What are the appropriate analgesics for patients with End-Stage Renal Disease (ESRD) undergoing dialysis?

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Last updated: March 27, 2025 • View editorial policy

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From the Guidelines

For patients with End-Stage Renal Disease (ESRD) undergoing dialysis, opioids with no active metabolites, such as fentanyl, sufentanil, and methadone, are preferred for pain management due to the reduced risk of toxicity and accumulation. When considering analgesics for these patients, it is crucial to prioritize medications that do not rely on renal excretion for their elimination to minimize the risk of adverse effects. According to the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement published in the Mayo Clinic Proceedings in 2021 1, medications like meperidine, codeine, and morphine should be avoided in patients with renal insufficiency (GFR <30 mL/min/1.73 m2) and ESRD due to their active metabolites and potential for accumulation.

Key Considerations for Analgesic Selection

  • Avoid meperidine, codeine, and morphine in patients with ESRD due to their active metabolites and accumulation potential 1.
  • Use hydrocodone, oxycodone, and hydromorphone with caution and adjust dosages in renal insufficiency and ESRD, as they may still be used but require careful monitoring 1.
  • Fentanyl, sufentanil, and methadone are preferred opioids for patients with renal insufficiency or ESRD because they have no active metabolites, reducing the risk of toxicity 1.
  • Methadone should be administered by experienced clinicians due to its risk of accumulation and complex pharmacokinetics 1.

Additional Recommendations

  • Non-opioid analgesics like acetaminophen can be considered for mild to moderate pain but with careful dosing to avoid hepatotoxicity.
  • Gabapentin may be useful for neuropathic pain, starting at low doses and titrating as needed and tolerated.
  • NSAIDs should be used with caution or avoided if possible due to their potential to worsen kidney function and increase bleeding risk.

Given the complexities of pain management in ESRD patients undergoing dialysis, consultation with both nephrology and pain management specialists is essential to develop an individualized pain management plan that balances efficacy with safety, considering the patient's specific clinical circumstances and dialysis schedule.

From the Research

Appropriate Analgesics for ESRD Patients Undergoing Dialysis

  • The management of pain in ESRD patients is complex and requires a comprehensive approach, including non-pharmacological and pharmacological therapies 2, 3.
  • Non-opioid analgesics, such as acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants (TCAs), may be considered for pain management in ESRD patients, with careful dose considerations 3.
  • Opioids, such as tramadol, oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine, can be used in ESRD patients, but with caution and close monitoring due to the increased risk of side effects and overdosing 2, 4, 3, 5.
  • Buprenorphine appears to be a promising and safer option for pain management in ESRD patients due to its partial agonism at the mu opioid receptor 3, 5.
  • Methadone, fentanyl, and buprenorphine are considered ideal analgesics in ESRD patients, but require careful monitoring and dose adjustment 2, 4.

Considerations for Opioid Use in ESRD Patients

  • Opioid use should be minimized and reserved for patients who have failed other therapies, due to the increased risk of adverse events in ESRD patients 3, 5.
  • The half-life of opioid compounds and their metabolites is increased in ESRD patients, requiring careful monitoring and dose reduction 4.
  • NSAIDs may be used in ESRD patients for short durations, but with careful monitoring due to the risk of adverse effects 3.

Non-Pharmacological Therapies for Pain Management

  • Non-pharmacological therapies, such as exercise, massage, heat/cold therapy, acupuncture, meditation, distraction, music therapy, and cognitive behavioral therapy, can be effective for pain management in ESRD patients 2, 3.
  • Complementary therapies, such as physical activity and other non-pharmacologic therapies, may be used in combination with pharmacological therapies for pain management in ESRD patients 3, 6.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Management of pain in end-stage renal disease patients: Short review.

Hemodialysis international. International Symposium on Home Hemodialysis, 2018

3
Research

Pain management in patients with chronic kidney disease and end-stage kidney disease.

Current opinion in nephrology and hypertension, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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