Test Your Knowledge: Pain

We are releasing a quiz* each week from the eight regions of NephMadness 2019, in anticipation of the NephMadness 2020 logo reveal at Kidney Week. We focused on Plasma Exchange last week and now turn to the Pain Region. Whenever we consider giving a medication for pain, we must weigh the potential benefits against the potential harms. Test your knowledge on pain management in patients with kidney diseases with the quiz* below.

For a PDF version of the questions & answers, please click here.

A 47-year-old man with CKD stage 4 from diabetes mellitus presents to the ER with acute severe left leg lower leg pain after a significant fall. He is found to have a tibial shaft fracture. He currently rates his pain a 9/10. Which of the following would be the best initial choice for acute pain management?
Correct! The patient has CKD stage 4 and acute severe pain. Ketorolac should be avoided given the severity of his CKD due to the risk of worsening kidney function. Codeine and morphine should be avoided due to the risk of accumulation of the morphine-6-glucuronide metabolite that is biologically active. Hydromorphone is a good choice for severe pain and does not have a biologically active metabolite. [Reference: Pham, P.C., Khaing, K., Sievers, T.M., et al. 2017 update on pain management in patients with chronic kidney disease. Clin Kidney J 2017; 10(5): 688-97.]
2. A 47-year-old woman with ESKD on hemodialysis and rheumatoid arthritis presents with worsening arthritis symptoms. She is currently on hydroxychloroquine for her rheumatoid arthritis. She is completely anuric. Which of the following complications is she most likely to have if an NSAID is added to her regimen?
GI bleeding
Correct! Without an intact, functioning, distal tubule (i.e. an anuric dialysis patient), the main prostaglandin effects on the kidney of hyperkalemia, hypertension, edema cannot occur. However, NSAIDs effects on the gastric mucosa still exist. [References: (1) Jankovic, S.M., Aleksic, J., Rakovic, S., et al. Nonsteroidal antiinflammatory drugs and risk of gastrointestinal bleeding among patients on hemodialysis. J Nephrol 2009; 22(4): 502-7. (2) Kurella, M., Bennett, W.M., and Chertow, G.M. Analgesia in patients with ESRD: a review of available evidence. Amer Jour of Kidney Dis 2003; 42(2): 217-228.]
Worsened edema
3. A 63-year-old man with ESKD on in-center hemodialysis was brought in to the emergency department by his wife with increasing sedation over the last two days. He has not missed any recent hemodialysis treatments; his last treatment was 2 days ago. He has not had any other symptoms. His medications include sevelamer, carvedilol, lisinopril, and baclofen, which was started 1 week ago  for muscle spasms. He takes no over-the-counter medications and is not known to use illicit drugs. On exam his blood pressure is 110/64 mm Hg and heart rate is 59 beats per minute. He is obtunded and only responds to sternal rub. He has no facial asymmetry. His deep tendon reflexes are reduced in all extremities. His exam is otherwise unremarkable. His lab findings are unremarkable. What is the most likely cause of his altered mental status?
Baclofen neurotoxicity
Correct! Baclofen is excreted by the kidneys. Neurotoxicity is not uncommon in patients with reduced renal function and can progress to coma in patients with ESRD. [Reference: Khazneh, E., Shamlawi, A., Jebrin, K., Hamdan, Z., and Sawalmeh, O. Single-dose baclofen-induced neurotoxicity in a patient with end stage renal disease: case report. BMC Nephrol 2018; 19(1): 352.]
Uremic encephalopathy
Acute stroke
Heroin overdose
4. A 57-year-old woman with ESKD on hemodialysis presents complaining of worsening osteoarthritis pain in her knees and hands. She has been on a stable dose of tramadol for 2 years for her arthritis. She also takes cinacalcet 30 mg per day (started 1 month ago), sevelamer 1600 mg with meals, and lisinopril 40 mg per day. What is the most likely reason for her worsening pain?
Increased inactivation of the active metabolite of tramadol
Decreased metabolism of tramadol to its active metabolite
Correct! Tramadol itself is a very weak opioid agonist and it needs to be metabolized to its M1 metabolite for effective analgesia. Tramadol requires the CYP2D6 enzyme for this. Cinacalcet is a strong inhibitor of CYP2D6; in this case, it was recently started and has caused decrease in the amount of M1 present and thus less analgesia. [References: (1) Padhi, D. and Harris R. Clinical pharmacokinetic and pharmacodynamic profile of cinacalcet hydrochloride. Clinical pharmacokin 2009; 48(5): 303-11. (2) Lassen, D., Damkier, P., and Brøsen, K. The pharmacogenetics of tramadol. Clinical pharmacokin 2015; 54(8): 825-836.]
Worsening of her underlying osteoarthritis
Increased tolerance to tramadol

For a PDF version of the questions & answers, please click here.


–  Quiz prepared by Anna Burgner, NephMadness Executive Team and AJKD Social Media Advisory Group Member. Follow her @anna_burgner.


To view the full Pain region (FREE), please visit AJKDBlog.org.

Title: NephMadness 2019: Pain Region
Writer: Samantha Gelfand @SammyG
Expert: David Juurlink @DavidJuurlink


*Questions in this quiz was originally featured in the MOC Post-Test Questions for NephMadness 2019.


#NephMadness @NephMadness | #PainRegion




2 Comments on Test Your Knowledge: Pain

  1. Thanks a lot
    I learnt

  2. niwrutti hase // April 16, 2020 at 2:04 pm // Reply

    thanks a lot
    It changed my practice of pain management

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