Prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent hemodialysis: a systematic review

Two Weeks of Continuous Opioid Treatment in an Adenine-Induced Mouse Model of Chronic Kidney Disease Exacerbates the Bone Inflammatory State and Increases Osteoclasts

Patients with chronic kidney disease (CKD) report high pain levels, but reduced renal clearance eliminates many analgesic options; therefore, 30-50% of CKD patients have chronic opioid prescriptions. Opioid use in CKD is associated with higher fracture rates. Opioids may directly alter bone turnover directly through effects on bone cells and indirectly via increasing inflammation. We hypothesized that continuous opioid exposure would exacerbate the high bone turnover state of CKD and be associated with elevated measures of inflammation. Male C57Bl/6J mice after 8 weeks of adenine-induced CKD (AD) and non-AD controls (CON) had 14-day osmotic pumps (0.25-µL/hr release) containing either saline or 50-mg/mL oxycodone (OXY) surgically implanted in the subscapular region. After 2 weeks, all AD mice had elevated blood urea nitrogen, parathyroid hormone, and serum markers of bone turnover compared to controls with no effect of OXY. Immunohistochemical staining of the distal femur showed increased numbers of osteocytes positive for the mu opioid and for toll-like receptor 4 (TLR4) due to OXY. Osteocyte protein expression of tumor necrosis factor-α (TNF-α) and RANKL were higher due to both AD and OXY so that AD + OXY mice had the highest values. Trabecular osteoclast-covered surfaces were also significantly higher due to both AD and OXY, resulting in AD + OXY mice having 4.5-fold higher osteoclast-covered surfaces than untreated CON. These data demonstrate that opioids are associated with a pro-inflammatory state in osteocytes which increases the pro-resorptive state of CKD.

The effect of urgent-start peritoneal dialysis and urgent-start hemodialysis on clinical outcomes in patients with chronic kidney disease: an updated systematic review and meta-analysis

OBJECTIVE

Recently, urgent-start peritoneal dialysis (PD) has been suggested in place of urgent-start hemodialysis (HD) in cases of chronic kidney disease (CKD). However, the comparative effectiveness of these methods is still unclear. This study compared the outcomes of urgent-start PD and urgent-start HD in CKD patients.

METHODS

Electronic searches were conducted in PubMed, EMbase, Google Scholar databases, and Cochrane Library, up to 30th July 2023 for studies reporting data on all-cause mortality. Secondary outcomes included dialysis-related infectious and mechanical complications. Risk ratios (RRs) with 95% confidence interval (CI) were calculated.

RESULTS

Nine eligible studies involving 941 PD and 779 HD patients were analyzed. Pooled analysis demonstrated elevated risk of all-cause mortality (RR: 1.06, 95% CI: 1.02 to 1.09), dialysis-related infectious complications (RR: 1.05, 95% CI: 1.02 to 1.07), and mechanical complications (RR: 1.08, 95% CI: 1.04 to 1.13) in patients undergoing urgent-start HD than in patients on urgent-start PD.

CONCLUSION

Our findings indicate that CKD patients that received urgent-start HD are at increased risk of all-cause mortality and infectious, and mechanical complications that are associated with the dialysis than patients that received urgent-start PD. These findings have to be considered when making treatment decisions for patients with acute kidney injury. Better understanding of the mechanism of these differences may help to create guidelines for more informed clinical practices.

Prevalence and factors associated with the correlation between malnutrition and pain in hemodialysis patients

Malnutrition and pain are common in patients with chronic kidney disease who undergo hemodialysis. Although both pain and malnutrition are associated with increased morbidity and mortality, few studies have explored the correlation between pain and nutritional status. This study aimed to investigate the factors associated with pain intensity in patients undergoing hemodialysis, focusing on the risk of malnutrition. This was a cross-sectional study conducted at a regional dialysis center in a large tertiary hospital. Convenience sampling was used to recruit adult patients who had undergone hemodialysis for more than three months. An interviewer-administered questionnaire was used to gather sociodemographic and clinical data related to dialysis status, comorbidities, and body mass index (BMI). Pain severity and pain interference with functioning domains of the Brief Pain Index (BPI) were used to assess pain, and the malnutrition inflammation score (MIS) was used to assess nutritional status. Descriptive and inferential statistics were used to report the findings. The data were analyzed using the 25th version of the Statistical Package for the Social Sciences (IBM-SPSS) software. Of the final sample of 230 patients, 63.0% were males and 37.0% were females, with an average age of 58.3 years. Almost one-third of the participants had a BMI within the normal range (33.9%), and nearly one-third had a BMI within the underweight range (33.9%). Slightly more than half had a normal nutritional status or mild malnutrition (54.8%), while just under half had moderate or severe malnutrition (45.2%). The prevalence of pain was 47.0%. At the multivariate level, the severity of pain was associated with malnutrition (p < 0.001). Pain interference with function was associated with marital status (p = 0.045), number of comorbidities (p = 0.012), and malnutrition (p < 0.001). The MIS was positively correlated with both the severity of pain and the interference score. Pain and malnutrition were found to be prevalent in patients undergoing hemodialysis. Pain severity was associated with malnutrition, and pain interference was associated with malnutrition, marital status, and the number of comorbidities. Hemodialysis treatment should follow a patient-tailored approach that addresses pain, nutritional status, and associated chronic conditions. In addition, pain assessment and management should be included in the curriculum of nephrology training programs.

Central sensitization: its prevalence and impact on quality of life among hemodialyzed patients

BACKGROUND/AIM

Data on the role of central sensitization in hemodialyzed patients are scarce. The aim was to identify the impact of central sensitization on quality of life and elucidate the risk factors for the development of central sensitization in patients receiving hemodialysis.

METHODS

Central sensitization, quality of life, psychological well-being, and sleep were assessed by the Central Sensitization Inventory (CSI), abbreviated version of the World Health Organization Quality of Life Instrument (WHOQOL-BREF), Hospital Anxiety and Depression Scale (HADS), and Jenkins Sleep Evaluation Scale (JSS), respectively. The effect of central sensitization on quality of life and the predictors of the development of central sensitization were assessed by regression analyses.

RESULTS

The frequency of central sensitization was 48% in the study population (n = 100). Patients with central sensitization had significantly higher pain intensity, worse sleep quality, and more impaired psychological status (p < 0.05 for all). The CSI score negatively affected all quality of life domains on its own (p < 0.001 for all, adjusted R2 ranged from 0.17 to 0.47). Dialysis vintage (OR, 0.8; 95% CI, 0.7 to 1.0), pain (OR, 1.5; 95% CI, 1.1 to 2.0), JSS (OR, 1.3; 95% CI, 1.1 to 1.5), and HADS-total (OR, 1.1; 95% CI, 1.0 to 1.2) were determined as the independent risk factors for central sensitization (p < 0.05 for all).

CONCLUSION

This study confirms that given the high frequency of central sensitization and its significant negative impact on quality of life, the presence of central sensitization should be investigated in patients undergoing hemodialysis.

Prevalence and Management of Chronic Pain, Including Neuropathic Pain, in Dialysis Patients with End-Stage Renal Disease

BACKGROUND Chronic kidney disease (CKD) is a growing global health concern. Chronic pain, as a common symptom of CKD, particularly among patients with end-stage renal disease (ESRD), is influenced by complications, dialysis procedures, and comorbidities. We aimed to evaluate chronic pain and probable neuropathic pain in 96 dialysis patients with ESRD using the Douleur Neuropathique 4 (DN4) questionnaire. MATERIAL AND METHODS A total of 96 patients from a single dialysis center were enrolled for the purpose of this study. ESRD was caused by diseases causing kidney damage, such as diabetes. The average duration of maintenance dialysis was 4.6±5.67 years. Comorbidities, functional and mental assessment, and pharmacological treatment data were collected using a questionnaire. The satisfaction with life scale was also used. Chronic pain was defined as lasting more than 3 months. The DN4 was used to determine the neuropathic component of pain. RESULTS Chronic pain was observed in 63.5% of the study participants, with 47.5% of them reporting the presence of neuropathic pain accompanied by a neuropathic component. Significantly more patients with chronic pain reported mood disorders and reduced life satisfaction, but there was no difference in their activities of daily living-assessed functional status or duration of dialysis. Patients experiencing chronic pain received non-steroidal anti-inflammatory drugs, paracetamol, and opioids. CONCLUSIONS Chronic pain, especially with a neuropathic component, is highly prevalent in patients with CKD, and its treatment remains ineffective. Undiagnosed components of pain can contribute to underdiagnosis and inadequate therapy. Further studies and staff education are needed to address this important issue.

Pain and quality of life of patients with end-stage renal disease undergoing hemodialysis in Aseer region, Saudi Arabia

BACKGROUND

Pain has an adverse effect on HRQoL and has social, psychological, and physical repercussions for ESRD patients. In the present study, we assessed chronic pain in ESRD patients on HD in terms of severity and interference with activity. We also assessed the impact it has on these patients, along with looking at the factors that were linked to QoL in this population.

METHODS

A multicenter, cross-sectional study carried out between April and July of 2023 in the hemodialysis units of Asir Central Hospital and Khamis Mushait General Hospital. Brief Pain Inventory and European Quality of Life scale 5 dimensions (EQ-5D) scale, including its European Quality of Life visual analogue scale (EQ-VAS) component, were used to assess pain and QoL, respectively.

RESULTS

A total of 97 participants were included in the final study. The average interference level of pain with daily functions was 22.5 ± 15.0 out of 70. The mean interference score was significantly higher among patients at rural areas (28.2 ± 16.3; P = 0.012), and those who undergone dialysis session for ≥ 4 times per week (31.6 ± 16.7; P = 0.026). The overall score of quality of life ranged from 20% to 92% with mean score of 36.5 ± 12.8%. The multiple linear regression analysis revealed that patients with higher BMI, more frequent dialysis sessions per week, and higher level of pain interference with daily functions demonstrated lower QoL (B= - 2.36, - 1.46, and - 0.64, respectively.

CONCLUSIONS

Pain has a significant negative impact on QoL in ESRD patients undergoing HD. Patients with higher BMI, more frequent dialysis sessions, and higher level of pain interference with daily functions are at higher risk of lower QoL. These findings provide valuable information for educators, physicians, and other healthcare providers working with patients undergoing HD.

Effectiveness of the Eutectic Mixture of Local Anaesthetics Cream in the Management of Arteriovenous Fistula Needle Insertion Pain in Patients Undergoing Haemodialysis

This review aimed to assess the effectiveness of the eutectic mixture of local anaesthetics (EMLA) cream in the management of arteriovenous fistula (AVF) needle insertion pain in adult patients undergoing haemodialysis (HD) compared with other alternative interventions. The main search was conducted in November 2020 and updated in December 2021. In the search strategy, keywords and synonyms were used and multiple databases were searched with no date limitation to ensure a comprehensive search that would yield all studies relevant to the review and minimise location bias. A total of 209 studies were found in this search and filtered. After filtering through these studies, only five studies were finally included in the review. EMLA-cream was found to be effective in reducing AVF needle insertion pain among adult patients undergoing HD. Despite EMLA cream's effectiveness in reducing HD needle insertion pain and its fewer side effects, the findings of the included studies should be interpreted with caution, as there are some limitations, and further research is required.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

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.

Chronic Pain and Quality of Life in Maintenance Hemodialysis Patients in China: A Multicenter, Cross-Sectional Study

Purpose

Patients undergoing maintenance hemodialysis (MHD) frequently experience chronic pain, which can severely affect their quality of life (QOL). The objective of this study was to evaluate the prevalence of chronic pain in MHD patients and examine the factors associated with QOL.

Patients and Methods

A cross-sectional questionnaire-based survey was conducted between October 2020 and April 2021, 1204 MHD patients from nine hemodialysis units were screened for chronic pain in Chengdu, China, and 296 MHD patients with chronic pain were enrolled in this study. We analyzed data on clinicodemographic characteristics, pain interference and severity (Brief Pain Inventory), QOL (Medical Outcomes Study 36-item Short Form Health Survey - mental component summary [MCS] and physical component summary [PCS]), pain self-efficacy (Pain Self-Efficacy Questionnaire), and social support (Social Support Rating Scale).

Results

The prevalence of chronic pain in MHD patients was 26.74% in this study. The most common areas of pain were lower back (63.5%), lower limbs (55.0%), and head (33.5%), 36.5% did not implement any measures to relieve it. Of the patients who did receive pain treatment or medication, 56.9% reported that the measures they took had less than half of the pain relief. MHD patients with chronic pain had poor QOL based on scores on the MCS (53 ± 16.76) and PCS (40.56 ± 13.81). Stepwise multiple regression identified age, financial strain, pain interference, social support, and pain self-efficacy as independent predictors of QOL. Pain self-efficacy was significantly associated with social support (r = 0.5, p < 0.01), MCS (r = 0.69, p < 0.01), and PCS (r = 0.8, p < 0.01). The mediating effects of pain self-efficacy were 70.31% on the relationship between social support and MCS, and 75.62% on the relationship between social support and PCS.

Conclusion

Chronic pain is prevalent and undermanaged in Chinese MHD patients, resulting in worse QOL. Healthcare providers should focus on pain management and the impact of psychosocial factors on patient QOL. Further research should deepen our understanding of how pain self-efficacy mediates the relationship between social support and QOL.

Emerging Patient-Centered Concepts in Pain Among Adults With Chronic Kidney Disease, Maintenance Dialysis, and Kidney Transplant

Patient reports of moderate to severe pain are common across the spectrum of chronic kidney disease. The synergistic effects of comorbid depression and anxiety can lead to maladaptive coping responses to pain, namely pain catastrophizing and illness-related post-traumatic stress disorder. If underlying depression and anxiety and associated maladaptive coping responses are not treated, patients can experience an increased perception of pain, worsened disability, decreased quality of life, withdrawal from social activities, and increased morbidity and mortality. Meanwhile, interest in nonpharmacologic treatments for pain that targets coping as well as comorbid anxiety and depression has been increasing, particularly given the significant societal damage that has resulted from the opioid epidemic. Evidence-based, nonpharmacologic treatments have shown promise in treating pain in areas outside of nephrology. Currently, little is known about the effects of these treatments among adults with CKD, and particularly end-stage kidney disease, when chronic pain can become debilitating. In this review, we examine patient-centered concepts related to pain that have received little attention in the nephrology literature. We also describe emerging areas of research, including omics technologies for biomarker discovery and advanced symptom clustering methods for symptom phenotyping, which may be useful to future kidney disease research and treatment.

Pain in Hemodialysis Patients: Prevalence, Intensity, Location, and Functional Interference in Daily Activities

Although pain is a frequent complaint of patients with chronic kidney disease who undergo hemodialysis, few studies have assessed the functional interference of pain in activities of daily living (ADLs). Hence, the aim of this study was to evaluate the prevalence, location, intensity, and functional interference of pain in ADLs of chronic kidney disease patients undergoing hemodialysis and to estimate the association of specific pain sites with severe functional interference by pain in ADLs. This cross-sectional study included patients with chronic kidney disease undergoing hemodialysis. The prevalence, intensity, and functional interference of pain in ADLs were assessed using the brief pain inventory. Poisson regression was used to calculate the prevalence ratio. A total of 65 patients participated in the study. The overall prevalence of pain was 89.23%; the prevalence of headache was 18.46% and that of pain in the trunk was 55.38%, upper limbs was 35.38%, and lower limbs was 60.00%. The prevalence of moderate and severe pain at the time of hemodialysis was 13.85% and 21.54%, respectively. A high prevalence of severe functional interference of pain in general activity (61.54%), mobility (56.92%), and disposition (55.38%) was observed. Pain is a frequent complaint in patients undergoing hemodialysis, mainly musculoskeletal and intradialytic, and it interferes with ADLs and incapacitates the patient. Pain was highly prevalent in the upper and lower limbs and the trunk. Furthermore, a higher prevalence of severe pain at the time of hemodialysis and functional interference of pain, mainly in general activity, mobility, and disposition, were observed.

Perceptions of exercise benefits and barriers: the influence on physical activity behaviour in individuals undergoing haemodialysis and peritoneal dialysis

Background

Despite growing evidence about the benefits of physical activity and exercise in patients receiving dialysis, physical inactivity is highly prevalent. This may be due to uncertainty and lack of appropriate guidance about exercise, or driven by the relative barriers and benefits that patients perceive. Understanding these perceptions in dialysis patients may inform interventions aimed to increase exercise participation.

Methods

Perceived benefits and barriers to exercise were measured by the ‘Dialysis Patient-perceived Exercise Benefits and Barriers Scale’ (DPEBBS). Self-reported physical activity status was assessed by the ‘General Practice Physical Activity Questionnaire’. Barriers and benefits to exercise were classed as binary variables (i.e. yes and no). Frequency analyses and chi-squared tests were conducted to compare the differences perceived by people on haemodialysis (HD) and peritoneal dialysis (PD). Binominal logistical regression was performed to determine which perceived barriers and benefits had the biggest impact on physical activity status.

Results

One thousand twenty-two HD and 124 PD patients completed the DPEBBS. A greater proportion of HD than PD patients reported ‘reduces body pain’ (P = 0.013), ‘delays decline in body function’ (P = 0.01), and ‘improves quality of life’ (P = 0.033) as benefits of exercise. No differences in barriers were observed. Tiredness was the most reported barrier to exercise. Patients who perceived ‘other comorbidities’ (OR 3.389, P < 0.001) or ‘burden of family’ (OR 3.168, P < 0.001) as barriers were 3 times more likely to be inactive.

Conclusions

Dialysis patients perceive several barriers which may prevent them from engaging in physical activity. Addressing these barriers may be key to increasing participation in physical activity and exercise.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01024-y.

Exploring factors associated with pain in hemodialysis patients: a multicenter cross-sectional study from Palestine

BACKGROUND

Chronic kidney disease (CKD) is a rising medical concern around the world. End-stage kidney disease (ESKD) is the last stage of CKD stages that necessitates renal replacement therapy (RRT), such as hemodialysis (HD), which seems to be the most commonly used type. However, patients on HD still suffer from high mortality and morbidity rates compared to those who receive a kidney transplant. Therefore, we aimed in this study to assess the prevalence of pain among ESKD patients on HD, as well as to explore the factors that were associated with this complaint.

METHODS

We conducted a multicenter cross-sectional study in the West Bank, Palestine, between August and November 2018. We used questionnaire-based direct interviews with subjects. After reviewing previous studies in the field, we developed our questionnaire and included items on patients' social, demographic, and clinical characteristics, including dialysis-related data. It also contained the Brief Pain Inventory (BPI) to assess different aspects of pain symptoms. A convenience sampling technique was used to collect data.

RESULTS

Of the 300 participants, 66.3 % reported having chronic pain. HD sessions themselves were the most commonly cited cause for pain (21.6 %). The most commonly cited site of pain was the upper and lower limbs (37.3 %). Paracetamol was the most frequently used pharmacotherapy for pain alleviation. Multiple regression analysis showed that BMI (p = 0.018), gender (p = 0.023), and the number of comorbidities (p < 0.001) were independently associated with pain severity score.

CONCLUSIONS

Pain is a highly prevalent symptom among HD patients in Palestine. Subpopulations with higher pain severity include females, patients with higher BMI, and those with multiple comorbidities. Healthcare providers should routinely assess pain in HD patients as it is considered a significant concern. This would involve pain assessment and development of a treatment plan to improve clinical outcomes. The nephrology associations should also push for pain management in HD patients as a clinical and research priority to improve pain-related disability.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.

Objectives:

To determine the prevalence and severity of chronic pain 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 glomerular filtration rate (GFR) category 3 to 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 pain, and severity of pain.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain 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 was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.

Results:

Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.

Limitations:

Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.

Conclusions:

Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.

Trial registration:

PROSPERO Registration number CRD42020166965

The impact of pain on the quality of life of patients with end-stage renal disease undergoing hemodialysis: a multicenter cross-sectional study from Palestine

BACKGROUND

Chronic kidney disease is considered as a global health problem. Hemodialysis (HD), following renal transplantation, is the most common form of renal replacement therapy. However, HD may impact the quality of life (QOL). Pain is a frequent complaint among this population that also affects their QOL. The purposes of this study were to assess pain and QOL among end-stage renal disease (ESRD) patients on HD and to examine their association.

METHODS

This was a multicenter, cross-sectional study that occurred in Palestine between August and November 2018. Brief Pain Inventory and European Quality of Life scale 5 dimensions (EQ-5D) scale, including its European Quality of Life visual analogue scale (EQ-VAS) component, were used to assess pain and QOL, respectively.

RESULTS

A total of 300 participants were included in the final study. The average age of the subjects was 54 ± 16 years. Their median EQ-5D score was 0.68 [0.54-0.88], whereas their median EQ-VAS score was 60 [40-75]. A statistically significant association of pain severity score with EQ-5D score was found (r = - 0.783, p < 0.001). The association between pain interference score and EQ-5D score was also found to be statistically significant (r = - 0.868, p < 0.001). Similarly, pain severity score was significantly assocsiated with EQ-VAS score (r = - 0.590, p < 0.001), the same as was the pain interference score (r = - 0.647, p < 0.001). Moreover, age, gender, BMI, employment, educational level, income level, dialysis vintage, previous kidney transplantation, and chronic medication use were all significantly correlated with QOL. Regression analysis showed that patients aged < 60 years (p < 0.001), those with lower pain severity scores (p = 0.003), and those with lower pain interference scores (p < 0.001) had significantly higher QOL scores.

CONCLUSIONS

Pain has a significant negative impact on QOL in ESRD patients undergoing HD. The subgroups that were at higher risk included elderly patients, females, those with higher BMI, those without a formal education, those unemployed, those living with low monthly income, smokers, those who have multiple comorbidities, and patients with longer dialysis vintage. Our findings provide reliable data for educators and clinicians working with HD patients.

Opioids in Hemodialysis Patients

Chronic pain and prescription opioid use are prevalent among patients with end-stage kidney disease treated with hemodialysis. Vulnerabilities to complications from opioid use are high in this patient population, as shown in many recent, well-conducted, patient-oriented studies. Such studies have highlighted the need for a balanced approach to pain management in hemodialysis patients that includes careful assessment of the risks and benefits of opioid prescriptions in this population. In this article, we review the available literature and experience regarding opioid prescriptions among hemodialysis patients, discuss clinical implications, and outline ongoing research.

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.

Pharmacotherapeutic Management of Neuropathic Pain in End-Stage Renal Disease

Background

Chronic noncancer pain is pervasive throughout the general patient population, transcending all chronic disease states. Patients with end-stage renal disease (ESRD) present a complicated population for which medication management requires careful consideration of the pathogenesis of ESRD and intimate knowledge of pharmacology. The origin of pain must also guide treatment options. As such, the presentation of neuropathic pain in ESRD can present a challenging case. The authors aim to provide a review of available classes of medications and considerations for the treatment of neuropathic pain in ESRD.

Summary

In this narrative review, the authors discuss important strategies and considerations for the treatment of neuropathic pain in ESRD, including the pathogenesis of neuropathic pain, physiological changes for consideration in ESRD patients, and disease-specific consideration for medication selection. Pharmacotherapeutic classes discussed include: anticonvulsants, antiarrhythmics, antidepressants, topicals, and opioids.

Key Message

Pain management in ESRD patients requires careful assessment of drug-specific properties, accumulation, metabolism (presence of active/toxic metabolites), extraction by dialysis, and presence of drug - drug interactions. In the absence of pharmacokinetic data in ESRD patients, therapeutic window and potential risks should be factored in the decision making along with continued monitoring throughout therapy.

Transcranial direct current stimulation in management of pain, mood, functionality, and quality of life in patients undergoing hemodialysis: a study protocol for a double-blind controlled randomized trial

BACKGROUND

Persistent pain can lead to incapacitation requiring long-term pharmacological treatment. Up to 82% of chronic kidney disease (CKD) patients undergoing hemodialysis (HD) have chronic pain and most do not respond to usual medication. Advances in non-pharmacological treatments are necessary to promote pain relief without side effects and to restore functionality. Transcranial direct current stimulation (tDCS) promises to be a novel, cost-efficient, non-pharmacological treatment for CKD patients with chronic pain. In this study, we hypothesize that tDCS could improve pain, depression, functionality, and quality of life in patients with CKD undergoing HD.

METHODS/DESIGN

We describe a single-center, parallel-design, double blind randomized, sham-controlled trial. Forty-five subjects with CKD undergoing HD will be randomized to a motor cortex (M1), a dorso lateral prefrontal cortex (DLPFC), or a sham group. A total of ten sessions will be administered to participants over 4 weeks using a monophasic continuous current with an intensity of 2 mA for 20 min. Participants will be evaluated at baseline, immediately after the tenth session, and at 1 week and 4 weeks of follow-up after the intervention. Pain, depression, functionality, and quality of life will be evaluated.

DISCUSSION

The results from this study will provide initial clinical evidence on the efficacy and safety of tDCS in patients with CKD undergoing HD.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry/Registro Brasileiro de Ensaios Clínicos (ensaiosclinicos.gov.br), 1111-1216-0137. Registered on 20 June 2018.

Effectiveness of music therapy for alleviating pain during haemodialysis access cannulation for patients undergoing haemodialysis: a multi-facility, single-blind, randomised controlled trial

Background

Repeated pain during haemodialysis access cannulations is a serious problem for haemodialysis patients even when prescribed oral or topical analgesics. Although some studies have observed the efficacy of music therapy for improving pain and anxiety, its effectiveness during haemodialysis access cannulations during dialysis is uncertain. The purpose of this study is to investigate the effects of music therapy for pain when cannulating haemodialysis access for haemodialysis patients.

Methods

A prospective, multi-facility, single-blind, crossover, randomised controlled trial will be implemented. The intervention includes listening to Mozart, along with a white noise control condition. One hundred twenty haemodialysis patients will be enrolled across five facilities. Patients will be randomly allocated to either an Early-sequence group or a Later-sequence group. The Early-sequence group will receive cannulation while listening to Mozart’s Sonata for two pianos in D major (K.448) during the second week (Music period) and white noise during the fourth week (White noise period). The Later-sequence group will receive cannulation along with white noise first, followed by Mozart. All patients will also undergo cannulation during a no-sound period (wearing only headphones) during the first and third week (No-sound period). The music or no-music protocol will begin 8 min prior to the cannulating procedure, and participants will finish listening after starting haemodialysis during each period. The primary outcomes that will be assessed include the Visual Analogue Scale (VAS) score for pain during cannulation, and secondary outcomes are blood pressure, heart rate, VAS anxiety score, State-Trait Anxiety Inventory score, and salivary amylase activity. The operators who are in charge of haemodialysis access cannulation will be blind to the listening condition and VAS report.

Discussion

The proposed study has several methodological benefits. First, using white noise is a suitable control condition for addressing the role of sound in pain management. Additionally, using a crossover design with repeated measurements can help control individual differences between participants, which should better distinguish between- and within-participant variability. Overall, music therapy is a safe and inexpensive intervention that does not have the problematic side effects typically associated with pharmacological treatment. If effective, music therapy can be easily implemented for reducing pain and anxiety during cannulation.

Trial registration

This trial was prospectively registered to UMIN Clinical Trials Registry on 1 July 2018 (UMIN 000032850).

Promoting Self-Regulatory Management of Chronic Pain Through Dohsa-hou: Single-Case Series of Low-Functioning Hemodialysis Patients

Hemodialysis patients suffer from long-term pain that drains their energy and contributes to behavioral interference and other negative effects on their daily lives that result in or exacerbate functional limitations. In addition, they deal with dietary restrictions, symptoms such as itching, lack of energy, and psychological stressors like the loss of self-concept and self-esteem. Self-regulation involves the capacity to notice, inform, and modulate responses and behavior, and research indicates that it promotes rehabilitation in chronic pain patients. Research on the aspects of self-regulation afforded by the Japanese psychotherapy Dohsa-hou correspond to psychological processes tied to the sense of self-control that clients realize over their body movements. This study pilot tested a hospital-integrated implementation of Dohsa-hou relaxation tasks as a chronic pain management behavioral intervention for five female hemodialysis patients between the ages of 59–62 years. We conducted an ABABABA single-case design to compare baseline A-phases (treatment-as-usual: TAU) taken at recurring 1 week intervals (three sessions per week for a total of 4 weeks, 12 total recordings) with an intervention of Dohsa-hou B-phases every 4 weeks (three sessions per week for 12 weeks, 36 total recordings) over the span of 4 months to compare effectiveness. Visual Analogue Scale (VAS) pain scores between phases were taken and self-regulatory progress was tracked and summarized from a series of semi-structured interviews. Visual analysis of scores for each participant as single cases indicated decreases for the Dohsa-hou phase compared to baseline treatment-as-usual. As a result, participants reported using Dohsa-hou to reduce pain and experienced improvements in quality of life associated with greater self-regulatory capacity to attend to personal care and domestic activities. These preliminary findings suggest that Dohsa-hou body movement relaxation tasks were feasible as a coping skill in a hospital-integrated setting and at home and show promise for promoting quality of life vis-a-vis the management of severe and chronic bodily pain associated with end-stage renal disease and its treatment, particularly by improving aspects of pain-mediated self-regulatory fatigue.

Association between NSAID use and mortality risk in patients with end-stage renal disease: a population-based cohort study

Background: Pain is one of the most common symptoms experienced by patients with end-stage renal disease. Although NSAIDs may lead to adverse events, NSAID use appears to be considerably high in patients with end-stage renal disease. However, whether NSAID use is associated with an increased risk of mortality in this population remains unknown.

Aim: This study aimed to investigate the association between the use of NSAIDs and the risk of mortality in patients with end-stage renal disease.

Patients and methods: We used the population-based Taiwan National Health Insurance Research Database to investigate the association between the use of NSAIDs and the risk of mortality in patients with end-stage renal disease receiving dialysis. A total of 3,383 patients with newly diagnosed end-stage renal disease requiring long-term dialysis between 1998 and 2012 were included in the current study, and the study outcome was evaluated until December 31, 2013. Time-dependent Cox regression models were applied to examine the association between NSAID use and mortality risk.

Results: In the study cohort, 2,623 (78%) patients used NSAIDs during the follow-up period. The median follow-up period was 4.0 years, during which 1,515 patients died. The results of multivariable analysis demonstrated that compared with NSAID nonuse, the use of any NSAIDs, nonselective NSAIDs, and selective cyclooxygenase-2 inhibitors was associated with a significantly increased risk of all-cause mortality with an adjusted HR (95% CI) of 1.39 (1.21–1.60), 1.36 (1.19–1.55), and 1.61 (1.42–1.83), respectively.

Conclusion: The results suggest that NSAID use was associated with an increased risk of mortality in the patients with end-stage renal disease. Future randomized controlled trials are needed to validate these observational findings.

Assessing and Treating Chronic Pain in Patients with End-Stage Renal Disease

Pain is one of the most common symptoms among patients with end-stage renal disease (ESRD), and is often under recognized and not adequately managed in hemodialysis (HD) patients. Barriers to adequate pain management include poor awareness of the problem, insufficient medical education, fears of possible drug-related side effects, and common misconceptions about the inevitability of pain in elderly and HD patients. Caregivers working in HD should be aware of the possible consequences of inadequate pain assessment and management. Common pain syndromes in HD patients include musculoskeletal diseases and metabolic neuropathies, associated with typical intradialytic pain. Evaluating the etiology, nature, and intensity of pain is crucial for choosing the correct analgesic. A mechanism-based approach to pain management may result in a better outcome. Pharmacokinetic considerations on clearance alterations and possible toxicity in patients with ESRD should drive the right analgesic prescription. Comorbidities and polymedications may increase the risk of drug-drug interactions, therefore drug metabolism should be taken into account when selecting analgesic drugs. Automedication is common among HD patients but should be avoided to reduce the risk of hazardous drug administration. Further research is warranted to define the efficacy and safety of analgesic drugs and techniques in the context of patients with ESRD as generalizing information from studies conducted in the general population could be inappropriate and potentially dangerous. A multidisciplinary approach is recommended for the management of complex pain syndromes in frail patients, such as those suffering from ESRD.