The “Nephrology Quiz and Questionnaire 2019” session was held on Nov 7, 2019, at the ASN #KidneyWk in Washington, DC.

Click here for more KidneyWk 2019 coverage on AJKD Blog. This is Part 3 of the Kidney STARS’ write-up of KidneyWk sessions.

During the final presentation of this session at #KidneyWk 2019, Dr Louise Moist discussed the problems of pain and pain management among patients with end-stage kidney disease (ESKD). Some causes of dialysis-related pain in patients with ESKD include muscle cramps, headaches, pruritic pain, pain related to AV fistula needling, ischemic pain from hypotension, musculoskeletal pain from spending so much time sitting, as well as pain secondary to anxiety or depression.

Dr Moist recommends a stepwise approach to treating pain in patients with ESKD.  For patients with neuropathic pain, providers should start with 100 mg of gabapentin, titrating up to a maximum of 300 mg every night if necessary.

If the pain persists, she recommends progressing to carbamazepine 100 mg twice a day, and if that fails, to add on tricyclic antidepressants. If this approach to neuropathic pain in the ESKD patient is still not successful, or if the patient has nociceptive pain rather than neuropathic pain, Dr. Moist recommends acetaminophen, at a maximum of 3 g/day. If the patient has nociceptive pain in a small joint, a topical NSAID may be used instead. If these approaches are unsuccessful, the clinician may progress to using an opioid analgesic.

When opioids are considered, Dr Moist suggests starting with 0.5 mg hydromorphone PO q4-6h PRN and titrating to the lowest effective dose. It is important to note that increased use of opioids (more than 60 morphine equivalents per day) is associated with an increased risk of altered mental status, falls, and fractures. Patients with CKD also have an increased risk for hospitalization if they were prescribed more than one opioid analgesic.

Furthermore, patients with CKD and ESKD are commonly on many other medications to treat their underlying kidney disease or other comorbid conditions, and many of these medications may interfere with the metabolism of opioid analgesics. These interactions may either decrease their analgesic effect or increase their toxicity.

Tramadol is another medication that is commonly used for patients with CKD/ ESKD. With 2 receptors, there are also 2 mechanisms of action: as an anti-depressant, and as an analgesic. It is particularly important to understand its efficacy is variable due to its CYP2D6 metabolism, which can vary between individuals.

This should bring back memories of #NephMadness 2018’s Pain Region, and the Curbsiders podcast that accompanied it.

The take-home message for me as a medical student and future clinician is that chronic pain is a major problem for many of our patients with ESKD, and we have a responsibility to help our patients manage their pain while keeping them safe. The use of opioids in patients with ESKD is sometimes indicated, but they should only be used as a last resort and clinicians must monitor these patients closely to prevent adverse events.

-Blog post prepared by:

Evan Singleton @Evan_Singleton, Medical Student at University of Cincinnati, College of Medicine, Cincinnati, OH;

and Edgar Lerma @edgarvlermamd, AJKD Social Media Advisory Board Member