National Kidney Foundation position paper

Analgesics and the kidney: Summary and recommendations to the Scientific Advisory Board of the National Kidney Foundation from an ad hoc Committe of the National Kidney Foundation

Safe analgesic choices are limited in chronic kidney disease (CKD). We conducted a comparative analysis of harm from opioids versus nonsteroidal anti-inflammatory drugs (NSAIDs) in CKD.

Prospective cohort study.

3,939 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study.

30-day analgesic use reported at annual visits.

A composite outcome of 50% glomerular filtration rate reduction and kidney failure requiring kidney replacement therapy (KRT), as well as the outcomes of kidney failure requiring KRT, hospitalization, and pre–kidney failure death.

Marginal structural models with time-updated exposures.

Participants were followed up for a median of 6.84 years, with 391 (9.9%) and 612 (15.5%) reporting baseline opioid and NSAID use, respectively. Time-updated opioid use was associated with the kidney disease composite outcome, kidney failure with KRT, death (HRs of 1.4 [95% CI, 1.2-1.7], 1.4 [95% CI, 1.1-1.7], and 1.5 [95% CI, 1.2-2.0], respectively), and hospitalization (rate ratio [RR], 1.7; 95% CI, 1.6-1.9) versus opioid nonusers. Similar results were found in an analysis restricted to a subcohort of participants reporting ever using other (nonopioid and non-NSAID) analgesics or tramadol. Time-updated NSAID use was associated with increased risk for the kidney disease composite (HR, 1.2; 95% CI, 1.0-1.5) and hospitalization (RR, 1.1; 95% CI, 1.0-1.3); however, these associations were not significant in the subcohort. The association of NSAID use with the kidney disease composite outcome varied by race, with a significant risk in blacks (HR, 1.3; 95% CI, 1.0-1.7). NSAID use was associated with lower risk for kidney failure with KRT in women and individuals with glomerular filtration rate < 45 mL/min/1.73 m² (HRs of 0.63 [95% CI, 0.45-0.88] and 0.77 [95% CI, 0.59-0.99], respectively).

Limited periods of recall of analgesic use and potential confounding by indication.

Opioid use had a stronger association with adverse events than NSAIDs, with the latter’s association with kidney disease outcomes limited to specific subgroups, notably those of black race.

Les inhibiteurs de l’interleukine (IL)-1β, efficaces dans les crises de goutte, sont recommandés en cas de contre-indications à la prise en charge standard, notamment insuffisance rénale chronique (IRC) de stade 4 ou 5. Or, il existe peu de données disponibles sur l’efficacité et la sécurité de ces agents dans cette population de patients. Nous avons souhaité explorer l’efficacité et la sécurité de l’anakinra utilisé pour traiter les crises de goutte chez des patients présentant une IRC de stade 4 ou 5 ou ayant subi une transplantation rénale.

Cette étude rétrospective menée dans trois centres universitaires a inclus des patients consécutifs présentant une IRC de stade 4 ou 5 ou ayant subi une transplantation rénale qui prenaient de l’anakinra en traitement d’une arthrite goutteuse aiguë et avaient effectué au moins une visite de suivi. L’efficacité, la survenue d’infections et les variations de la fonction rénale ont été consignées.

Sur les 31 patients inclus (24 hommes, âge moyen 72 ± 11 ans), 25 n’avaient pas subi de transplantation et présentaient une IRC de stade 4 ou 5 (estimation du débit de filtration glomérulaire moyen [eDFG] selon la formule MDRD 22,7 ± 6,5 mL/min/1,73 m²) et 6 avaient subi une transplantation rénale (eDFG moyen 41,5 ± 22,8 mL/min/1,73 m²). La durée médiane de la goutte était de 3,5 ans et le taux moyen d’uricémie de 8,7 mg/dL. Vingt-et-un patients (68 %) présentaient des tophi et 21, une arthropathie goutteuse. L’anakinra a été efficace chez tous les patients (EVA final 10 et CRP finale 10 mg/L). Dix patients (32 %) étaient dépendants de l’anakinra (c.-à-d. qu’un traitement prolongé d’anakinra était nécessaire). Une infection grave a été enregistrée chez une seule patiente, trois mois après l’instauration de l’anakinra. Aucune variation significative de la fonction rénale n’a été observée.

L’anakinra peut constituer une option thérapeutique sûre chez les patients goutteux présentant une IRC à un stade avancé. Des études comparatives randomisées supplémentaires sont nécessaires pour confirmer nos résultats.

Cinnamomum zeylanicum, a widely used spice and flavor, is used in the treatment and prevention of many diseases. In the current study, Balb/c mice were pretreated with cinnamon bark aqueous extract (200 mg/kg/day i.g.) 14 days prior to intragastrically administer single toxic dose of acetaminophen (200 mg/kg). Blood samples were collected for analysis of biochemical and oxidative stress parameters and liver and kidney samples were collected for histopathological analysis. The results indicate that cinnamon aqueous extract exhibit a highly significant preventive potential by ameliorating APAP-induced elevated levels of serum alanine aminotransferase, aspartate aminotransferase, creatinine, urea and macroscopic and histological alterations in liver and kidney. Moreover, significant increase in total oxidant status and decrease in total antioxidant capacity accompanied by APAP exposure, were restored by cinnamon pretreatment. We found that prior administration of cinnamon prevented the toxic changes induced by acetaminophen as confirmed by histopathological examination, more possibly owing to its antioxidant potential. In conclusion, the pretreatment with cinnamon provide potential therapeutic applications in acute liver and kidney injury induced by APAP in experimental animal model and it could have therapeutic potential in oxidative stress associated diseases.

Interleukin (IL)-1β blocking is effective for the treatment of gout flares and is recommended in patients with contraindications to the standard of care, such as stage 4–5 chronic kidney disease (CKD) patients. However, efficacy and safety data regarding these agents are lacking in this population. We aimed to investigate the efficacy and safety of anakinra for the treatment of gout flares in patients with stage 4–5 CKD or renal transplantation.

This retrospective study encompassing 3 academic centres included consecutive patients with stage 4–5 CKD or kidney transplantation who received anakinra for the treatment of acute gouty arthritis and completed at least one follow-up visit. Efficacy, occurrence of infection, and renal function variations were recorded.

Of the 31 included patients (24 men, mean age 72 ± 11 years), 25 were non-transplant subjects with stage 4–5 CKD (mean estimated glomerular filtration rate, MDRD formula (eGFR) 22.7 ± 6.5 mL/min/1.73 m²), and six had undergone kidney transplantation (mean eGFR 41.5 ± 22.8 mL/min/1.73 m²). Median gout duration was 3.5 years, and the mean serum urate (SUA) level was 8.7 mg/dL. Twenty-one (68%) patients had tophi, and 21 had gout arthropathy. Anakinra was efficacious in all patients (final VAS 10 and CRP level 10 mg/L). Ten patients (32%) were anakinra dependent (i.e., required prolonged treatment with anakinra). A serious infection was recorded in only one patient, occurring 3 months after starting anakinra. No significant variation in renal function was observed.

Anakinra may be a safe therapeutic option for gout patients with advanced CKD. Further randomized controlled studies are required to confirm our results.

The main advantage of laparoscopic surgery is that it is minimally invasive because of the use of small incisions. An approach using small incisions offers many benefits including attenuation of surgical wound pain. However, the presence of postoperative pain may undermine the advantages of laparoscopic surgery as a minimally invasive technique. In addition, perioperative pain management is an important factor affecting recovery after surgery. This study investigated the usefulness of a multimodal approach to postoperative pain management with acetaminophen as a baseline analgesic after minimally invasive laparoscopic colorectal surgery.

The study included 40 patients who underwent laparoscopic colorectal surgery for colorectal cancer. 20 patients received acetaminophen as a baseline analgesic for postoperative pain management and 20 received epidural anesthesia.

The urethral catheter could be removed earlier in the acetaminophen group (2.1 ± 0.22 days postoperatively) compared with the epidural group (4.1 ± 0.45days postoperatively). The frequencies of vertigo were significantly lower in the acetaminophen than epidural group (10.0% and 45.0%, respectively). The frequencies of the use of analgesics on an as-needed basis for postoperative pain relief as well as the variabilities in these frequencies, although not significantly different between the acetaminophen and epidural groups, were lower in the acetaminophen group than the epidural group.

We herein demonstrated that postoperative pain management with acetaminophen as a baseline analgesic, and without the use of epidural anesthesia, is a safe and useful analgesic modality.

Although pain is one of the most commonly experienced symptoms by patients with chronic kidney disease, it is under-recognized, the severity is underestimated, and the treatment is inadequate. Pain management is one of the general primary palliative care competencies for medical providers. This review provides nephrology providers with basic skills for pain management. These skills include recognition of types of pain (nociceptive and neuropathic) syndromes and appropriate history-taking skills. Through this history, providers can identify clinical circumstances in which specialist referral is beneficial, including those who are at high risk for addiction, at risk for adverse effects to medications, and those with complicated care needs such as patients with a limited prognosis. Management of pain begins with the development of a shared treatment plan, identification of appropriate medications, and continual follow-up and assessment of efficacy and adverse effects. Through adequate pain management, providers can positively affect the health of individual patients and the performance of health care systems.