenomenon. This comprehensive analysis is vital for understanding the intricate roles of opioids in renal pathophysiology, potentially informing the development of novel therapeutic strategies for preventing or treating hypoxic kidney injury.

Continuous flow local anesthetic wound infusion for post-operative analgesia following kidney transplantation

BACKGROUND

Some patients with end stage renal disease are or will become narcotic-dependent. Chronic narcotic use is associated with increased graft loss and mortality following kidney transplantation. We aimed to compare the efficacy of continuous flow local anesthetic wound infusion pumps (CFLAP) with patient controlled analgesia pumps (PCA) in reducing inpatient narcotic consumption in patients undergoing kidney transplantation.

MATERIALS AND METHODS

In this single-center, retrospective analysis of patients undergoing kidney transplantation, we collected demographic and operative data, peri-operative outcomes, complications, and inpatient oral morphine milligram equivalent (OME) consumption.

RESULTS

Four hundred and ninety-eight patients underwent kidney transplantation from 2020 to 2022. 296 (59%) historical control patients received a PCA for postoperative pain control and the next 202 (41%) patients received a CFLAP. Median age [53.5 vs. 56.0 years, p = .08] and BMI [29.5 vs. 28.9 kg/m2, p = .17] were similar. Total OME requirement was lower in the CFLAP group [2.5 vs. 34 mg, p < .001]. Wound-related complications were higher in the CFLAP group [5.9% vs. 2.7%, p = .03]. Two (.9%) patients in the CFLAP group experienced cardiac arrhythmia due to local anesthetic toxicity and required lipid infusion.

CONCLUSIONS

Compared to PCA, CFLAP provided a 93% reduction in OME consumption with a small increase in the wound-related complication rate. The utility of local anesthetic pumps may also be applicable to patients undergoing any unilateral abdominal or pelvic incision.

Long-term Outcomes Following a Comprehensive Quality Assurance and Process Improvement Endeavor to Minimize Opioid Use After Kidney Transplant

Importance

Opioid use following kidney transplant is associated with an increased risk of graft loss and mortality. Opioid minimization strategies and protocols have shown reductions in short-term opioid use after kidney transplant.

Objective

To evaluate the long-term outcomes associated with an opioid minimization protocol following kidney transplant.

Design, Setting, and Participants

This single-center quality improvement study evaluated postoperative and long-term opioid use before and after the implementation of a multidisciplinary, multimodal pain regimen and education process in adult kidney graft recipients from August 1, 2017, through June 30, 2020. Patient data were collected from a retrospective chart review.

Exposures

Preprotocol and postprotocol implementation use of opioids.

Main Outcomes and Measures

Between November 7 and 23, 2022, opioid use before and after protocol implementation was evaluated up to 1 year after transplant using multivariable linear and logistic regression.

Results

A total of 743 patients were included, with 245 patients in the preprotocol group (39.2% female and 60.8% male; mean [SD] age, 52.8 [13.1 years]) vs 498 in the postprotocol group (45.4% female and 54.6% male; mean [SD] age, 52.4 [12.9 years]). The total morphine milligram equivalents (MME) in the 1-year follow-up in the preprotocol group was 1203.7 vs 581.9 in the postprotocol group. In the postprotocol group, 313 patients (62.9%) had 0 MME in the 1-year follow-up vs 7 (2.9%) in the preprotocol group (odds ratio [OR], 57.52; 95% CI, 26.55-124.65). Patients in the postprotocol group had 99% lower odds of filling more than 100 MME in the 1-year follow-up (adjusted OR, 0.01; 95% CI, 0.01-0.02; P < .001). Opioid-naive patients postprotocol were one-half as likely to become long-term opioid users vs preprotocol (OR, 0.44; 95% CI, 0.20-0.98; P = .04).

Conclusions and Relevance

The study's findings show a significant reduction in opioid use in kidney graft recipients associated with the implementation of a multimodal opioid-sparing pain protocol.

Prevention and Management of Chronic Postsurgical Pain and Persistent Opioid Use Following Solid Organ Transplantation: Experiences From the Toronto General Hospital Transitional Pain Service

BACKGROUND

With >700 transplant surgeries performed each year, Toronto General Hospital (TGH) is currently one of the largest adult transplant centers in North America. There is a lack of literature regarding both the identification and management of chronic postsurgical pain (CPSP) after organ transplantation. Since 2014, the TGH Transitional Pain Service (TPS) has helped manage patients who developed CPSP after solid organ transplantation (SOT), including heart, lung, liver, and renal transplants.

METHODS

In this retrospective cohort study, we describe the association between opioid consumption, psychological characteristics of pain, and demographic characteristics of 140 SOT patients who participated in the multidisciplinary treatment at the TGH TPS, incorporating psychology and physiotherapy as key parts of our multimodal pain management regimen.

RESULTS

Treatment by the multidisciplinary TPS team was associated with significant improvement in pain severity and a reduction in opioid consumption.

CONCLUSIONS

Given the risk of CPSP after SOT, robust follow-up and management by a multidisciplinary team should be considered to prevent CPSP, help guide opioid weaning, and provide psychological support to these patients to improve their recovery trajectory and quality of life postoperatively.

Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study

OBJECTIVES

Opioids are commonly used to manage pain, despite an increased risk of adverse events and complications when used against recommendations. This register study uses data of osteoarthritis (OA) patients with joint replacement surgery to identify and characterize problematic opioid use (POU) prescription patterns.

METHODS

The study population included adult patients diagnosed with OA in specialty care undergoing joint replacement surgery in Denmark, Finland, Norway, and Sweden during 1 January 2011 to 31 December 2014. Those with cancer or OA within three years before the first eligible OA diagnosis were excluded. Patients were allocated into six POU cohorts based on dose escalation, frequency, and dosing of prescription opioids post-surgery (definitions were based on guidelines, previous literature, and clinical experience), and matched on age and sex to patients with opioid use, but not in any of the six cohorts. Data on demographics, non-OA pain diagnoses, cardiovascular diseases, psychiatric disorders, and clinical characteristics were used to study patient characteristics and predictors of POU.

RESULTS

13.7% of patients with OA and a hip/knee joint replacement were classified as problematic users and they had more comorbidities and higher pre-surgery doses of opioids than matches. Patients dispensing high doses of opioids pre-surgery dispensed increased doses post-surgery, a pattern not seen among patients prescribed lower doses pre-surgery. Being dispensed 1-4,500 oral morphine equivalents in the year pre-surgery or having a non-OA pain diagnosis was associated with post-surgery POU (OR: 1.44-1.50, and 1.11-1.20, respectively).

CONCLUSIONS

Based on the discovered POU predictors, the study suggests that prescribers should carefully assess pain management strategies for patients with a history of comorbidities and pre-operative, long-term opioid use. Healthcare units should adopt risk assessment tools and ensure that these patients are followed up closely. The data also demonstrate potential areas for further exploration in improving patient outcomes and trajectories.

Drug Therapies Affecting Renal Function: An Overview

Undesirable side effects of medication are inevitable. Due to the role of the kidneys in clearance and filtration, the renal system faces a unique situation when it comes to the side effects of drugs. It has an important role for different classes of drugs to be excreted, and drugs are a key factor for this system to be at risk. Medications in articles were divided into classes using the standard set by the Saudi Pharmaceutical Journal. Many drug classes cause renal insults. The top six classes were pain killers, antibiotics, proton pump inhibitors, antidiabetics, antihyperlipidemics, and agents for erectile dysfunction. Renal insults caused by these agents could vary in severity. Some drugs could cause nephrotoxicity from one dose, while others may only need continuous monitoring. Different populations also operate under different rules, as some people need dose adjustments while others who are medically free of major illnesses do not. A variety of unfavorable outcomes for the kidney could take place, such as acute kidney injury, chronic kidney disease, and end-stage renal disease, and unfortunately, some of these issues could lead to the need for renal replacement therapies. The outcome of this review paper will help multidisciplinary physicians to understand the renal side effects of the most used drug classes in the Kingdom of Saudi Arabia, their destructive mechanisms, and most importantly, the clinical presentations of renal dysfunction in relation to each class. Emphasizing these adverse effects will prevent future unfavorable outcomes, especially in commonly used drugs that are frequently prescribed for different age groups. Moreover, some of these drugs are considered to be over-the-counter medications, which makes them a serious problem that needs to be handled cautiously.

Analgesic use and associated adverse events in patients with chronic kidney disease: a systematic review and meta-analysis

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).

Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage

BACKGROUND

Kidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills.

MATERIALS AND METHODS

A historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected.

RESULTS

270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02).

CONCLUSIONS

A protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.

Evaluation of an opioid restrictive pain management initiative in adult kidney transplant recipients

PURPOSE

Evidence to guide opioid utilization following kidney transplantation is lacking. The purpose of this study is to evaluate the implementation of an opioid restrictive post-operative pain management protocol in adult kidney transplant recipients.

METHODS

We analyzed patients who underwent kidney transplant between 1/1/2017 to 8/15/2018. A standardized, opioid restrictive pain management protocol was implemented in February 2018. The primary outcome was quantity of opioid tablets prescribed at discharge. Secondary outcomes included amount of opioid prescribed within first 30 days, number of patient calls for pain, and opioid prescription in electronic medical record (EMR) at 90 days and 1 year.

RESULTS

After implementation, significantly fewer opioid tablets were prescribed at discharge (4 vs. 60 tablets, p < .001) and less oral morphine milligram equivalence (OME) were prescribed within 30 days of transplant (38 vs. 300, p < .001). In cohort 2, fewer patients received more than one opioid prescription, more patients received truncal block and only 5 patients received patient controlled analgesia compared to all in cohort 1.

CONCLUSION

A standardized, patient-centered pain management strategy after kidney transplantation reduced opioid prescribing without increasing readmissions or clinic calls. This data may be used to inform guidelines for appropriate OME prescribing at discharge after kidney transplantation.

Pancreas transplantation would be easy if the recipients were not diabetic: A practical guide to post-operative management of diabetic complications in pancreas transplant recipients

Diabetes mellitus remains a major public health problem throughout the United States with over $300 billion spent in total cost of care annually. In addition to being a leading cost of kidney failure, diabetes causes a host of secondary hyperglycemic-related complications including gastroparesis and orthostatic hypotension. While pancreas transplantation has been established as an effective treatment for diabetes, providing long-term normoglycemia in recipients, the secondary complications of diabetes mellitus persist complicating the post-operative course of an otherwise successful pancreas transplantation. This review describes the mechanism and impact of diabetic gastroparesis and orthostatic hypotension in the post-operative course of pancreas transplant patients and analyzes the various treatment modalities, based on current data and extensive experience at our institution, to treat these respective complications. While gastroparesis and orthostatic hypotension remain challenging post-operative conditions, the establishment of institutional protocols and step-up treatment algorithms can help define more effective therapies.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

The impact of pretransplant opioid exposure on healthcare utilization and costs in kidney transplant

STUDY OBJECTIVE

Opioid use has been associated with significant morbidity and mortality in the United States. Studies within kidney transplantation have also shown increased risk of mortality, graft loss, and complications in kidney transplant recipients who use opioids prior to transplant. The objective of this analysis was to identify if recent pretransplant opioid exposure would be an effective risk-stratifier for patients at risk for readmissions and readmission costs. Further, the objective was to see if a brief assessment of recent opioid use could predict chronic opioid use post-transplant."

PATIENTS AND DESIGN

This study was a single-center, retrospective cohort analysis of adult renal transplant recipients between January 2010 and December 2016 assessing the impact of pretransplant opioid use on posttransplant readmissions at 1 year postsurgery, as well as it's ability to identify patients at risk of chronic opioid use post-transplant. Opioid use was identified using medication reconciliation or a national prescription database, and readmissions and normalized costs for hospitalizations were identified via the Vizient clinical database.

MAIN RESULTS

Pretransplant opioid exposure occurred in 271 (24%) of 1129 patients transplanted during the study time period. There were no differences in index hospitalization length of stay or cost; however, patients with opioid exposure were significantly more likely to have been admitted within 1-year postsurgery (51 vs. 43%, p = 0.023), had more readmissions per patient (0.93 vs. 0.72, p = 0.010), and had higher normalized readmissions costs ($12,556 vs. $8344, p = 0.009). Patients with opioid exposure were also more likely to be admitted for readmissions, had more admissions per patient, and had higher readmission costs at 30 and 90 days postsurgery. There were no differences in preventability of readmissions between cohorts or in general causes of readmissions. A multivariable logistic regression demonstrated that being opioid experienced and having a history of diabetes mellitus were independently associated with readmissions at 1 year postsurgery. In addition, having opioid exposure at the time of transplant, a history of diabetes mellitus, and younger age were independently associated with chronic opioid use after transplant.

CONCLUSION

This study demonstrated that recent exposure to opioids prior to kidney transplant was significantly and independently associated with increased readmissions and readmission costs at multiple timepoints up to 1 year posttransplant as well as chronic opioid use after transplant.It also demonstrated that a brief assessment of recent opioid use may be able to identify patients at risk for chronic opioid use. Because opioid use is associated with multiple diseases, it is important to continue to study the association of opioid use, and the potential for disease-modifying interactions, with various clinical outcomes.

Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Pretransplant Opioid Use and Survival After Lung Transplantation

BACKGROUND

The impact of opioid use in lung transplant candidates on posttransplant outcomes is unknown. Studies on opioid therapy in kidney and liver transplant candidates have suggested increased risk of graft failure or death. We sought to analyze the relationship between pretransplant opioid use in lung transplant candidates and retransplant-free survival.

METHODS

We retrospectively reviewed adult patients transplanted consecutively between November 2004 and August 2015. The exposure was any opioid use at time of transplant listing and primary outcome was retransplant-free survival, analyzed via Cox regression model adjusted for recipient age, gender, ethnicity, diagnosis, and bridging status. Secondary outcomes included duration of ventilation, intensive care unit and hospital length of stay, 3-month and 1-year survival, continuing opioid use at 1 year, and time to onset of chronic lung allograft dysfunction.

RESULTS

The prevalence of opioid use at time of listing was 14% (61/425). Median daily oral morphine equivalent dose was 31 mg (18-54). Recipient ethnicity was associated with pretransplant opioid use. Opioid use at time of listing did not increase risk of death or retransplantation in an adjusted model (hazard ratio 1.12 [95% confidence interval 0.65-1.83], P = 0.6570). Secondary outcomes were similar between groups except hospital length of stay (opioid users 35 versus nonusers 27 d, P = 0.014). Continued opioid use at 1-year posttransplant was common (27/56, 48%).

CONCLUSIONS

Pretransplant opioid use was not associated with retransplant-free survival in our cohort and should not necessarily preclude listing. Further work stratifying opioid use by indication and the association with opioid use disorder would be worthwhile.

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

Association Between Sex and Opiate and Benzodiazepine Prescription Among Patients With CKD: Research Letter

Background

Opiate and benzodiazepine use is associated with increased mortality and poorer transplant outcomes in patients with chronic kidney disease (CKD).

Objective

To determine the predictors of opiate and benzodiazepine prescription in people with kidney disease.

Design

Cross-sectional, observational study.

Setting

Outpatient clinics at Kingston Health Sciences Centre or at affiliated sites as of June 2017.

Patients

Individuals with CKD being treated at clinics or with various dialysis modalities at Kingston Health Sciences Centre and affiliated sites.

Measurements

The total number of regular opioid and benzodiazepine prescriptions was recorded for each patient. Patients were stratified based on clinical (eg, dialysis modality) and demographic (sex, age, diabetes mellitus [DM], ethnicity) characteristics, as elicited below.

Methods

We evaluated opiate and benzodiazepine use by chart review in the following patient groups: conventional hemodialysis (HD) (n = 359), home hemodialysis (HHD) (n = 21), peritoneal dialysis (PD) (n = 95), patients attending the multidisciplinary chronic kidney disease clinic (MCKDC) (n = 322), and kidney transplant (KT) recipients (n = 176). Opiates and benzodiazepines were classified according to the American Hospital Formulary Service system. Patients were also stratified as white (n = 855), indigenous (n = 66), or all others (n = 48).

Results

The mean age was 66.2 ± 14.9 years, 602 (61.9%) were men, and 439 (45.1%) had DM. Opiates were prescribed to 223 patients (22.9%), most frequently to HD (32.3%), followed by MCKDC (20.8%), HHD (19.0%), PD (14.7%), and KT (12.5%) (P < .001). The independent predictors of opiate prescription included DM (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.6; P < 0.001), conventional HD (vs all other treatment modalities) (OR, 1.8; 95% CI, 1.3-2.5; P < .001), and female sex (OR, 1.4; 95% CI, 1.0-1.9; P = .041) after adjustment for age and ethnicity (R ² = 0.037, P < .001). Benzodiazepines were prescribed to 106 patients (10.9%), most frequently to HD (15.9%), followed by HHD (9.5%), KT (9.1%), MCKDC (7.5%), and PD (7.4%) (P = .005). The independent predictors of benzodiazepine use included female sex (OR, 2.3; 95% CI, 1.5-3.4; P < .001) and dialysis modality (excluding MCKDC and KT) (OR, 1.8; 95% CI, 1.2-2.8; P = .006) after adjustment for ethnicity, DM, and age (R ² = 0.027, P < .001).

Limitations

We were not able to ascertain the indication for prescription of these drugs or patient adherence.

Conclusions

Women with kidney disease are significantly more likely to be prescribed opiates and benzodiazepines than men with kidney disease. Further research is required to determine whether these medications contribute to increased morbidity and mortality in women with kidney disease.

Trial Registration

This manuscript does not meet the criteria for requiring registration or a statement of written consent from study participants. The previous submission of this manuscript already made mention of Research Ethics Board approval.

Lung Transplant Pulmonologists' Views of Specialty Palliative Care for Lung Transplant Recipients

Background: Lung transplant recipients with serious illness may benefit from but rarely receive specialty palliative care (SPC) services. Transplant pulmonologists' views of SPC may be key to understanding SPC utilization but have not been well characterized. Objectives: (1) To understand how transplant pulmonologists view SPC and decide to refer transplant recipients and (2) to identify unique aspects of lung transplantation that may influence referral decisions. Design: We conducted semistructured interviews with transplant pulmonologists at nine geographically diverse high-volume North American transplant centers with SPC services. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework related to SPC views and referral decisions. Results: We interviewed 38 transplant pulmonologists; most (36/38) had referred lung transplant recipients to SPC. Participants described SPC as a medical specialty that aims to improve quality of life and distinguished SPC from hospice care, which was considered end-of-life care. Participants who viewed transplant as a temporary solution (n = 17/38, 45%) described earlier utilization of SPC alongside disease-directed therapies, whereas those who viewed transplant as survival-focused (n = 21/38, 55%) described utilization of SPC after disease-directed therapies were exhausted. Concerns about one-year survival metrics and use of addicting medications for symptom palliation were barriers to referral. Conclusions: Transplant pulmonologists' SPC referral practices may be related to their views of lung transplantation. Optimizing use of SPC in lung transplantation will require improving communication between transplant pulmonology and SPC to ensure a collaborative effort toward patient-centered goals while addressing unique barriers to SPC referral.

Associations of Opioid Prescriptions with Death and Hospitalization across the Spectrum of Estimated GFR

BACKGROUND AND OBJECTIVES

Most opioids undergo kidney excretion. The goal of this study was to evaluate opioid-associated risks of death and hospitalization across the range of eGFR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study population included adult primary care patients in Geisinger Health (Danville, PA) between 2008 and 2017. People receiving their first opioid prescription were propensity matched to people receiving NSAIDS (and, in sensitivity analysis, gabapentinoids) and the risk of death and hospitalization were compared, classifying opioid medication exposure as time-varying daily oral morphine milligram equivalents (MMEs) across time-varying eGFR.

RESULTS

The propensity-matched cohort included 46,246 patients prescribed either opioids or NSAIDs between 2008 and 2017 (mean [SD] age, 54 [16] years; 56% female; 3% of black race). Prescriptions for 1-59 and ≥60 MMEs were associated with higher risk of death (HR, 1.70; 95% CI, 1.41 to 2.05 for 1-59 MMEs; HR, 2.25; 95% CI, 1.82 to 2.79 for ≥60 MMEs) and hospitalization (HR, 1.38; 95% CI, 1.30 to 1.46 for 1-59 MMEs; HR, 1.68; 95% CI, 1.56 to 1.81 for ≥60 MMEs) compared with NSAID prescriptions, when evaluated at eGFR 80 ml/min per 1.73 m². The relative risk of death associated with ≥60 MMEs was higher at lower GFR (e.g., eGFR, 40 ml/min per 1.73 m²; HR, 3.94; 95% CI, 2.70 to 5.75; P for interaction, 0.01). When gabapentinoids were used as the comparison medication, only ≥60 MMEs were significantly associated with higher risk of death (HR, 2.72; 95% CI, 1.71 to 4.34), although both 1-59 and ≥60 MMEs were associated with risk of hospitalization (HR, 1.22; 95% CI, 1.04 to 1.43 for 1-59 MMEs; HR, 1.54; 95% CI, 1.28 to 1.86 for ≥60 MMEs).

CONCLUSIONS

The receipt of prescription opioids was associated with a higher risk of death and hospitalization compared with other pain medications, particularly with higher doses and at lower eGFR.

Opioids Preconditioning Upon Renal Function and Ischemia-Reperfusion Injury: A Narrative Review

Kidneys have an important role in regulating water volume, blood pressure, secretion of hormones and acid-base and electrolyte balance. Kidney dysfunction derived from acute injury can, under certain conditions, progress to chronic kidney disease. In the late stages of kidney disease, treatment is limited to replacement therapy: Dialysis and transplantation. After renal transplant, grafts suffer from activation of immune cells and generation of oxidant molecules. Anesthetic preconditioning has emerged as a promising strategy to ameliorate ischemia reperfusion injury. This review compiles some significant aspects of renal physiology and discusses current understanding of the effects of anesthetic preconditioning upon renal function and ischemia reperfusion injury, focusing on opioids and its properties ameliorating renal injury. According to the available evidence, opioid preconditioning appears to reduce inflammation and reactive oxygen species generation after ischemia reperfusion. Therefore, opioid preconditioning represents a promising strategy to reduce renal ischemia reperfusion injury and, its application on current clinical practice could be beneficial in events such as acute renal injury and kidney transplantation.