How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis?

When assessing pain, assess both the severity of the pain (such as on an analogue scale, 0-10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both.

Key Points

  • Safe nonopioid options for pain management in renally impaired and dialysis patients include acetaminophen and certain NSAIDs, such as ibuprofen.
  • Fentanyl, hydrocodone, and hydromorphone are the safest opioids to use in renally impaired and dialysis patients.
  • Tramadol in lower doses may also be safely used in renally impaired and dialysis patients.
  • Low-dose gabapentin and lidocaine patches can be safely used as adjunctive therapy in renally impaired and dialysis patients; TCAs may also be used in lower doses in renally impaired patients.

Additional Reading

Case

A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his pain be managed?

Overview

Pain is a common problem in patients with renal insufficiency and end-stage renal disease (ESRD) and can have a significant effect on the patient’s quality of life.1 When assessing a patient’s pain, assess both the severity of the pain (such as on an analogue scale, 0-10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both. Nociceptive pain can be further classified as arising from either somatic or visceral sources, and is often described as dull, throbbing, cramping, and/or pressurelike.1 Neuropathic pain is often described as tingling, numbing, burning, and/or stabbing.

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