Pain in Dialysis Patients: Prevalence and Impact

For many end stage renal disease (ESRD) patients receiving dialysis, chronic pain is often a persistent factor that can profoundly impact their daily lives and ultimately worsen their overall health. Pain can result from comorbid conditions, such as diabetes and its complications, and dialysis itself, which can cause muscle cramping, abdominal distension and pain from needle sticks. Recognizing the importance of pain management in this population, the Centers for Medicare & Medicaid Services (CMS) incorporated regular pain assessment as a reporting measure for the Quality Incentive Program (QIP) beginning in 2016. The measure requires dialysis facilities to report every six months on whether pain was assessed with a standardized tool and to indicate whether a follow-up plan was documented for patients experiencing pain.

To better understand pain and its prevalence among dialysis patients, DaVita set the goal of conducting monthly pain assessments for all of their patients. Patients who reported pain would complete a follow-up survey, which asked them about the location, duration and treatment of their pain, and how it affects their daily lives.

The assessment separated responses of in-center hemodialysis (ICHD) from peritoneal dialysis (PD) patients in order to glean any differences between the two populations.

Pain assessment results

The findings were gathered between May 2016 and April 2017 from a total of 1,094,897 pain assessments for 173,340 ICHD patients and 173,739 pain assessments for 25,820 PD patients. Of those, each ICHD patient was assessed 6.5 times on average, and each PD patient 7.2 times. A similar pattern in pain assessment scores for both groups. The findings included the following:

• 161,800 (14.8 percent) of pain assessments for ICHD and 23,101 (13.3 percent) for PD patients had pain scores of 2 or higher, meaning pain was present.
• 5 percent of ICHD and 40.5 percent of PD patients reported experiencing pain at least once during the survey period. These results are similar to a review recently commissioned by Kidney Disease: Improving Global Outcomes (KDIGO). In that report, pain prevalence ranged from 21 percent to 81 percent for ICHD patients (a weighted mean of 58.6 percent across 16 studies). Meanwhile, in PD patients, KDIGO showed a 38 percent pain prevalence in one study.

Additionally, we assessed the type of pain reported. Back pain was the most common, whereas very few patients reported their pain to be related to their dyalisis for either modality. Chronic pain—lasting three weeks or more—was a problem for the majority of respondents—reported by 73.8 percent of ICHD patients and 67 percent of PD patients.

Most patients reported using pain medication (74.8 percent of ICHD and 65.1 percent of PD respondents). The most commonly used was acetaminophen (30 percent of respondents), which is recommended as first-line therapy in ESRD patients. The second most common pain reliever was acetaminophen/hydrocodone (15 percent). These medications appeared to work well in the majority of cases—84.4 percent of ICHD and 78.2 percent of PD patients.

Impact on quality of life

Pain’s impact on patient quality of life was another important factor evaluated. Both ICHD and PD patients reported pain negatively affecting their quality of sleep, appetite, concentration and relationships. Pain also was linked to symptoms of depression, which prior studies have indicated. Depressed patients are more likely to be hospitalized and not adhere to dialysis schedules, resulting in greater likelihood of poor outcomes.

In sum, these observations are consistent with literature reports that pain in ESRD patients is linked to comorbid health problems rather than to dialysis alone. Over-the-counter pain medications appear to alleviate pain for most patients, meaning that low-cost, low-risk interventions can provide symptom relief to many. And, finally, providing regular pain screenings to dialysis patients can give clinicians better insight into and a greater ability to help address patients’ experience with pain.