Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management of chronic pain in chronic kidney disease

Sara N Davison, MD, MHSc, FRCP(C)
Section Editor
Gary C Curhan, MD, ScD
Deputy Editor
Alice M Sheridan, MD


Pain is one of the most common and distressing symptoms among patients with chronic kidney disease (CKD). The prevalence of pain has been associated with substantially lower health-related quality of life and greater psychosocial distress, insomnia, and depressive symptoms [1-9]. Many analgesics that are typically used in the non-CKD population should not be used among CKD patients. This topic reviews the management of chronic pain among CKD patients.

The evaluation and management of pain in the general adult population is reviewed elsewhere. (See "Overview of the treatment of chronic non-cancer pain" and "Evaluation of chronic pain in adults".)


Pain is more prevalent among CKD patients than in the general population. Over 60 percent of hemodialysis patients describe moderate or severe chronic pain [10-13]. By contrast, according to a national survey, approximately 19 percent of adults in the United States (both with and without CKD) have reported chronic pain, although prevalence rates increase with age and peak in adults aged 60 to 69 years at 29.6 percent [14].

Most studies of CKD patients have included only hemodialysis patients [13]. A few small studies have suggested that pain is as common among peritoneal dialysis patients and stage 5 CKD patients who are not on dialysis as among chronic hemodialysis patients [10-12].

Very few studies have reported the prevalence of pain among patients with earlier stages of CKD. A single, small study of 130 nondialysis CKD patients with varying severity of CKD suggested that the prevalence of pain was similar (64 to 75 percent) among all levels of CKD patients [15]. However, it is not clear that patients included in this study are representative of CKD patients in the general population, since all patients in this study were drawn from a CKD clinic; many individuals with mild declines in estimated glomerular filtration rate (eGFR; ie, 60 to 90 mL/min/1.73 m2) are not followed in CKD clinics.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 06, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Davison SN, Jhangri GS, Johnson JA. Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: a simple assessment of symptom burden. Kidney Int 2006; 69:1621.
  2. Davison SN, Jhangri GS, Johnson JA. Longitudinal validation of a modified Edmonton symptom assessment system (ESAS) in haemodialysis patients. Nephrol Dial Transplant 2006; 21:3189.
  3. Davison SN. Chronic pain in end-stage renal disease. Adv Chronic Kidney Dis 2005; 12:326.
  4. Davison SN, Jhangri GS. Impact of pain and symptom burden on the health-related quality of life of hemodialysis patients. J Pain Symptom Manage 2010; 39:477.
  5. Kimmel PL, Emont SL, Newmann JM, et al. ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity. Am J Kidney Dis 2003; 42:713.
  6. Leinau L, Murphy TE, Bradley E, Fried T. Relationship between conditions addressed by hemodialysis guidelines and non-ESRD-specific conditions affecting quality of life. Clin J Am Soc Nephrol 2009; 4:572.
  7. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant 2003; 18:1345.
  8. Weisbord SD, Fried LF, Arnold RM, et al. Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients. J Am Soc Nephrol 2005; 16:2487.
  9. Gamondi C, Galli N, Schönholzer C, et al. Frequency and severity of pain and symptom distress among patients with chronic kidney disease receiving dialysis. Swiss Med Wkly 2013; 143:w13750.
  10. Murtagh FE, Addington-Hall JM, Edmonds PM, et al. Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med 2007; 10:1266.
  11. Murphy EL, Murtagh FE, Carey I, Sheerin NS. Understanding symptoms in patients with advanced chronic kidney disease managed without dialysis: use of a short patient-completed assessment tool. Nephron Clin Pract 2009; 111:c74.
  12. Noble H, Meyer PJ, Bridge DJ, et al. Exploring symptoms in patients managed without dialysis: a qualitative research study. J Ren Care 2010; 36:9.
  13. Davison SN, Koncicki H, Brennan F. Pain in chronic kidney disease: a scoping review. Semin Dial 2014; 27:188.
  14. Kennedy J, Roll JM, Schraudner T, et al. Prevalence of persistent pain in the U.S. adult population: new data from the 2010 national health interview survey. J Pain 2014; 15:979.
  15. Pham PC, Dewar K, Hashmi S, et al. Pain prevalence in patients with chronic kidney disease. Clin Nephrol 2010; 73:294.
  16. Weisbord SD, Fried LF, Mor MK, et al. Renal provider recognition of symptoms in patients on maintenance hemodialysis. Clin J Am Soc Nephrol 2007; 2:960.
  17. Hearn J, Higginson IJ. Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group. Qual Health Care 1999; 8:219.
  18. Walke LM, Byers AL, McCorkle R, Fried TR. Symptom assessment in community-dwelling older adults with advanced chronic disease. J Pain Symptom Manage 2006; 31:31.
  19. Chiou CP. Development and psychometric assessment of the physical symptom distress scale. J Pain Symptom Manage 1998; 16:87.
  20. Weisbord SD, Fried LF, Arnold RM, et al. Development of a symptom assessment instrument for chronic hemodialysis patients: the Dialysis Symptom Index. J Pain Symptom Manage 2004; 27:226.
  21. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1:277.
  22. Joshi VD, Mooppil N, Lim JF. Validation of the kidney disease quality of life-short form: a cross-sectional study of a dialysis-targeted health measure in Singapore. BMC Nephrol 2010; 11:36.
  23. Wu AW, Fink NE, Cagney KA, et al. Developing a health-related quality-of-life measure for end-stage renal disease: The CHOICE Health Experience Questionnaire. Am J Kidney Dis 2001; 37:11.
  24. Davison SN. Edmonton Symptom Assessment System Revised: Renal (ESAS-r: Renal). http://www.albertahealthservices.ca/ps-1022201-narp-tools-esas.pdf (Accessed on June 12, 2014).
  25. Noordzij M, Boeschoten EW, Bos WJ, et al. Disturbed mineral metabolism is associated with muscle and skin complaints in a prospective cohort of dialysis patients. Nephrol Dial Transplant 2007; 22:2944.
  26. Davison SN. Pain in hemodialysis patients: prevalence, cause, severity, and management. Am J Kidney Dis 2003; 42:1239.
  27. Institute for Clinical Systems Improvement. Health care guideline: Assessment and management of chronic pain. Fourth edition November 2009. http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline_.html (Accessed on December 09, 2010).
  28. Barakzoy AS, Moss AH. Efficacy of the world health organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol 2006; 17:3198.
  29. Davison SN, Chambers EJ, Ferro CJ. Management of pain in renal failure. In: Supportive Care for the Renal Patient, 2nd ed., Chambers EJ, Brown E, Germain M (Eds), Oxford University Press, New York 2010. p.139.
  30. World Health Organization. Cancer pain releif. World Health Organization; Geneva, 1990.
  31. Acute pain management: Scientific evidence. In: Australian and New Zealand College of Anaesthetic (ANZCA) and Faculty of Pain Medicine, 3rd ed., Macintyre P, Scott DA, Schug SA, et al (Eds), 2010.
  32. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10:113.
  33. Horber FF, Guentert TW, Weidekamm E, et al. Pharmacokinetics of tenoxicam in patients with impaired renal function. Eur J Clin Pharmacol 1986; 29:697.
  34. Daousi C, Nurmikko T. Painful diabetic neuropathy. In: Evidence-Based Chronic Pain Management, Stannard C, Kalso E, Ballantyne J (Eds), BMJ Books, London 2010.
  35. Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc 2010; 85:S3.
  36. Kahan M, Wilson L, Mailis-Gagnon A, et al. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations. Can Fam Physician 2011; 57:1269.
  37. Trescot AM, Helm S, Hansen H, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines. Pain Physician 2008; 11:S5.
  38. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009; 57:1331.
  39. Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract 2008; 8:287.
  40. Broadbent A, Khor K, Heaney A. Palliation and renal failure: Common non-opioid medication dosage guidelines. Prog Palliat Care 2003; 59.
  41. Davison SN, Ferro CJ. Management of pain in chronic kidney disease. Prog Palliat Care 2009; 17:186.
  42. Davison SN. The prevalence and management of chronic pain in end-stage renal disease. J Palliat Med 2007; 10:1277.
  43. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage 2004; 28:497.
  44. Harris D. Pain management in patients with renal impairment. Eur J Palliat Care 2008; 15:214.
  45. Kurella M, Bennett WM, Chertow GM. Analgesia in patients with ESRD: a review of available evidence. Am J Kidney Dis 2003; 42:217.
  46. Launay-Vacher V, Karie S, Fau JB, et al. Treatment of pain in patients with renal insufficiency: the World Health Organization three-step ladder adapted. J Pain 2005; 6:137.
  47. Clinical Algorithm & Preferred Medications to Treat Pain in Dialysis Patients. Mid-Atlantic Renal Coalition and the Kidney End-of-Life Coalition, 2009.
  48. Moss AH. Pain Management in ESKD. Presentation from Kidney End-of-Life Coalition (USDA).
  49. Murtagh FE, Addington-Hall JM, Donohoe P, Higginson IJ. Symptom management in patients with established renal failure managed without dialysis. EDTNA ERCA J 2006; 32:93.
  50. Murtagh FE, Chai MO, Donohoe P, et al. The use of opioid analgesia in end-stage renal disease patients managed without dialysis: recommendations for practice. J Pain Palliat Care Pharmacother 2007; 21:5.
  51. Naylor HK, Raymond CB. Treatment of neuropathic pain in patients with chronic kidney disease. CANNT J 2011; 21:34.
  52. Young BA, Hynes J, McComb T, Blagg CR. Associations with home hemodialysis modality failure and mortality. Hemodial Int 2004; 8:344.
  53. Niscola P, Scaramucci L, Vischini G, et al. The use of major analgesics in patients with renal dysfunction. Curr Drug Targets 2010; 11:752.
  54. Pham PC, Toscano E, Pham PM, et al. Pain management in patients with chronic kidney disease. NDT Plus 2009; 2:111.
  55. Forrest JA, Clements JA, Prescott LF. Clinical pharmacokinetics of paracetamol. Clin Pharmacokinet 1982; 7:93.
  56. Lintz W, Erlaçin S, Frankus E, Uragg H. [Biotransformation of tramadol in man and animal (author's transl)]. Arzneimittelforschung 1981; 31:1932.
  57. Gibson TP. Pharmacokinetics, efficacy, and safety of analgesia with a focus on tramadol HCl. Am J Med 1996; 101:47S.
  58. Lee MA, Leng ME, Tiernan EJ. Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med 2001; 15:26.
  59. Davison SN, Mayo PR. Pain management in chronic kidney disease: the pharmacokinetics and pharmacodynamics of hydromorphone and hydromorphone-3-glucuronide in hemodialysis patients. J Opioid Manag 2008; 4:335.
  60. Babul N, Darke AC, Hagen N. Hydromorphone metabolite accumulation in renal failure. J Pain Symptom Manage 1995; 10:184.
  61. Fainsinger R, Schoeller T, Boiskin M, Bruera E. Palliative care round: cognitive failure and coma after renal failure in a patient receiving captopril and hydromorphone. J Palliat Care 1993; 9:53.
  62. Pohland A, Boaz HE, Sullivan HR. Synthesis and identification of metabolites resulting from the biotransformation of DL-methadone in man and in the rat. J Med Chem 1971; 14:194.
  63. Kreek MJ, Schecter AJ, Gutjahr CL, Hecht M. Methadone use in patients with chronic renal disease. Drug Alcohol Depend 1980; 5:197.
  64. Furlan V, Hafi A, Dessalles MC, et al. Methadone is poorly removed by haemodialysis. Nephrol Dial Transplant 1999; 14:254.
  65. McClain DA, Hug CC Jr. Intravenous fentanyl kinetics. Clin Pharmacol Ther 1980; 28:106.
  66. Koehntop DE, Rodman JH. Fentanyl pharmacokinetics in patients undergoing renal transplantation. Pharmacotherapy 1997; 17:746.
  67. Bower S. Plasma protein binding of fentanyl: the effect of hyperlipoproteinaemia and chronic renal failure. J Pharm Pharmacol 1982; 34:102.
  68. Mercadante S, Caligara M, Sapio M, et al. Subcutaneous fentanyl infusion in a patient with bowel obstruction and renal failure. J Pain Symptom Manage 1997; 13:241.
  69. Hand CW, Sear JW, Uppington J, et al. Buprenorphine disposition in patients with renal impairment: single and continuous dosing, with special reference to metabolites. Br J Anaesth 1990; 64:276.
  70. Filitz J, Griessinger N, Sittl R, et al. Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine. Eur J Pain 2006; 10:743.
  71. Healy DG, Ingle GT, Brown P. Pregabalin- and gabapentin-associated myoclonus in a patient with chronic renal failure. Mov Disord 2009; 24:2028.
  72. Torregrosa-de Juan E, Olagüe-Díaz P, Royo-Maicas P, et al. Acute renal failure due to gabapentin. A case report and literature. Nefrologia 2012; 32:130.
  73. Bassilios N, Launay-Vacher V, Khoury N, et al. Gabapentin neurotoxicity in a chronic haemodialysis patient. Nephrol Dial Transplant 2001; 16:2112.
  74. Randinitis EJ, Posvar EL, Alvey CW, et al. Pharmacokinetics of pregabalin in subjects with various degrees of renal function. J Clin Pharmacol 2003; 43:277.
  75. Pilowsky I, Hallett EC, Bassett DL, et al. A controlled study of amitriptyline in the treatment of chronic pain. Pain 1982; 14:169.
  76. Jaeschke R, Adachi J, Guyatt G, et al. Clinical usefulness of amitriptyline in fibromyalgia: the results of 23 N-of-1 randomized controlled trials. J Rheumatol 1991; 18:447.
  77. Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007; 132:237.
  78. Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain 2005; 118:289.
  79. Barnes JN, Williams AJ, Tomson MJ, et al. Dihydrocodeine in renal failure: further evidence for an important role of the kidney in the handling of opioid drugs. Br Med J (Clin Res Ed) 1985; 290:740.
  80. Guay DR, Awni WM, Findlay JW, et al. Pharmacokinetics and pharmacodynamics of codeine in end-stage renal disease. Clin Pharmacol Ther 1988; 43:63.
  81. Davies G, Kingswood C, Street M. Pharmacokinetics of opioids in renal dysfunction. Clin Pharmacokinet 1996; 31:410.
  82. Barnes JN, Goodwin FJ. Dihydrocodeine narcosis in renal failure. Br Med J (Clin Res Ed) 1983; 286:438.
  83. Gibson TP, Giacomini KM, Briggs WA, et al. Propoxyphene and norpropoxyphene plasma concentrations in the anephric patient. Clin Pharmacol Ther 1980; 27:665.
  84. Nickander RC, Emmerson JL, Hynes MD, et al. Pharmacologic and toxic effects in animals of dextropropoxyphene and its major metabolite norpropoxyphene: a review. Hum Toxicol 1984; 3 Suppl:13S.
  85. Säwe J, Odar-Cederlöf I. Kinetics of morphine in patients with renal failure. Eur J Clin Pharmacol 1987; 32:377.
  86. Sear JW, Hand CW, Moore RA, McQuay HJ. Studies on morphine disposition: influence of renal failure on the kinetics of morphine and its metabolites. Br J Anaesth 1989; 62:28.
  87. Chauvin M, Sandouk P, Scherrmann JM, et al. Morphine pharmacokinetics in renal failure. Anesthesiology 1987; 66:327.
  88. Osborne R, Joel S, Slevin M. Morphine intoxication in renal failure; the role of morphine-6-glucuronide. Br Med J (Clin Res Ed) 1986; 293:1101.
  89. Wolff J, Bigler D, Christensen CB, et al. Influence of renal function on the elimination of morphine and morphine glucuronides. Eur J Clin Pharmacol 1988; 34:353.
  90. Hanna MH, D'Costa F, Peat SJ, et al. Morphine-6-glucuronide disposition in renal impairment. Br J Anaesth 1993; 70:511.
  91. Kirvela M, Lindgren L, Seppala T, Olkkola KT. The pharmacokinetics of oxycodone in uremic patients undergoing renal transplantation. J Clin Anesth 1996; 8:13.
  92. Pöyhiä R, Seppälä T, Olkkola KT, Kalso E. The pharmacokinetics and metabolism of oxycodone after intramuscular and oral administration to healthy subjects. Br J Clin Pharmacol 1992; 33:617.
  93. Lee MA, Leng ME, Cooper RM. Measurements of plasma oxycodone, noroxycodone and oxymorphone levels in a patient with bilateral nephrectomy who is undergoing haemodialysis. Palliat Med 2005; 19:259.
  94. Foral PA, Ineck JR, Nystrom KK. Oxycodone accumulation in a hemodialysis patient. South Med J 2007; 100:212.
  95. Szeto HH, Inturrisi CE, Houde R, et al. Accumulation of normeperidine, an active metabolite of meperidine, in patients with renal failure of cancer. Ann Intern Med 1977; 86:738.