Sixty to 90% of (chronic kidney disease) CKD patients receiving renal replacement therapy report experiencing pain. Of those, 75% say their pain management regimens are insufficient. Understanding pain—including types of pain, their causes, and how to manage them—is crucial to exploring how pain relief for patients living with CKD can be better managed in primary care settings.*

Types of pain

There are two primary types of pain: acute and chronic.

Acute pain usually results from:

• Localized trauma and injury from an external source
• Obstruction or distension of internal organs

If identified quickly and treated appropriately, acute pain usually wanes within seven to 30 days, as the injury heals or the abnormality is corrected. When acute pain and its causes are inadequately managed, however, the pain can become chronic. 

Chronic pain generally lasts beyond three months and results from the persistent activation of specialized sensory neurons (nociceptors) from:

• Prolonged tissue injury or inflammation
• A lesion or disease of the somatosensory system
• Idiopathic (unknown) causes

How CKD causes pain

The pain experienced by people living with CKD is multifaceted. 

Symptoms can result from the:

• Active disease process
• Underlying medical conditions, such as diabetes or vascular disease 
• Dialysis treatment procedure

Peripheral and overlapping conditions, such as anxiety, depression, and insomnia, can compound and exacerbate a person’s experience of physical pain. 

Assessing pain and setting goals

An effective pain relief regimen starts with assessing a patient’s pain concerning:

• Intensity (or degree, and how tolerable it is)
• Chronicity (how often it occurs)
• Type, referring to either:
  • Nociceptive pain (aching, dull, throbbing)
  • Neuropathic pain (burning, stabbing, tingling)

The more accurate your answers to the assessment questions, the more effective your pain relief regimen is likely to be. Realistic expectations are also critical when setting pain management goals with your provider.  A 30% reduction in pain is often the maximum relief that can be achieved. 

Creating a pain management plan

In any pain management plan, nonpharmacologic interventions should be attempted first,  followed by non-opioid analgesic agents rather than opioids. 

The World Health Organization (WHO) recommends a three-step approach to pain management. Originally created for analgesic pain control in cancer patients, the approach has also been approved for use with CKD patients. 

• Step 1: Treat mild pain with non-opioid analgesics, such as:
  • Acetaminophen (favored by the National Kidney Foundation)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are not generally given to patients with an eGFR of <60. 
• Step 2: Treat moderate pain by adding mild opioids, such as:
  • Tramadol
  • Low-dose oxycodone
  • Low-dose hydromorphone
• Step 3: Treat severe pain by administering stronger opioids, such as:
  • Higher doses of oxycodone/hydromorphone
  • Fentanyl
  • Methadone
  • Buprenorphine 

Supporting medications may be added during any of the three steps, and these include:

• Gabapentin 
• Pregabalin 
• Tricyclic antidepressants (TCAs)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Considerations for pain management

When considering pharmacological pain management, doctors must consider the potential toxic effects on residual renal function. 

Toxicities can include:

• Acute kidney injury (AKI) by way of acute interstitial nephritis 
• Vasoconstriction
• Acute tubular necrosis, which can hasten CKD progression  

Non-renal adverse reactions may include:

• Increased blood pressure
• Decreased effectiveness of certain antihypertensives (medications for high blood pressure)
• Increased risk of gastrointestinal bleeding

When stepping up treatment to the use of opioids for pain management, the chemical makeup and effects of each agent—along with the metabolites (end products of metabolism) with which it is associated—must also be taken into account. 

For instance, normeperidine (the active metabolite of meperidine) is highly neurotoxic. When it builds up in patients with end-stage kidney disease (ESKD), it increases their risk for seizures. Meperidine, morphine, and codeine are generally not given to patients with damaged kidneys.

Nonpharmacologic treatment options

According to the National Center for Complementary and Integrative Health (NCCIH), pain is the primary reason that patients seek nonpharmacologic interventions. In 2016, the organization sifted the myriad available nonpharmacologic treatment options into the following categories: 

• Mind-body interventions, such as Mindfulness-Based Stress Reduction (MBSR)
• Diet and other lifestyle modifications
• Herbal remedies
• Manual healing modalities, such as chiropractic, physical therapy, and massage
• Bioelectromagnetics
• Pharmacologic-biologic treatments

Chronic pain is the collective result of multiple biological, psychological, and social components. An effective pain management plan will address most, if not all, of these factors. 

*Lowe, K., and Robinson, D. R. Jr. (2020, Jan.). Pain management for patients with chronic kidney disease in the primary care setting. The Nurse Practitioner. https://journals.lww.com/tnpj/fulltext/2020/01000/pain_management_for_patients_with_chronic_kidney.4.aspx