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Original ArticlesMaintenance Dialysis
Open Access

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Julie H. Ishida, Charles E. McCulloch, Michael A. Steinman, Barbara A. Grimes and Kirsten L. Johansen
CJASN May 2018, 13 (5) 746-753; DOI: https://doi.org/10.2215/CJN.09910917
Julie H. Ishida
Departments of Medicine andDivision of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and
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Charles E. McCulloch
Epidemiology and Biostatistics, University of California, San Francisco, California;
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Michael A. Steinman
Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
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Barbara A. Grimes
Epidemiology and Biostatistics, University of California, San Francisco, California;
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Kirsten L. Johansen
Departments of Medicine andDivision of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; andEpidemiology and Biostatistics, University of California, San Francisco, California;
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Abstract

Background and objectives Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.

Design, setting, participants, & measurements Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).

Results The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.

Conclusions Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

  • hemodialysis
  • clinical epidemiology
  • United States Renal Data System
  • opioid
  • Humans
  • United States
  • Middle Aged
  • Analgesics, Opioid
  • Cohort Studies
  • Opioid-Related Disorders
  • Pain
  • Morphine
  • Medicare
  • hospitalization
  • renal dialysis
  • Emergency Service, Hospital
  • Received September 8, 2017.
  • Accepted January 24, 2018.
  • Copyright © 2018 by the American Society of Nephrology

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Clinical Journal of the American Society of Nephrology: 13 (5)
Clinical Journal of the American Society of Nephrology
Vol. 13, Issue 5
May 07, 2018
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Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients
Julie H. Ishida, Charles E. McCulloch, Michael A. Steinman, Barbara A. Grimes, Kirsten L. Johansen
CJASN May 2018, 13 (5) 746-753; DOI: 10.2215/CJN.09910917

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Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients
Julie H. Ishida, Charles E. McCulloch, Michael A. Steinman, Barbara A. Grimes, Kirsten L. Johansen
CJASN May 2018, 13 (5) 746-753; DOI: 10.2215/CJN.09910917
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  • Appropriate Use of Opioids in Patients with Kidney Diseases
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Keywords

  • hemodialysis
  • clinical epidemiology
  • United States Renal Data System
  • Opioid
  • Humans
  • United States
  • Middle Aged
  • Analgesics, Opioid
  • Cohort Studies
  • Opioid-Related Disorders
  • Pain
  • Morphine
  • Medicare
  • hospitalization
  • renal dialysis
  • Emergency Service, Hospital

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