Analgesic prescription patterns among hemodialysis patients in the DOPPS: Potential for underprescription

ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.

Opioids for chronic pain management in patients with dialysis-dependent kidney failure

Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.

Safe and appropriate use of diclofenac in chronic kidney disease: An Indian perspective

Pain is most common symptom associated with progressive disorder, chronic kidney disease (CKD), and is usually undertreated during the early stages of CKD. So, present review was conducted to evaluate the challenges for the management of pain in CKD patients and addresses the scope for considering Diclofenac as suitable alternative for pain management in CKD patient. The database PubMed and Google Scholar were searched from 1970 to Dec 2020 for literature published in English and all studies, review articles that examined the use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in pain management in CKD patients were included. Literatures revealed that there is a considerable challenge in appropriate management of pain in CKD patients include understanding the altered pharmacokinetics and pharmacodynamics of analgesics in CKD patients and the risk of acute interstitial nephritis. The shorter duration of analgesics is acceptable and considered to pose a low risk of acute interstitial nephritis in patients. Considering that Diclofenac has a shorter half-life and high efficacy, it may be well tolerated in patients with CKD. The acceptance of Diclofenac is partly attributed to being a potent COX-2 inhibitor with the lowest IC50 and its rapid onset of action at lowest effective dose. In conclusion, diclofenac may be well tolerated in patients of renal impairment when used at lowest effective dose for shortest dose duration. Diclofenac is worthy of consideration in mild to moderate cases of CKD. For effective pain management, it is vital to evaluate the tolerability and efficacy of the available analgesics critically.

Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature

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.

Pain Management Evaluation in Maintenance Hemodialysis Patients

CONTEXT

Pain is a common complaint in maintenance hemodialysis (MHD) patients, and it is often inadequately assessed and inappropriately treated.

OBJECTIVES

The study goal was to preliminarily evaluate pain management in MHD patients.

METHODS

The study was a cross-sectional study conducted in 2013-2015. A sample of 277 MHD patients who reported pain within the last 24 hours from five hospital hemodialysis units in Israel were interviewed and evaluated. Study tools included the Brief Pain Inventory, the Pain Management Index (PMI), demographic and clinical characteristics. Pharmacy computerized data were reviewed to identify the type of analgesics used.

RESULTS

Mean pain level was 7.2 ± 2.2 (median: 8). Pain level was mild in 17 (6.1%), moderate in 120 (43.3%) and severe in 140 (50.5%) of patients. Only 185 participants (66.8%) were treated with analgesics during the year prior to the interview. Of these, 99 (53.5%) received opioids. Using the PMI to preliminarily assess the appropriateness of the treatment, 214 (77.3%) of patients with pain in the last 24 hours were undertreated, and 52 patients (18.8%) were appropriately treated. In a multivariable analysis, factors associated with inappropriate treatment were severe pain intensity and a higher Functional Independent Measure (FIM). A lower FIM was associated with opioid use in a multivariable analysis.

CONCLUSIONS

According to the PMI, most dialysis patients were found to be inappropriately treated. About one third received opioids, but even among them, inappropriate treatment was common. Pain management in MHD patients needs to be improved.

Nonsteroidal anti-inflammatory drugs in end-stage kidney disease: dangerous or underutilized?

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are a popular class of analgesic and anti-inflammatory medications, but their use is often avoided in end-stage kidney disease (ESKD) patients due to their reputation for nephrotoxic side effects. This removes a useful agent from the analgesic arsenal, even as ESKD patients suffer from proportionally more severe chronic pain than the general population as well as from a large reliance on opioid medications. Areas Covered: This paper reviews the current literature to comprehensively define the pharmacologic mechanisms and adverse effects of NSAIDs and reassesses the viability of their use in ESKD patients. Expert opinion: The evidence directly examining the impact of NSAIDs on long-term outcomes in ESKD is limited. Further study quantifying the risk of NSAID use - especially in dialysis-dependent patients - is warranted. Given the difficulty in achieving adequate pain control in ESKD patients, limited use of NSAIDs in these patients may yet be justified.

Frailty modifies the association between opioid use and mortality in chronic kidney disease patients with diabetes: a population-based cohort study

The prevalence of chronic pain in patients with chronic kidney disease (CKD) and diabetes mellitus is high and correlates with higher frailty risk, but satisfactory pain control frequently fails, necessitating opioid initiation. We aimed to examine whether opioid use affected their outcomes and whether such a relationship was modified by frailty. From the longitudinal cohort of diabetes patients (n = 840,000), we identified opioid users with CKD (n = 26,029) and propensity score-matched them to opioid-naïve patients in a 1:1 ratio. We analyzed the associations between opioid use and long-term mortality according to baseline frailty status, defined by the modified FRAIL scale. Among all, 20.3% did not have any FRAIL items, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items, respectively. After 4.2 years, 16.4% died. Cox proportional hazard regression showed that opioid users exhibited an 18% higher mortality risk (HR 1.183, 95% CI 1.13-1.24) with a dose- and duration-responsive relationship, compared to opioid-naive ones. Furthermore, the mortality risk posed by opioids was observed only in CKD patients without frailty but not in those with frailty. In conclusion, opioid use increased mortality among patients with CKD, while this negative outcome influence was not observed among frail ones.

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.

Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists

In patients suffering from moderate-to-severe chronic kidney disease (CKD) or end-stage renal disease (ESRD), subjected to hemodialysis (HD), pain is very common, but often underestimated. Opioids are still the mainstay of severe chronic pain management; however, their prescription in CKD and HD patients is still significantly low and pain is often under-treated. Altered pharmacokinetics and the lack of clinical trials on the use of opioids in patients with renal impairment increase physicians' concerns in this specific population. This narrative review focused on the correct and safe use of opioids in patients with CKD and HD. Morphine and codeine are not recommended, because the accumulation of their metabolites may cause neurotoxic symptoms. Oxycodone and hydromorphone can be safely used, but adequate dosage adjustments are required in CKD. In dialyzed patients, these opioids should be considered as second-line agents and patients should be carefully monitored. According to different studies, buprenorphine and fentanyl could be considered first-line opioids in the management of pain in CKD; however, fentanyl is not appropriate in patients undergoing HD. Tapentadol does not need dosage adjustment in mild-to-moderate renal impairment conditions; however, no data are available on its use in ESRD. Opioid-related side effects may be exacerbated by common comorbidities in CKD patients. Opioid-induced constipation can be managed with peripherally-acting-μ-opioid-receptor-antagonists (PAMORA). Unlike the other PAMORA, naldemedine does not require any dose adjustment in CKD and HD patients. Accurate pain diagnosis, opioid titration and tailoring are mandatory to minimize the risks and to improve the outcome of the analgesic therapy.

Lower opioid and higher adjuvant analgesic use in patients on haemodialysis: A single-centre cross-sectional study

WHAT IS KNOWN

Opioids are often used to treat chronic non-cancer pain (CNCP) in patients on haemodialysis. Altered pharmacokinetics in this population increases risk for opioid-related adverse events. Although useful in pain management, there is a lack of opioid prescribing guidance for end-stage kidney disease.

OBJECTIVE

To characterize opioid usage for CNCP in an outpatient haemodialysis unit.

METHODS

Cross-sectional, single-centre, retrospective cohort study of 272 patients receiving outpatient haemodialysis between 01 June and 31 December 2017. Prevalence of prescription or non-prescription opioids, formulation, indication, dosing, prescriber type and therapeutic effectiveness were evaluated.

RESULTS

A total of 27 (10%, aged 58 + 12.1 years, 59% women) patients received opioids for CNCP during the study period. Pain aetiology was diverse; 14 (52%) patients experienced multiple concurrent chronic pain conditions. Hydromorphone (55%) and oxycodone (37%) were the most common prescriptions. A majority (85%) of patients used non-opioid analgesics as adjunct therapy, while half (48%) used benzodiazepines or zopiclone concurrently. Patients who completed a pain scale (n = 10) reported a median pain intensity of 6.8/10 ([IQR], 4.5-7.3).

DISCUSSION

Opioid usage was lower than expected despite a higher prevalence of concurrent chronic pain conditions. Though this was within opioid usage guidelines, pain may not be sufficiently controlled. High concomitant use of benzodiazepines and Z-drugs introduces the potential for additive adverse effects. Judicious opioid usage can be facilitated with stewardship to effectively treat pain while avoiding associated harms and manage potential drug-drug interactions with common concomitant medications.

WHAT IS NEW AND CONCLUSION

The prevalence of chronic opioid use for non-cancer pain in haemodialysis patients was lower than expected at our centre. Despite following the recommended guidelines, pain management was relatively ineffective, and concomitant use of non-opioid analgesics was widespread. Opioid stewardship is recommended to optimize pain treatment and mitigate drug interaction risks.

Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Pain is common in patients with chronic kidney disease (CKD). Analgesics may be appropriate for some CKD patients.

Objectives:

To determine the prevalence of overall analgesic use and the use of different types of analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvants, and opioids in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.

Patients:

Adults with stage 3-5 CKD including dialysis patients and those managed conservatively without dialysis.

Measurements:

Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of analgesic use, and the types of analgesics prescribed.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of analgesic use and the I2 statistic was computed to measure heterogeneity. Random-effects models were used to account for variations in study design and sample populations, and a double arcsine transformation of the prevalence variables was used to accommodate potential overweighting of studies with very large or very small prevalence measurements. Sensitivity analyses were performed to determine the magnitude of publication bias and assess possible sources of heterogeneity.

Results:

Forty studies were included in the analysis. The prevalence of overall analgesic use in the random-effects model was 50.8%. The prevalence of acetaminophen, NSAIDs, and adjuvant use was 27.5%, 17.2%, and 23.4%, respectively, while the prevalence of opioid use was 23.8%. Due to the possibility of publication bias, the actual prevalence of acetaminophen use in patients with advanced CKD may be substantially lower than this meta-analysis indicates. A trim-and-fill analysis decreased the pooled prevalence estimate of acetaminophen use to 5.4%. The prevalence rate for opioid use was highly influenced by 2 large US studies. When these were removed, the estimated prevalence decreased to 17.3%.

Limitations:

There was a lack of detailed information regarding the analgesic regimen (such as specific analgesics used within each class and inconsistent accounting for patients on multiple drugs and the use of over-the-counter analgesics such as acetaminophen and NSAIDs), patient characteristics, type of pain being treated, and the outcomes of treatment. Data on adjuvant use were very limited. These results, therefore, must be interpreted with caution.

Conclusions:

There was tremendous variability in the prescribing patterns of both nonopioid and opioid analgesics within and between countries suggesting widespread uncertainty about the optimal pharmacological approach to treating pain. Further research that incorporates robust reporting of analgesic regimens and links prescribing patterns to clinical outcomes is needed to guide optimal clinical practice.

Opioid Safety and Concomitant Benzodiazepine Use in End-Stage Renal Disease Patients

Background

Opioid use is common in end-stage renal disease (ESRD) patients. However, safety of individual opioids and concomitant benzodiazepine use has not been studied.

Objective

To study the epidemiology of opioid and concomitant benzodiazepine use in ESRD population. To study the clinical safety profile of individual opioids in patients on hemodialysis.

Design

Retrospective analysis of the U.S. Renal Data System. A comprehensive review of the current literature was performed to update currently used opioid safety classification.

Participants

ESRD patients ≥18 years on hemodialysis who were enrolled in Medicare A and B and Part D between 2006 and 2012, excluding those with malignancy.

Main Measures

Hospital admission with diagnosis of prescription opioid overdose within 30, 60, and 90 days of prescription; death due to opioid overdose.

Results

Annually, the percentage of patients prescribed any opioid was 52.2%. Overall trend has been increasing except for a small dip in 2011, despite which the admissions due to opioid overdose have been rising. 30% of those who got a prescription for opioids also got a benzodiazepine prescription. 56.5% of these patients received both prescriptions within a week of each other. Benzodiazepine use increased the odds of being on opioids by 3.27 (CI 3.21–3.32) and increased the odds of hospitalization by 50%. Opioids considered safe such as fentanyl and methadone were associated with 3 and 6 folds higher odds of hospitalization within 30 days of prescription. Hydrocodone had the lowest odds ratio (1.9, CI 1.8–2.0).

Conclusions

Concurrent benzodiazepine use is common and associated with higher risk of hospitalization due to opioid overdose. Possible opioid-associated hospital admission rate is 4-5 times bigger in ESRD population than general population. Current safety classification of opioids in these patients is misleading, and even drugs considered safe based on pharmacokinetic data are associated with moderate to very high risk of hospitalization. We propose a risk-stratified classification of opioids and suggest starting to use them in all ESRD patients.

Trends in Opioid Prescribing Among Hemodialysis Patients, 2007-2014

BACKGROUND

Hemodialysis (HD) patients frequently experience pain. Previous studies of HD patients suggest increased opioid prescribing through 2010. It remains unclear if this trend continued after 2010 or declined with national trends.

METHODS

Longitudinal cohort study of 484,745 HD patients in the United States Renal Data System/Medicare data. We used Poisson/negative binomial regression to estimate annual incidence rates of opioid prescribing between 2007 and 2014. We compared prescribing rates with the general US population using IQVIA's National Prescription Audit data. Outcomes included the following: percent of HD patients receiving an opioid prescription, rate of opioid prescriptions, quantity, days supply, morphine milligram equivalents (MME) dispensed per 100 person-days, and prescriptions per person.

RESULTS

In 2007, 62.4% of HD patients received an opioid prescription. This increased to 63.2% in 2010 then declined to 53.7% by 2014. Opioid quantity peaked in 2011 at 73.5 pills per 100 person-days and declined to 62.6 pills per 100 person-days in 2014. MME peaked between 2010 and 2012 then declined through 2014. In 2014, MME rates were 1.8-fold higher among non-Hispanic patients and 1.6-fold higher among low-income patients. HD patients received 3.2-fold more opioid prescriptions per person compared to the general US population and were primarily prescribed oxycodone and hydrocodone. Between 2012 and 2014, HD patients experienced greater declines in opioid prescriptions per person (18.2%) compared to the general US population (7.1%).

CONCLUSION

Opioid prescribing among HD patients declined between 2012 and 2014. However, HD patients continue receiving substantially more opioids than the general US population.

Prescription opioid use before and after kidney transplant: Implications for posttransplant outcomes

Evolving literature suggests that the epidemic of prescription opioid use affects the transplant population. We examined a novel database wherein national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007-2015) to characterize prescription opioid use before and after kidney transplant, and associations (adjusted hazard ratio, _95%LCL aHR_95%UCL ) with death and graft loss. Among 75 430 eligible patients, 43.1% filled opioids in the year before transplant. Use was more common among recipients who were women, white, unemployed, publicly insured, and with longer pretransplant dialysis. Of those with the highest level of pretransplant opioid use, 60% continued high-level use posttransplant. Pretransplant opioid use had graded associations with one-year posttransplant outcomes; the highest-level use predicted 46% increased risk of death (aHR _1.28 1.46_1.66 ) and 28% increased risk of all-cause graft failure (aHR _1.17 1.28_1.41 ). Effects of high-level opioid use in the first year after transplant were stronger, predicting twice the risk of death (aHR _1.93 2.24_2.60 ) and 68% higher all-cause graft failure risk (aHR _1.50 1.68_1.89 ) over the subsequent year; increased risk persisted over five years. While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.

Reiki for Pain During Hemodialysis: A Feasibility and Instrument Evaluation Study

PURPOSE

Pain is a problem for individuals undergoing hemodialysis. Renal disease, comorbidities, concurrent symptoms, and dialysis procedures pose barriers to adequate pain management. The purpose of this study was to evaluate feasibility, examine construct validity of The Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing (CAT) instruments, and explore pain benefits of Reiki sessions conducted during hemodialysis.

DESIGN

A one group, repeated-measures design was used.

METHOD

Fifteen participants received Reiki for 20 minutes, twice a week for 4 weeks. Pain, fatigue, and depression were evaluated using established symptom scales and PROMIS CAT instruments.

FINDINGS

Participants reported general relaxation feelings with Reiki and acceptability of using a touch-screen device to respond to web-based measures. Although staff were initially reluctant to engage patients for Reiki, they reported Reiki did not interfere with workflow and thought Reiki could be integrated into the practice setting. Significant, strong correlations with established symptom scales support construct validity of PROMIS CAT instruments. There was a significant decrease in mean symptom scores after four weeks of Reiki. Effect size values suggest a range of practical significance.

CONCLUSIONS

Findings suggest Reiki provides symptom relief for individuals receiving hemodialysis, and randomized clinical trials to establish Reiki's pain benefits in this population are warranted.

Pain in Maintenance Hemodialysis Patients: A Multicenter Study

CONTEXT

Pain is a common complaint in maintenance hemodialysis (MHD) patients yet is often inadequately assessed and undertreated.

OBJECTIVES

The objective of this study was to evaluate the prevalence, characteristics, intensity, and impact of pain in MHD patients.

METHODS

In a cross-sectional study conducted between 2013 and 2015, 336 MHD patients from five hemodialysis units in hospitals owned by Clalit were interviewed and evaluated. Study tools included the Brief Pain Inventory, The Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale, and demographic and clinical characteristics. In addition, computerized pharmaceutical data were reviewed.

RESULTS

Pain was experienced by 82% of the study population (mean pain level: 7.2 ± 2.2) in the 24-hour period before the interview, while 61.5% experienced neuropathic pain characteristics. Of patients with pain, two-thirds reported being regularly treated with pain medications, while 24.5% received nondrug pain treatment. Mean pain relief due to Brief Pain Inventory was 62.5 ± 30%. In multivariate analysis, female gender, a high comorbidity index, and time on dialysis >24 months were associated with the presence of significant pain in the previous 24 hours. In addition, severe pain report was associated with female gender, depression, ≥4 painful sites, and unemployment. Finally, neuropathic pain was associated with time on dialysis >24 months, depression, ≥4 painful sites, and current intensity of pain >2.

CONCLUSION

Pain is common in MHD patients and is significantly associated with female gender, comorbidity, time on dialysis, and depression. Results of this study may serve as a starting point for palliative interventions for MHD patients.

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

BACKGROUND AND OBJECTIVES

Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).

RESULTS

The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.

CONCLUSIONS

Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

Prescribing for patients on dialysis

The pharmacokinetics of a drug may be altered in patients with renal impairment who require dialysis. Some drugs are contraindicated. The drug's clearance and therapeutic index determine if a dose adjustment is needed. A lower dose or less frequent dosing may be required. Consult a reference source or the patient's nephrologist before prescribing. Start at a low dose and increase gradually. If possible give once-daily drugs after dialysis.

Perioperative Pharmacologic Management of Patients with End Stage Renal Disease

The pharmacokinetics of numerous medications used in the perioperative period are altered in patients with end-stage renal disease. Clearance of drugs, or their metabolites, that are normally excreted by the kidney is markedly reduced in ESRD. In addition, patients with ESRD may also have alterations in gastrointestinal absorption, volume of distribution, protein binding, and metabolic clearance of pharmacologic agents. Finally, drug removal may be augmented during dialysis. All of these factors contribute to the need for dose adjustment of medications, including analgesics, anesthetics, neuromuscular blockers, and antimicrobial agents, which may be used in the perioperative management of the ESRD patient.

An Approach to Pain Management in End Stage Renal Disease: Considerations for General Management and Intradialytic Symptoms

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.

Improving arteriovenous fistula patency: Transdermal delivery of diclofenac reduces cannulation-dependent neointimal hyperplasia via AMPK activation

Creation of an autologous arteriovenous fistula (AVF) for vascular access in haemodialysis is the modality of choice. However neointimal hyperplasia and loss of the luminal compartment result in AVF patency rates of ~ 60% at 12 months. The exact cause of neointimal hyperplasia in the AVF is poorly understood. Vascular trauma has long been associated with hyperplasia. With this in mind in our rabbit model of AVF we simulated cannulation autologous to that undertaken in vascular access procedures and observed significant neointimal hyperplasia as a direct consequence of cannulation. The neointimal hyperplasia was completely inhibited by topical transdermal delivery of the non-steroidal anti-inflammatory (NSAID) diclofenac. In addition to the well documented anti-inflammatory properties we have identified novel anti-proliferative mechanisms demonstrating diclofenac increases AMPK-dependent signalling and reduced expression of the cell cycle protein cyclin D1. In summary prophylactic transdermal delivery of diclofenac to the sight of AVF cannulation prevents adverse neointimal hyperplasic remodelling and potentially offers a novel treatment option that may help prolong AVF patency and flow rates.

Dialysis chains and placement on the waiting list for a cadaveric kidney transplant

BACKGROUND

The proliferation of multi-unit for-profit dialysis chains in the ESRD industry has raised concerns for patient quality of care including access to renal transplantation therapy (RTT). The effect of dialysis facility chain status on RTT is unknown.

METHODS

Data from the United States Renal Data System were used to identify 4,465 dialysis facilities and 56,714 dialysis patients who started hemodialysis in 2006. Patients were followed from initiation of hemodialysis in 2006 to placement on the renal transplant waiting list or to December 31, 2009. The role of dialysis facility chain status (affiliation, size, and ownership) on placement on the renal transplant waiting list was evaluated by multi-level mixed-effect regression models that account for clustering within facilities.

RESULTS

Patients from for-profit chain facilities, compared to nonprofit chain facilities, were 13% (95% CI 0.77-0.98) less likely to be waitlisted. In contrast, among nonchains, facility ownership did not influence likelihood of being waitlisted. There was also a marginally significant difference in waiting list placement by chain size: large chains compared with mid or small chains were 8% (95% CI 0.84-1.00) less likely to place patients on the waiting list. After adjustment for patient and facility characteristics, dialysis facility chain affiliation (chain-affiliated or not) was not found to be independently associated with the likelihood of placement on the transplant waitlist.

CONCLUSION

Dialysis chain affiliation expands previously observed ownership-related differences in placement on the waiting list. For-profit ownership of dialysis chain facilities appears to be a significant impediment to access to renal transplants.

Measuring pain in patients undergoing hemodialysis: a review of pain assessment tools

Background

Patients undergoing hemodialysis frequently report pain with multifactorial causes, not limited to that experienced directly from hemodialysis treatment. Their pain may be nociceptive, neuropathic, somatic or visceral in nature. Despite this, pain in this population remains under-recognized and under-treated. Although several tools have been used to measure pain in patients undergoing hemodialysis as reported in the literature, none of them have been validated specifically in this population. The objective for this review was to compare and contrast these pain assessment tools and discuss their clinical utility in this patient population.

Methods

To identify pain assessment tools studied in patients undergoing hemodialysis, a literature search was performed in PubMed and Medline. An expert panel of dialysis and pain clinicians reviewed each tool. Each pain assessment tool was assessed on how it is administered and scored, its psychometric properties such as reliability, validity and responsiveness to change, and its clinical utility in a hemodialysis population. Brief Pain Inventory, McGill Pain Questionnaire, Pain Management Index, Edmonton Symptom Assessment System, Visual Analogue Scale and Faces Pain Scale were evaluated and compared.

Results

This assessment will help clinicians practicing in nephrology to determine which of these pain assessment tools is best suited for use in their individual clinical practice.

The ethics of end-of-life care for patients with ESRD

Patients with ESRD have extensive and unique palliative care needs, often for years before death. The vast majority of patients, however, dies in acute care facilities without accessing palliative care services. High mortality rates along with a substantial burden of physical, psychosocial, and spiritual symptoms and an increasing prevalence of decisions to withhold and stop dialysis all highlight the importance of integrating palliative care into the comprehensive management of ESRD patients. The focus of renal care would then extend to controlling symptoms, communicating prognosis, establishing goals of care, and determining end-of-life care preferences. Regretfully, training in palliative care for nephrology trainees is inadequate. This article will provide a conceptual framework for renal palliative care and describe opportunities for enhancing palliative care for ESRD patients, including improved chronic pain management and advance care planning and a new model for delivering high-quality palliative care that includes appropriate consultation with specialist palliative care.

Renal provider perceptions and practice patterns regarding the management of pain, sexual dysfunction, and depression in hemodialysis patients

BACKGROUND

Although pain, sexual dysfunction, and depression are common in patients receiving chronic hemodialysis, these symptoms frequently remain untreated. We sought to characterize renal provider perceptions and practice patterns regarding the treatment of these symptoms.

METHODS

We surveyed renal providers whose patients were participating in a clinical trial of symptom management at nine hemodialysis units in southwestern Pennsylvania. We used Spearman's correlation to assess the association of provider characteristics with the reported frequency of providing treatment.

RESULTS

Overall, 27 of 35 (77%) providers completed the survey. While 21 (78%) believed symptom management to be "very" important and 23 (85%) reported spending a "moderate" to "a lot" of time managing symptoms, <50% reported treating pain and <20% reported treating sexual dysfunction or depression "most" or "all" of the time. Most providers believed it was nonrenal providers' responsibility to treat these symptoms. A greater reported comfort level managing symptoms was associated with a higher reported frequency of treating pain (r=0.6; p<0.01), sexual dysfunction (r=0.67; p<0.01), and depression (r=0.43; p<0.03). Providers who believed it was nonrenal providers' responsibility to treat these symptoms reported treating pain (r=-0.62; p<0.01) and depression (r=-0.48; p=0.02) less frequently.

CONCLUSIONS

Despite reporting considerable importance and substantial time managing symptoms in general, renal providers commonly describe not treating pain, sexual dysfunction, and depression in hemodialysis patients. Given renal providers' beliefs that nonrenal clinicians are primarily responsible for treating these symptoms, multidisciplinary approaches to symptom management in these patients are needed.

Prevalence and correlates of erectile dysfunction in men on chronic haemodialysis: a multinational cross-sectional study

BACKGROUND

Factors associated with erectile dysfunction in men on haemodialysis are incompletely identified due to suboptimal existing studies. We determined the prevalence and correlates of erectile dysfunction and identified combinations of clinical characteristics associated with a higher risk of erectile dysfunction using recursive partitioning and amalgamation (REPCAM) analysis.

METHODS

We conducted a multinational cross-sectional study in men on haemodialysis within a collaborative network. Erectile dysfunction and depressive symptoms were evaluated using the erectile function domain of the International Index of Erectile Function questionnaire and the Center for Epidemiological Studies-Depression Scale, respectively.

RESULTS

Nine hundred and forty-six (59%) of 1611 eligible men provided complete data for erectile dysfunction. Eighty-three per cent reported erectile dysfunction and 47% reported severe erectile dysfunction. Four per cent of those with erectile dysfunction were receiving pharmacological treatment. Depressive symptoms were the strongest correlate of erectile dysfunction [adjusted odds ratio 2.41 (95% confidence interval (CI) 1.57-3.71)]. Erectile dysfunction was also associated with age (1.06, 1.05-1.08), being unemployed (1.80, 1.17-2.79) or receiving a pension (2.05, 1.14-3.69) and interdialytic weight gain (1.9-2.87 kg, 1.92 [CI 1.19-3.09]; >2.87 kg, 1.57 [CI 1.00-2.45]). Married men had a lower risk of erectile dysfunction (0.49, 0.31-0.76). The prevalence of erectile dysfunction was highest (94%) in unmarried and unemployed or retired men who have depressive symptoms.

CONCLUSIONS

Most men on haemodialysis experience erectile dysfunction and are untreated. Given the prevalence of this condition and the relative lack of efficacy data for pharmacological agents, we suggest that large trials of pharmacological and non-pharmacological interventions for erectile dysfunction and depression are needed.

Pain in chronic kidney disease: prevalence, cause and management

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.

Preserving residual renal function in dialysis patients: an update on evidence to assist clinical decision making

It has been documented that preservation of residual renal function in dialysis patients improves quality of life as well as survival. Clinical trials on strategies to preserve residual renal function are clearly lacking. While waiting for more results from clinical trials, patients will benefit from clinicians being aware of available knowledge. The aim of this review was to offer an update on current evidence assisting doctors in clinical practice.

Opioid and benzodiazepine use in end-stage renal disease: a systematic review

BACKGROUND AND OBJECTIVES

Chronic pain and psychiatric disorders are common in dialysis patients, but the extent to which opioids and benzodiazepines are used is unclear. We conducted a systematic review to determine the: (1) prevalence of opioid and benzodiazepine use among dialysis patients; (2) reasons for use; (3) effectiveness of symptom control; and (4) incidence of adverse events.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Two authors reviewed all relevant citations in MEDLINE/EMBASE/CINAHL/BIOSIS Previews/Cochrane and hand-searched bibliographies. Studies after 1990 reporting prevalence estimates for opioid and/or benzodiazepine use in ≥50 dialysis patients were included.

RESULTS

We identified 15 studies from 12 countries over 1995 to 2006. Sample size ranged from 75 to 12,782. Prevalence of opioid and benzodiazepine use was variable, ranging from 5 to 36% (95% CI, 4.1 to 45.5%; n=10) and 8 to 26% (95% CI, 7.1 to 27.3%; n=9), respectively. Prevalence was positively correlated with years on dialysis. Five studies reported on the same cohorts but gave different prevalence estimates. One study verified medication use through patient interviews. Reasons for use were reported in one study. Effectiveness of pain control varied from 17 to 38%, and 72 to 84% of patients with significant pain had no analgesia (n=2). No study rigorously examined for adverse events.

CONCLUSIONS

The prevalence of opioid and benzodiazepine use in dialysis patients is highly variable between centers. Further information is needed regarding the appropriateness of these prescriptions, adequacy of symptom control, and incidence of adverse effects in this population.

Undertreatment of symptoms in patients on maintenance hemodialysis

CONTEXT

Hemodialysis patients suffer a large symptom burden, and little is known about how effectively symptoms are treated.

OBJECTIVES

To assess the management of treatable symptoms in hemodialysis patients, we administered a 30-item questionnaire on physical and emotional symptoms to patients receiving outpatient hemodialysis at the University of Virginia.

METHODS

We asked patients whether they were prescribed therapy for potentially treatable symptoms and assessed who prescribed the therapy. By means of chart review, we also documented whether medications were prescribed for these symptoms.

RESULTS

We approached 87 patients and enrolled 62 (71%). The most commonly reported, potentially treatable symptoms included bone/joint pain, insomnia, mood disturbance, sexual dysfunction, paresthesia, and nausea. Only 45% of patients with bone/joint pain reported receiving an analgesic medication. Twenty-three percent of patients with trouble falling asleep and 53% of patients with nausea reported receiving a medication to alleviate this symptom. Chart review revealed that 58% of patients who reported the presence of bone/joint pain were prescribed an analgesic, 23% of patients with trouble falling asleep were prescribed a sleep aid, and 42% of patients with nausea received an antiemetic. Primary care providers were more likely than nephrologists to provide for all symptoms except nausea and numbness or tingling in the feet, and this difference was significant for the treatment of worrying (3/3 vs. 0/3, P=0.05) and nervousness (4/5 vs. 0/5, P=0.02).

CONCLUSION

Potentially treatable symptoms in hemodialysis are undertreated. Pharmacologic therapy, particularly for emotional symptoms, was more commonly prescribed by primary care providers than nephrologists. Additional study of the barriers to symptom treatment and interventions that increase nephrologist and primary care provider symptom management are needed.