Pain Management in Patients With Kidney Disease-A Nephrologist and Dialysis Care Team Responsibility: KDOQI Controversies Series.

Related article, p. 9

Pain is a common and distressing symptom experienced by patients with chronic kidney disease (CKD), including those with end-stage kidney disease (ESKD). Approximately one-half of patients with CKD experience pain, and among patients treated with hemodialysis, the presence of pain is consistently and strongly associated with lower health-related quality of life, greater psychosocial distress, and other symptoms such as depression and poor sleep. The presence of uncontrolled pain in patients with ESKD has been independently associated with missed or shortened dialysis treatments and increased health services use, including more frequent emergency department visits and hospitalizations.

All medical providers, including nephrologists, have a moral and ethical obligation to ease their patients’ suffering by treating their pain. It is their duty to provide medical care that maximizes benefit while minimizing harm to patients. Making a willful decision to inadequately assess and treat pain out of concern for regulatory scrutiny or misguided beliefs concerning addiction or dependence violates basic ethical principals of respect for persons, beneficence, and nonmaleficence.

With a 5-year survival of ESKD of ≤50% among dialysis patients and an incidence of pain of ∼50%, one could argue that pain in ESKD should be assessed and treated as aggressively as pain in patients with cancer. Imagine a scenario in which a medical oncologist refused to treat his or her patient’s pain and the repercussions of this approach. First, the patient suffers needlessly from pain and develops other symptoms affecting their quality of life, eventually becoming unable to meaningfully participate in their daily routine and less likely to attend to children or other loved ones, to work and financially support themselves and their family, or to enjoy hobbies that normally help them cope. Second, the patient develops a disdain and distrust for the oncologist who watches them suffer and instead defers their pain management to primary care providers or pain specialists. However, the patient may struggle to obtain timely visits with these other providers. Eventually the patient stops seeing the oncologist because they perceive that the oncologist either does not trust them or simply does not care enough to help relieve their suffering. Because of this, the patient does not receive the cancer care they need, but instead the cancer progresses untreated. Would we find this to be an acceptable practice from an oncologist? Most would say no. Then why would we find this to be an acceptable practice for nephrologists? While many perceive cancer pain to warrant aggressive treatment given the poor prognosis of many malignancies, the overall 5-year survival of long-term dialysis patients is comparable to or worse than that of many malignancies. Nephrologists caring for patients with ESKD should address pain given the high frequency of pain and the effect of pain on patient well-being.

As nephrology providers, we see our dialysis patients at least once a month and as often as once a week. This regular interaction provides us the opportunity to develop a trusting and therapeutic relationship between provider and patient. More so than a primary care provider or pain specialist, we are in a unique position to be able to see the patient frequently, assess and diagnose their pain, make a recommendation, and determine response to therapy without imposing the burden of another trip to the clinic or hospital in addition to required dialysis sessions. To help us further, we have a multidisciplinary nephrology team of nurses, social workers, and dieticians that we can enlist to help provide a patient-centered approach to pain and other symptom management. Members of our multidisciplinary team may be able to offer or provide referrals to resources for nonpharmacologic options for pain management when appropriate and help with transportation to these resources. The multidisciplinary nephrology team members often see the patient even more frequently than the nephrology provider and are an essential resource for eliciting medication side effects, reinforcing treatment instructions and adherence, providing feedback regarding the patient’s perceived utility of treatment, and relaying instructions from the provider should the recommendation change.

Pain is a complex symptom. Its accurate assessment, diagnosis, and treatment require not only an understanding of the different pain syndromes that commonly affect patients with kidney disease and their treatments but also recognition that the symptom of pain frequently does not exist in isolation. As stated, pain as experienced by patients with CKD is often intricately co-related with other symptoms such as depression and impaired sleep, all of which affect the patient’s ability to participate in their daily activities. For example, if a patient experiences pain, which when inadequately treated eventually results in the development of depression and poor sleep, the solution would not be to give a medication to treat sleep or depression but rather to treat the root of the problem, the pain. Nephrology providers are better equipped than most to determine which analgesic agents should be avoided or dose-reduced in the setting of CKD or ESKD. To add to the complexity, pain and other symptoms in patients with CKD and ESKD may have different pathophysiology and may be experienced differently than the same symptoms in patients without kidney disease. As shown in Table 1, the use of pharmacologic treatments for pain in hemodialysis has a number of considerations relating to drug clearance and side effects. Although there is a paucity of quality data on the treatment of pain in patients with ESKD, emerging data demonstrate that other common symptoms in patients with CKD, such as depression or pruritus, may not respond to treatments effective in the general population but rather require therapies unique to the context of CKD or ESKD.,

Table 1

Systemic Pharmacologic Options for Pain in Hemodialysis: Benefits and Limitations

Class	Benefits	Limitations
NSAIDs	Effective pain control; inexpensive; no CNS effects	May accelerate loss of residual kidney function; GI bleeding
COX-2 inhibitors	Effective pain control; no CNS effects	May accelerate loss of residual kidney function; prothrombotic
Acetaminophen	Very safe, inexpensive	Often insufficient pain control; rare liver toxicity
Tricyclic antidepressants	May be effective for treating neuropathic pain	Anticholinergic side effects, particularly in the elderly
SSRIs/SNRIs	May be effective for treating neuropathic and headache pain	May exacerbate RLS, which is common in dialysis; dosing considerations for some agents
Gabapentin/pregabalin	Likely effective for neuropathic pain	High toxicity risk in dialysis, including mental status changes, hypotension, and somnolence
Opioids	May offer most substantial pain relief	Addiction potential, constipation, mental status changes; significant side effects that vary by agent but include somnolence and respiratory depression; lack of efficacy data for chronic pain management

Abbreviations: CNS, central nervous system; COX-2, cyclooxygenase 2; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; RLS, restless legs syndrome; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

In conclusion, pain is a common and distressing symptom in patients with CKD and ESKD that is associated with impaired quality of life and poor outcomes. Although the aggressive diagnosis and management of pain in patients with malignancy is considered standard of care, dialysis patients have similar symptom burden and similarly poor survival but are more commonly denied adequate pain treatments. Nephrology providers are uniquely equipped to assess and manage pain in their dialysis patients. Furthermore, the effective treatment of pain and other symptoms in patients with CKD and ESKD may differ significantly from the approach to these symptoms in the general population. As such, rather than attempt to delegate the treatment of pain and other symptoms to others, as nephrology providers it is our duty to develop knowledge and skills in the assessment and management of pain and other symptoms for us to provide the best possible patient-centered care for our patients with CKD and ESKD.