This is important because we see many dialysis patients in surgery.
In a retrospective cohort study published in the Clinical Journal of the American Society of Nephrology, opioids were found to be associated with adverse events in older Medicare beneficiaries receiving hemodialysis.
The investigators used the US Renal Data System to evaluate adverse events in 140,899 Medicare beneficiaries (median age, 61 years; 52% men; 50% whites) who received hemodialysis in 2011. The risk for adverse events was evaluated in patients receiving average daily total opioid doses >60 mg, ≤60 mg, and per 60-mg dose increment), and for specific opioid agents (per 60-mg dose increment).
A total of 90,124 patients within the cohort (64%) were prescribed opioid analgesics, and 32,730 patients (23%) were prescribed ≥1 high-dose opioid medication.
Of patients treated with opioids, 17% experienced an adverse event, with 11% experiencing altered mental status (15,658 events), 5% experiencing a fall (7646 events), and 3% experiencing a fracture (4151 events). Each 60-mg increment of standardized oral morphine equivalent opioid dose was associated with a 29% increased hazard for altered mental status (95% CI, 26%-33%; P<.001), a 4% increased hazard for falls (3%-5%; P <.001), and a 4% higher hazard for fracture (4%-5%; P <.001).
Opioid use was associated in a dose-dependent manner with a higher risk for altered mental status (lower dose: hazard ratio [HR], 1.28; 95% CI, 1.23-1.34; P <.001; higher dose: HR, 1.67; 95% CI, 1.56-1.78; P <.001), a higher risk for falls (lower dose: HR, 1.28; 95% CI, 1.21-1.36; P <.001; higher dose: HR, 1.45; 95% CI, 1.31-1.61; P <.001) and fractures (lower dose: HR, 1.44; 95% CI, 1.33-1.56; P <.001; higher dose: HR, 1.65; 95% CI, 1.44-1.89; P <.001), compared with no opioid use.
Limitations of this study include its observational design and its lack of data on whether patients actually took their prescribed medications.
“Opioid use in patients on hemodialysis may not be as safe as guidelines suggest, and the benefit-to-risk ratio of their use in this population should be carefully considered. Future research and strategies to predict and mitigate the risks of opioid use in patients on hemodialysis are warranted,” concluded the study authors.
Ishida JH, McCulloch CE, Steinman MA, Grimes BA, Johansen KL. Opioid analgesics and adverse outcomes among hemodialysis patients. Clin J Am Soc Nephrol. 2018;13:746-753.