Pain Management of Patients with Chronic Renal Failure: A Case Study of Patients in a Private Renal Facility
Introduction: At least 82% of patients with chronic kidney disease (CKD) report pain of moderate to severe intensity . Despitethis high prevalence, a growing body of literature has shown that pain in the CKD population is under-recognised and ineffectively treated -. There are multidimensional causes of pain, for example, from the kidney disease itself, the dialysis procedures or diabetic neuropathy . Pain has consistently shown to negatively impact health-related quality of life -. Pain also causes other symptoms, such as, depression, cramps, aching bones and headaches and pain is associated with sleep disturbances and may adversely affect dialysis treatment such as non-compliant behaviour -.
Pain management is highly complex in patients with CKD because there is a very narrow margin between pain relief and toxicity. Opioids can accumulate in the body and cause adverse effects, such as, respiratory distress, sedation and myoclonus -. In the last decade research has demonstrated that the implementation of the World Health Organisation (WHO) three-step analgesic ladder significantly reduces pain in CKD patients. - Non-pharmacological strategies to relieve pain symptoms such as psychological and cognitive behavioural therapy, for example, relaxation techniques, and spiritual counselling should also be recommended and supported by the renal professional team -.
Nephrologists and dialysis nursing staff are often inadequately prepared to recognize and treat pain, primarily due to the fact that pain management is not part of the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines . With the increase in the number of patients with CKD, it is increasingly relevant that measures should be implemented to identify, assess and provide appropriate analgesia and / or non-pharmacological therapies to reduce pain and bring comfort to patients experiencing debilitating types of pain.
Aims and objectives of the study: The overall aims and objectives of this study was to investigate the types, frequency and severity of pain experienced by patients with chronic kidney disease and to suggest strategies that patients and staff could use to manage the patients’ pain that was experienced.
Methodology: A total of 60 patients and 22 renal staff participated in the study. Questionnaires were administered to staff and patients at the Durban Kidney and Dialysis Centre. Inclusion and exclusion criteria were applied to the participants. Medical records of the patients were analysed. Minutes of staff meetings and the protocols of the Centre were scrutinised in terms of pain management strategies. The study was conducted between September 2017 and March 2018.
Results: Patients were on average 57 years of age and all were on haemodialysis. Results for this study show that 98% of patients reported pain symptoms during dialysis and for 72% of the patients, the pain experienced was moderate to severe indicating that pain is a major symptom burden in this patient population. The most frequently reported symptoms were lower back pain (80%), lower leg pain (52%) and upper chest pain (47%). Pain was frequently experienced by patients following the dialysis session (78%). Between 53% and 65% of patients reported that pain affected them mostly, for example, when climbing stairs or walking. Patients in this study had substantial co-morbid diseases with 27% reporting hypertension, diabetes and cardiac stent. Thus, the causes of pain are multi-factorial and make management thereof challenging. There was a significant association with pain and older age, long years of being on dialysis and the period at the end of the haemodialysis (HD) treatment session itself (p< 0.0 5). Patients (73%) shortened their time on dialysis because of severe pain experienced. Thus, this study shows that there is significant relation between compliance and pain. In this study, pain was not related to gender or race.
Depression was experienced by a large percentage (85%) of patients in this study. The severity of pain experienced caused 67% of the patients to be hospitalised and 87% stated that pain affected their ability to have a restful sleep. When this is seen in conjunction with the fact that 78% of patients responded that their pain impacted on their ability to work, one can see the distinct link that pain adversely impacts their functional status.
The pain medication that was primarily used by patients was Panado (53%) and nearly 60% of the patients reported using alternative means of pain relief such as a physiotherapist. Non-steroidal anti-inflammatory drugs (NSAIDs) use appears to be high and there is a low use of opioids. In addition, there was no indication that adjuvants were prescribed or used. Thus, the patterns of pain medication recommended and / or taken by the patients in this study show a simple, generalised pharmacological approach rather than a targeted therapeutic intervention specifically tailored to the type of pain experienced by the patient. Several international studies have shown that analgesic use is not high in CKD patients despite the high prevalence of pain.
Interesting to note that 91% of staff reported that Lyrica was recommended for muscle pain, joint pain and numbness but patients reported high usage of only Panado (53%). This could possibly indicate under-education of patients with regard to analgesics; under-recognition of the type of pain or lack of follow-up by staff. High cost of medication for the patients (68%) and unawareness of pain management strategies (72%) are also barriers to use of analgesics.
It is evident that all patients in this study do not do any form of exercise. It would, therefore, be important for these patients to be referred to a physiotherapist or bio-kinesthesis so that they receive appropriate physical training to help alleviate their pain symptoms.
The renal staff in the Centre are highly qualified to perform their duties. However, they did not offer analgesics for pain relief at the end of the dialysis session when many patients complained of pain and terminated their session early (73%). 100% of the staff ensured that patients were comfortable rather than offer analgesics to relieve pain (55%) during or after dialysis. However, there were no pain assessment instruments for staff to clinically assess types, frequency and severity of pain that was experienced by the patients. There was a lack of guidelines to assist staff to make decisions about analgesic use.
Conclusion: It is evident from the results of this study that pain management was neither done in a strategic manner nor was it tailored to the patient’s specific needs. For staff, there were no formal, clinical pain management assessment instruments or follow-up regarding adherence to the recommendations for pain analgesics. The patients (72%) revealed that they did not have in-depth knowledge of pain management treatments and associated with the fact that many did not comply with the full duration of the dialysis session, indicating that focused attempts must be made to instil patient education about pain management therapies in this vulnerable group. Both patients and staff would benefit from awareness about different types of pain management therapies, (both pharmacological and non-pharmacological) and the long term impact if pain continues to be under-diagnosed and under-treated.
The development of guidelines by the Centre to assist the staff to make decisions about analgesic use for the patients is essential. The specialist nephrologists should investigate and implement a combination of analgesics tailored to the needs of the patient. Future decisions can be based on the WHO three-step ladder on analgesic use. The patients would benefit from appropriate interventions to manage their pain.
Keywords - Analgesic, Chronic kidney disease, Pain management, Non-pharmacological strategies.