COX-2 selective inhibitors: analysis of the renal effects

Nonsteroidal anti-inflammatory drugs associated acute kidney injury in hospitalized children: A systematic review and meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are regarded as nephrotoxins. Children commonly use NSAIDs and are susceptible to nephropathy, but the relationship between acute kidney injury (AKI) and use of NSAIDs is not well examined yet.

OBJECTIVE

To evaluate the relationship between AKI and use of NSAIDs in hospitalized pediatric patients who are susceptible to nephropathy.

METHODS

We conducted this systematic review and meta-analysis of observational studies by searching PubMed, Embase, and Cochrane Database for articles published up to June 1, 2020. Reports included involved children (age < 18 years) who used NSAIDs for various reasons and were admitted in the hospital. The main outcome measure was whether AKI occurred, and pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using generic inverse variance methods.

RESULTS

Seven studies reporting risk of AKI in the hospitalized pediatric patients receiving NSAIDs were included applying a random-effects model. In the hospitalized pediatric population, the pooled OR of AKI for present NSAID exposure was 1.55 (95%CI 1.26-1.92).

CONCLUSIONS

NSAID exposure was associated with an approximate 1.6-fold rise in the odds of developing AKI in hospitalized pediatric patients. Avoidance, cautious use of NSAIDs and further evidence are needed. This study was registered with PROSPERO (identifier: CRD42021219779).

IL-17A as a Potential Therapeutic Target for Patients on Peritoneal Dialysis

Chronic kidney disease (CKD) is a health problem reaching epidemic proportions. There is no cure for CKD, and patients may progress to end-stage renal disease (ESRD). Peritoneal dialysis (PD) is a current replacement therapy option for ESRD patients until renal transplantation can be achieved. One important problem in long-term PD patients is peritoneal membrane failure. The mechanisms involved in peritoneal damage include activation of the inflammatory and immune responses, associated with submesothelial immune infiltrates, angiogenesis, loss of the mesothelial layer due to cell death and mesothelial to mesenchymal transition, and collagen accumulation in the submesothelial compact zone. These processes lead to fibrosis and loss of peritoneal membrane function. Peritoneal inflammation and membrane failure are strongly associated with additional problems in PD patients, mainly with a very high risk of cardiovascular disease. Among the inflammatory mediators involved in peritoneal damage, cytokine IL-17A has recently been proposed as a potential therapeutic target for chronic inflammatory diseases, including CKD. Although IL-17A is the hallmark cytokine of Th17 immune cells, many other cells can also produce or secrete IL-17A. In the peritoneum of PD patients, IL-17A-secreting cells comprise Th17 cells, γδ T cells, mast cells, and neutrophils. Experimental studies demonstrated that IL-17A blockade ameliorated peritoneal damage caused by exposure to PD fluids. This article provides a comprehensive review of recent advances on the role of IL-17A in peritoneal membrane injury during PD and other PD-associated complications.

Long-term Assessment of NSAID Prescriptions and Potential Nephrotoxicity Risk in Adult Kidney Transplant Recipients

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) use is recommended to be avoided in kidney transplantation, with a paucity of studies assessing their safety within this population. This study aims to use a large cohort of Veterans Affairs (VA) kidney transplantation recipients to assess the risk of acute kidney injury (AKI) with NSAID use.

METHODS

This is a 10-year longitudinal cohort study of adult kidney transplant recipients retrospectively followed in the VA system from 2001 to 2010 that assessed for risk of AKI with NSAID prescriptions. NSAID prescriptions, patient characteristics, and estimated glomerular filtration rates were abstracted from the VA comprehensive electronic health record. NSAID exposure was assessed by duration, dosage, and type. AKI events were defined by ≥50% decrease in estimated glomerular filtration rate. Risk was estimated using longitudinal multivariable generalized logistic regression model.

RESULTS

About 5100 patients were included with a total of 29 980 years of follow-up; 671 NSAID prescriptions in 273 (5.4%) patients (2.24 per 100 patient-y) with 472 (70%) high dose were identified. High-dose NSAID prescriptions were associated with 2.83 (95% confidence interval [CI], 1.55-5.19; P < 0.001) higher odds of AKI events within a given year; low dose was not associated with AKI (odds ratio, 1.93; 95 % CI, 0.95-6.02; P = 0.256). One 7-day NSAID course was associated with 5% higher odds of increasing AKI events, whereas chronic use (≥180 d) was associated with 3.25 (95% CI, 1.78-5.97; P < 0.001) higher odds of AKI.

CONCLUSIONS

Prescriptions for NSAIDs were uncommon in this cohort but were associated with a significant increase in the risk of AKI, which was impacted by higher NSAID dose and longer NSAID durations.

NSAIDs in CKD: Are They Safe?

The management of pain in patients with chronic kidney disease (CKD) is challenging for many reasons. These patients have increased susceptibility to adverse drug effects due to altered drug metabolism and excretion, and there are limited safety data for use in this population despite a high pain burden. Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been regarded as dangerous for use in patients with CKD because of their risk for nephrotoxicity and thus alternative classes of analgesics, including opioids, have become more commonly used for pain control in this population. Given the well-established risks that opioids and other analgesics pose, further characterization of the risk posed by NSAIDs in patients with CKD is warranted. NSAID use has been associated with acute kidney injury, progressive loss of glomerular filtration rate in CKD, electrolyte derangements, and hypervolemia with worsening of heart failure and hypertension. The risk for these nephrotoxicity syndromes is modified by many comorbid conditions, risk factors, and characteristics of use, and in patients with CKD, the risk differs between levels of glomerular filtration rate. In this review, we offer recommendations for the cautious use of NSAIDs in the CKD population after careful consideration of these risk factors on an individualized basis.

Cardiorenal Safety of OTC Analgesics

Over-the-counter analgesics are used globally for the relief of acute pain. Although effective, these agents can be associated with adverse effects that may limit their use in some people. In the early 2000s, observations from clinical trials of prescription-strength and supratherapeutic doses of nonselective and cyclooxygenase-2-selective nonsteroidal anti-inflammatory drugs (NSAIDs) raised safety concerns regarding the risk of cardiovascular adverse effects with the use of these medications. Subsequently, the US Food and Drug Administration mandated additional study of the cardiovascular safety of NSAIDs for a more comprehensive understanding of their risk. As these data were being collected, and based on a comprehensive review of prescription data and the recommendations of the US Food and Drug Administration Advisory Committee, the warning labels of over-the-counter NSAIDs were updated to emphasize the potential cardiovascular risks of these agents. The recently reported “Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen” (PRECISION) trial, in which participants with osteoarthritis or rheumatoid arthritis and underlying cardiovascular risk factors were treated with prescription-strength celecoxib, ibuprofen, or naproxen, revealed similar rates of cardiovascular events (death from cardiovascular causes including hemorrhagic death, nonfatal myocardial infarction, or nonfatal stroke) among the 3 treatment groups. Although informative, the cardiovascular safety findings derived from PRECISION cannot be extrapolated to the safety of the over-the-counter pain relievers ibuprofen and naproxen, given that the doses used were higher (mean [standard deviation]: ibuprofen, 2045 [246] mg; naproxen, 852 [103] mg) and the durations of use longer (∼20 months) than recommended with over-the-counter use of NSAIDs, which for ibuprofen is up to 10 days. This review discusses the cardiorenal safety of the most commonly used over-the-counter analgesics, ibuprofen, naproxen, and acetaminophen. Available data suggest that there is little cardiovascular risk when over-the-counter formulations of these agents are used as directed in their labels.

Nonsteroidal antiinflammatory drugs, cyclooxygenase-2, and the kidneys

Nonsteroidal antiinflammatory drugs (NSAIDs) are one of the most commonly used classes of medications in the world, which function by inhibiting the cyclooxygenase (COX) enzymes and downregulating the inflammatory pathway. COX enzymes are constitutively expressed in the kidneys and function to maintain a homeostatic environment in terms of maintaining the glomerular filtration rate, blood pressure, sodium, water, and osmotic regulation. When the COX enzymes are inhibited by NSAIDs, a multitude of renal and vascular complications occur. This article aims to enlighten primary care physicians of the complications that arise with NSAIDs from a renal perspective and to present some management strategies.

PTGER1 deletion attenuates renal injury in diabetic mouse models

We hypothesized that the EP1 receptor promotes renal damage in diabetic nephropathy. We rendered EP1 (PTGER1, official symbol) knockout mice (EP1(-/-)) diabetic using the streptozotocin and OVE26 models. Albuminuria, mesangial matrix expansion, and glomerular hypertrophy were each blunted in EP1(-/-) streptozotocin and OVE26 cohorts compared with wild-type counterparts. Although diabetes-associated podocyte depletion was unaffected by EP1 deletion, EP1 antagonism with ONO-8711 in cultured podocytes decreased angiotensin II-mediated superoxide generation, suggesting that EP1-associated injury of remaining podocytes in vivo could contribute to filtration barrier dysfunction. Accordingly, EP1 deletion in OVE26 mice prevented nephrin mRNA expression down-regulation and ameliorated glomerular basement membrane thickening and foot process effacement. Moreover, EP1 deletion reduced diabetes-induced expression of fibrotic markers fibronectin and α-actin, whereas EP1 antagonism decreased fibronectin in cultured proximal tubule cells. Similarly, proximal tubule megalin expression was reduced by diabetes but was preserved in EP1(-/-) mice. Finally, the diabetes-associated increase in angiotensin II-mediated constriction of isolated mesenteric arteries was blunted in OVE26EP1(-/-) mice, demonstrating a role for EP1 receptors in the diabetic vasculature. These data suggest that EP1 activation contributes to diabetic nephropathy progression at several locations, including podocytes, proximal tubule, and the vasculature. The EP1 receptor facilitates the actions of angiotensin II, thereby suggesting that targeting of both the renin-angiotensin system and the EP1 receptor could be beneficial in diabetic nephropathy.

Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy

WHAT IS KNOWN AND OBJECTIVE

Increasing attention is being paid to inappropriate medication prescribing for the elderly. A growing body of studies have detected a prevalence of inappropriate prescribing ranging from 12% to 40% worldwide, including Regione Emilia-Romagna, Italy. To improve quality of prescribing, a multi-phase pilot project in the Local Health Unit (LHU) of Parma, Regione Emilia-Romagna, was established. This phase aimed to assess primary care physicians' knowledge of appropriate prescribing in elderly patients.

METHODS

In total, 155 primary care physicians (51% of the total), convened by the LHU of Parma for an educational session, were asked to complete anonymously a 19-item paper survey. Knowledge of inappropriate medication use in the elderly was assessed using seven clinical vignettes based on the 2002 Beers Criteria. Topics tested included hypertension, osteoarthritis, arrhythmias, insomnia and depression. Data regarding physician's perceived barriers to appropriate prescribing for elderly patients were also collected. To evaluate the relationship between physician knowledge scores and physician characteristics, physicians were classified as having a 'low score' (three or below) or a 'high score' (six or more) with respect to their knowledge of prescribing for the elderly.

RESULTS AND DISCUSSION

All physicians completed the survey. Most physicians (88%) felt confident in their ability to prescribe appropriate medications for the elderly. Thirty-nine physicians (25%) received a 'high score' compared to 26 (17%) who received a 'low score'. 'Lower score' respondents had been in practice for a longer time (P < 0·05) than 'higher score' respondents. Perceived barriers to appropriate prescribing included potential drug interactions (79% of respondents) and the large number of medications a patient is already taking (75%).

WHAT IS NEW AND CONCLUSION

The study results show an unsatisfactory knowledge of appropriate prescribing among primary care physicians in the LHU of Parma, especially among older physicians. Educational strategies tailored to primary care physicians should be establish to enhance knowledge in this area and improve quality of prescribing.

Clinical pharmacokinetics of the cyclooxygenase inhibiting nitric oxide donator (CINOD) AZD3582

The clinical pharmacokinetics of the COX-inhibiting nitric oxide donator (CINOD) AZD3582 and its metabolites, including naproxen, nitric oxide and nitrate, are summarized. AZD3582 has low aqueous solubility, moderate and passive intestinal permeability and is degraded by intestinal esterases. Its oral bioavailability (F) appears to be maximally a few per cent, and increases by several-fold after food intake. Ninety-four per cent or more of an AZD3582 dose is absorbed, of which at least 9–20% appears to be taken up as intact substance. AZD3582 has a predicted plasma protein binding degree of ∼ 0.1%, a half-life (t½) of 3 to 10 h and does not accumulate after repeated once- and twice-daily dosing. In patients AZD3582 does not provide a significantly better gastrointestinal (GI) side-effect profile than the highly permeable and locally irritating naproxen. Possible reasons for this include considerable GI uptake as naproxen, limited duration and extent of nitric oxide donation in the GI mucosa and the circulation, tolerance development (involving auto-inhibition of nitric oxide catalysing enzymes) and mucosal damage caused by nitric oxide. Blood pressure data suggest that nitric oxide is mainly donated within 3h. The uptake of naproxen is slightly slower and lower (≥ 94% relative GI uptake and 80–85% relative F) after AZD3582 administration compared with naproxen dosing. The naproxen t½ and trough steady-state concentrations after AZD3582 and naproxen dosing are similar. The average systemic nitrate exposure is approximately doubled after dosing of 375 to 750 mg AZD3582 twice daily.

Pre-clinical pharmacokinetics of the cyclooxygenase-inhibiting nitric oxide donor (CINOD) AZD3582

The pre-clinical pharmacokinetics of AZD3582 (4-(nitrooxy)butyl-(2S)-2-(6-methoxy-2-naphthyl) propanoate) and its primary metabolites (naproxen and nitrate) were evaluated. AZD3582 had intermediate and passive intestinal permeability (40 times lower than for naproxen), high systemic plasma clearance (CL), substantial gastrointestinal hydrolysis, intermediate volume of distribution (Vss; ≥3.4 L kg−1) and half-life (t1/2; 7 h), negligible plasma protein binding (∼0.1%), low/intermediate oral uptake (≥13% as intact substance) and low and varying oral bioavailability (mean 1.4% in minipigs and 3.9% in dogs). Following administration of therapeutically relevant oral doses, plasma concentrations of AZD3582 were very low (≤ 13 nM in minipigs and ≤442 nM in dogs; rat data not available) and varying, and accumulation was not apparent. The pharmacokinetics of AZD3582 did not show apparent dose-, time- or gender-related dependency. In blood and intestine, AZD3582 was hydrolysed to naproxen, nitrate and other metabolites. The rate of this conversion was higher in rats than in non-rodents, including man. Despite near-complete to complete uptake of the oral dose, AZD3582 administration resulted in a lower bioavailability (F) of total naproxen than naproxen administration: 55% and 85% relative bioavailability (Frel) in rats and minipigs, respectively. An increased distribution to metabolizing tissues of naproxen (as AZD3582), and thereby enhanced naproxen CL, is believed to be responsible. Following dosing of AZD3582 or naproxen, the t1/2 of naproxen was 5, 9–10 and &gt;40 h in rats, minipigs and dogs, respectively. The Vss and CL for naproxen were small. Plasma protein binding was extensive, and saturation was observed within the therapeutic dose and concentration range. Intake of food prolonged the systemic absorption of naproxen in the minipig. The pharmacokinetics of naproxen did not show apparent time- or gender-related dependency. Following oral dosing of [3H]-, [14C]- and [15N]-AZD3582, most [14C]- and [3H]-activity was excreted in urine and expired air, respectively. Seventeen per cent of [15N] was recovered in minipig urine as [15N]-nitrate. About 30% of [3H]-activity (naproxen and/or naproxen-related metabolites) was excreted in bile and re-absorbed. Concentrations of [14C]-activity (nitrooxy-butyl group and/or its metabolites) in milk were higher than in plasma and [3H]-activity in milk. [3H]- and [14C]-excretion data indicated that intact AZD3582 was not excreted in urine, bile or milk to a significant extent. There was no apparent consistency between tissue distribution of [14C]- and [3H]-activity in the rat, which suggests rapid and extensive metabolism of extravascularly distributed AZD3582. A substantial increase of plasma nitrate levels was found after single and repeated oral doses of AZD3582 in the minipig. No inhibition or induction of CYP450 was found.

Burn treatment in the elderly

The population of elderly patients is expected to rise continuously over the next decades due to global demographic changes. The elderly seem to be most vulnerable to burns and their management remains undoubtedly a challenge. A clear age margin for elderly patients is not yet defined, but most studies adhere to the inclusion of patients 65 years and above, but the general condition and social situation must be taken into account. The understanding of the physiological basis of aging and its related pathophysiological changes has only marginally influenced treatment and decision making in elderly burn patients. When looking at treatment regimens currently applied in elderly burn patients, the discussion of standards in intensive care as well as surgical strategies is ongoing. However, trends towards a moderate, non-aggressive resuscitation approach and careful inclusion of key parameters like physiological age, pre-burn functional status and premorbid conditions, seem to be useful guidelines for interdisciplinary treatment decisions. Once ordered for surgical treatment, the amount of body surface area operated in one session should be adapted to the general status of the patient. Even if older burn victims have a reported higher mortality rate than younger patients, improved therapeutic options have contributed to a reduced mortality rate even in the elderly over the last decades. As a result of improved outcome, more attention has to be given to a comprehensive rehabilitation program. This review will give an overview of the current literature and will draw attention to specific topics related to this important subpopulation of burn patients.

Safety of the nonselective NSAID nabumetone : focus on gastrointestinal tolerability

Although effective in the treatment of pain associated with rheumatic conditions such as osteoarthritis and rheumatoid arthritis, long-term use of NSAIDs is primarily limited by their association with upper gastrointestinal (GI) toxicity. Adverse effects range from dyspepsia and abdominal pain to ulceration and bleeding. GI damage elicited by NSAIDs arises as the result of biochemically induced topical irritant effects and by topical and systemic pharmacological suppression of gastroprotective prostaglandins. Variation in the physicochemical properties and pharmacological profiles among the individual NSAIDs translate into inter-agent differences regarding propensity to cause adverse GI effects. Nabumetone is a nonselective NSAID that offers distinct advantages over other agents in this class with regard to GI tolerability. Its non-acidic nature and pro-drug formulation, together with the lack of biliary secretion of its active metabolite, 6-methoxy-2-naphthylacetic acid, are thought to contribute to the improved GI tolerability of this drug. In head-to-head trials with other NSAIDs, nabumetone has demonstrated significant benefits regarding the incidence of GI events and more serious perforations, ulcers and bleeds (PUBs). Pooled data from eight postmarketing, randomized, controlled trials demonstrated a lower cumulative frequency of PUBs with nabumetone (0.03%; 95% CI 0.0, 0.08) versus comparator NSAIDs (1.4%; 95% CI 0.5, 2.4). Large-scale database studies also indicate that risk of serious GI complications is lower with nabumetone than comparator NSAIDs. Limited comparative data suggest that nabumetone offers a GI tolerability profile similar to that of cyclo-oxygenase-2 selective NSAIDs (coxibs). Although adverse cardiovascular outcomes appear to be a class effect of the coxibs, conventional NSAIDs may also have the potential for causing atherothrombotic complications. However, based on available data, nabumetone does not appear to be associated with increased cardiovascular risk. Finally, there is no particular concern about the nephrotoxic and hepatotoxic potential of nabumetone. Nonetheless, the potential for adverse drug reactions remains, and hence nabumetone, as with any NSAID, should be used at the lowest dose, which is effective for each patient, and for the shortest time necessary to control symptoms.

Drug-induced nephropathy: an update

Medications cause renal disease by promoting various types of injury in the kidney. Several drugs reduce renal perfusion and cause prerenal azotemia. Vascular disease can develop following exposure to various medications through direct and indirect effects. A number of glomerular lesions have been described with therapeutic agents and illicit drugs. Acute interstitial nephritis occurs from a drug-induced allergic reaction, which promotes interstitial inflammation and tubular damage. Acute tubular necrosis is a dose-dependent process that occurs from direct drug toxicity on tubular epithelia. Other less common patterns of drug-induced tubular injury include osmotic nephropathy, crystal nephropathy and acute nephrocalcinosis. Finally, postrenal azotemia from structural or functional obstruction of the urinary tract also complicates therapy with a number of medications.

Drug dosing in chronic kidney disease

Patients with chronic kidney disease (CKD) are at high risk for adverse drug reactions and drug-drug interactions. Drug dosing in these patients often proves to be a difficult task. Renal dysfunction-induced changes in human pathophysiology regularly results may alter medication pharmacodynamics and handling. Several pharmacokinetic parameters are adversely affected by CKD, secondary to a reduced oral absorption and glomerular filtration; altered tubular secretion; and reabsorption and changes in intestinal, hepatic, and renal metabolism. In general, drug dosing can be accomplished by multiple methods; however, the most common recommendations are often to reduce the dose or expand the dosing interval, or use both methods simultaneously. Some medications need to be avoided all together in CKD either because of lack of efficacy or increased risk of toxicity. Nevertheless, specific recommendations are available for dosing of certain medications and are an important resource, because most are based on clinical or pharmacokinetic trials.

Adverse cardiorenal effects of aldosterone: is aldosterone antagonism beneficial?

Aldosterone has recently been recognized as an important factor in the development and progression of cardiorenal disease. Animal and human data suggest that aldosterone contributes importantly to several disease states. These include congestive heart failure, coronary heart disease and progression of kidney disease. Recently, the discovery that aldosterone antagonists decrease pathologic injury in the kidneys and nonepithelial tissues, such as the myocardium and endothelium, has generated great controversy regarding the actual mechanisms of benefit of these agents. The available data is reviewed and conclusions drawn regarding the relative benefits of modulating aldosterone effects in the cardiovascular system and the kidney. In particular, the authors review their effects on reductions in cardiovascular events and progression of chronic kidney disease, as well as the safety and tolerability of these agents.

COX-2 inhibition in cancer therapeutics: a field of controversy or a magic bullet?

Carcinogenesis is a multistep process of long-term accumulation of genetic and epigenetic aberrations at the molecular level. Understanding the mechanisms underlying carcinogenesis could further provide insights for rationally designed new therapeutic strategies for cancer prevention and treatment. Epidemiological and experimental evidence supports the preventative effect of non-steroidal anti-inflammatory drugs (NSAIDs) regarding cancer development. NSAIDs inhibit cyclooxygenase (COX) activity, thus blocking the endogenous prostaglandin production. COX-2 is a key isoenzyme in this biochemical cascade and is inducible by various oncogenic stimuli. A large volume of research data has shown that COX-2 is often upregulated in many malignant tumours, rendering it an attractive candidate target for cancer therapeutics. Various possible direct mechanisms for COX-2 implication in carcinogenesis have been suggested, whilst intense interest has recently been focused on COX-2-independent effects of NSAIDs. Several COX-2-selective inhibitors are currently under evaluation in preclinical and clinical studies, either as single agents or in combination with conventional chemotherapy, radiotherapy and other new molecularly-targeted compounds, with promising results. This article critically reviews already published data on COX-2-selective inhibitors that have been tested in cancer clinical trials, highlights ongoing research and considers the future perspectives of this novel class of agents.

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

BACKGROUND

Dialysis patients require special consideration regarding analgesics, given their altered pharmacokinetic and pharmacodynamic profiles and increased potential for adverse reactions.

METHODS

Analgesic prescription patterns were investigated using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), with 3749 patients in 142 United States facilities studied between May 1996 and September 2001.

RESULTS

The proportion of patients prescribed any analgesic decreased from 30.2% to 24.3%; narcotic prescriptions decreased from 18.0% to 14.9%. The most commonly prescribed narcotics were propoxyphene/acetaminophen combinations (47.2%). Combinations containing acetaminophen were prescribed concurrently for 84.1% of patients on narcotics. About one half of prescriptions for narcotics, acetaminophen, and cyclooxygenase-2 (COX-2) agents were for 12 months or more; one half of prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs) were for 8 months or more. The proportion of patients prescribed analgesics varied by facility (mean +/- SD = 27.9%+/- 18.9% for all analgesics, range 0% to 89.3%). Analgesic prescription was more likely among the elderly, women, and patients with cardiovascular disease (other than coronary artery disease or congestive heart failure), lung and psychiatric disease, cancer (other than skin), and recurrent cellulitis. Patients prescribed laxatives were almost twice as likely to be on a narcotic (odds ratio = 1.95, P < 0.0001). Analgesic prescription did not correlate with loss of residual renal function or hospitalization for a gastrointestinal disorder. Three-quarters of patients reporting moderate to very severe pain were not prescribed analgesics. Furthermore, 74% of patients with pain that interfered with work had no analgesic prescription.

CONCLUSION

Dialysis patients and providers may benefit from both refinement of existing guidelines and a renewed understanding regarding appropriate prescription of analgesics.