OpinionAbbreviations: ESRD: End Stage Renal Disease; CKD: Chronic kidney Diseases; WHO: World Health Organization
Introduction
End stage renal disease (ESRD) is defined as the final stage
of many chronic kidney diseases (CKD) and has several course
alternatives: death, renal replacement therapy (hemodialysis,
peritoneal dialysis), kidney transplantation. Pain is a complex
psycho-social phenomenon determined by the interaction of
multiple neuroanatomical and neurochemical systems with various
cognitive and affective processes. The International Association for
the Study of Pain (IASP) defines pain as “an unpleasant sensory
and emotional experience associated with actual or potential
tissue damage or described in terms of such damage” [1]. Disabling
osteodystrophy, calciphylaxis (calcific arteriopathy), development
of brown tumor, hypertensive encephalopathy, peripheral
neuropathy, generalized edema, are only few complications
associated to end stage renal disease with strong debilitating
potential. Another common problem of patient with CKD is related
to invasive investigations and treatments. The patient repeats
the painful experience whenever he returns for investigation
or renal replacement therapy, which may increase his anxiety
and repulsion. For this reason, is important that all measures be
taken for a psychological and analgesic preparation from the first
experience, in order that side effects should be anticipated by the
patient as minimal (Doctor-patient relationship, Iorga [2]). For all
these reasons pain is very common in CKD and ESRD patients; most
of these subjects are still under diagnosed and undertreated.
The perception of pain, along with somatic changes induced
by CKD, shapes the character of the chronic kidney disease child.
In this sense, medical therapy of the chronic kidney disease must
be backed up by adequate psychological support. Proper pain
management is mandatory for a better quality of life of this patient.
Quality of life can be understood according to the WHO definition
of health, in the sense of physical, mental and social well-being, and
there are situations when a good QoL can be achieved even if the
patient has a chronic condition.. Improving the quality of life is the
goal of chronic dialysis patient care and the measure of its quality.
The child’s perception of quality of life must be understood and
respected, it depends primarily on the basic processes of cognitive
development.
We conducted a small retrospective, nonrandomized study
about impact of chronic pain on the quality of life of the chronic dialysis patient. The study focused on the pediatric patients with
ESRD monitored in the Nephrology Department of the St. Mary’s
Emergency Clinical Hospital for Children, Iasi, a representative
unit for the Region of Moldova, Romania. The study included 28
patients with ESRD, aged between 0 and 18 years, followed for a
period of 5 years, 2015 - 2019. 28% were treated by peritoneal
dialysis, and 72% by hemodialysis, of which 60% on fistula arteriovenous,
the rest on the long-life central catheter. The Pediatric
Quality of Life Inventory and Illness Perception Questionnaire was
applied to assess quality of life and perception of the disease. The
available multidimensional questionnaires (Brief Pain Inventory,
McGill Pain Questionaire, Wong - Baker facial assessment scales,
Oucher scales) [3] allow the assessment of pain by assessing the
intensity, frequency, duration, quality and sensitivity of the child’s
pain. Pain overcoming strategies as well as the impact of pain on the
patient’s daily activity are also estimated. The pain was present in
the evolution of dialysis patients, being related to the pathology of
the venous approach and to infectious or thrombotic complications
of the central venous catheterization. One of the patients developed
complications related to the Gore Tex graft placed as a venous
approach for hemodialysis. Complications associated with AV
grafts included local hematoma, but also lower limb edema and
neuropathy, all accompanied by significant pain. The therapy
was a combination of anti-inflammatory drugs, carbamazepine
and gabapentin, but unsatisfactory control required intermittent
opioid use. In 4 patients the recurrent development of secondary
peritonitis required change of dialysis method, then access to a
kidney transplant. Sever pain needed in this case opioid use, along
with antibiotic therapy. Sever renal osteodystrophy complicated
the evolution in 4 cases of hemodialysis patients. Several patients
in the chronic extrarenal clearance program for more than 5
years have developed secondary neuropathy, requiring opioid
and gabapentin control, as well as associated antidepressant
medication. One of the patients developed septic necrosis of the
femoral head, requiring prosthesis, and another suffered multiple
fractures after a minor injury from falling. In the same patient,
calciphylaxis and adenomatous development of the parathyroid
glands were highlighted, requiring 2-stage surgical resection and
subsequent bisphosphonate therapy, after monitoring the case
together with the Endocrinology Clinic. Another two patients
died with severe calciphylaxis, uncontrolled by the therapy. They
complained of intense pain due to respiratory restriction by
pulmonary metastatic calcifications, but also by phenomena of
vascular ischemia secondary to mediocracies and increased arterial
stiffness, especially in the coronary and cerebral territory.
A recent review (Pain Management, [4]) highlights pain medication that are safe, but in adjusted dose, as well as drugs to be avoided in the management of pediatric kidney disease. Modifications in the prescription of some analgesics are required in CKD children, due to problems associated with reduced drug or metabolite elimination [5]. Acetaminophen should be used as a first-line therapy for pain management in children with CKD. In dialyzed patients, these opioids should be considered as secondline agents and patients should be carefully monitored. Opioid induced constipation can be managed with peripherally-acting-nopioid- receptor-antagonists. (Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists, By: Coluzzi Flaminia [6]). Opioids may be added to control moderate to severe pain. Because the nephrologist is a non a pain specialist, may be unfamiliar with different chronic pain syndromes and with safe and appropriate use of opioids. It should consider referral to pain specialists when pain is not adequately managed with standard analgesics. A multidisciplinary team should be involved in the management of vulnerable patients suffering from CKD or ESRD. Unfortunately, the number of clinical trials available on the use of opioids in ESRD in children is still limited, and extrapolating information by clinical studies on different children populations may not be prudent. Therefore, further trials are warranted to evaluate the efficacy and safety of opioids in CKD and ESRD patients.
References
- (2019) IASP's Proposed New Definition of Pain Released for Comment.
- Magdalena Starcea, Magdalena Iorga, Laszlo-Zoltan Sztankovszky, Mihaela Munteanu (2014) The doctor – patient relationship in childrens chronic kidney disease and itd importance for the quality of life for the dialysis patient, European Journal of Science and Theology 10(3): 27-36.
- Magdalena Iorga, Magdalena Starcea, Mihaela Munteanu, Laszlo-Zoltan Sztankovszky (2014) Psycological and social problems of children with chronic kidney disease, European Journal of Science and Theology 10(1): 179-188.
- Amanda Reis, Caitlyn Luecke, Thomas Keefe Davis, Aadil Kakajiwala (2018) Pain Management in Pediatric Chronic Kidney Disease, J Pediatr Pharmacol Ther 23(3): 192-202.
- Phuong-Chi T Pham, Edgar Toscano, Phuong-Mai T Pham, et al. (2009) Pain management in patients with chronic kidney disease, NDT Plus 2: 111-118.
- Flaminia Coluzzi, Francesca Felicia Caputi, Domenico Billeci (2020) Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists, Therapeutics and Clinical Risk Management 16: 821-837.
