**2. Epidemiology**

The prevalence of pain in patients with chronic kidney disease (CKD) has been shown in many epidemiologic studies, and all of them unanimously demonstrate that pain is more common in CKD patients than the general population.

**1.** Kidney damage for 3 months or more, represented by structural or functional abnormalities of the kidney, with or without decreased GFR and manifested by following:

**b.** Markers of kidney damage, such as abnormalities in the composition of the blood or

Evaluation of kidney function is more dependent on GFR or the presence of other markers of

The cause for acute pain is mainly acute injury such as surgery, procedures, and childbirth. It can be caused by acute inflammation or ischemia as well, for example, acute abdomen, colic, and ischemic heart diseases. Treatment should be directed to reduce the pain as soon as possible with multiple modalities; at the same time, the primary cause should be addressed. Blocking the pain along different parts of pain pathway allows reducing the required doses and diminishing side effects. This approach has been defined as multimodal analgesia.

Stage 5 15 or less End-stage renal disease/moderate to severe symptoms, may require dialysis

Multimodal analgesia can be achieved by combining systemic paracetamol, NSAID, opioids, and local anesthetics according to patient's condition. All these medications may require dose adjustment, and locoregional anesthesia may raise a concern of hematoma formation due to

Choice and dosage of medications depend on the condition of the kidneys; here the staging

reduced platelet activity and anticoagulant use in patients receiving hemodialysis [9].

for more than 3 months with or without kidney damage [8]

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**a.** Pathological abnormalities

**2.** GFR less than 60 mL/min/1.73 m2

**Stages GFR (mL/min/1.73 m2**

**4. Pain in patients with CKD**

**4.1. Acute pain in patients with CKD**

can roughly guide physicians to correct regimen.

urine, or abnormalities in imaging tests

kidney damage rather than a single serum creatinine reading.

**) Terms/uremic symptoms**

Stages of CKD according to GFR are described in **Table 1**.

Stage 1 90 or more Normal function/asymptomatic

Stage 4 15–29 Severe/mild to moderate symptoms

**Table 1.** Stages of chronic kidney disease according to glomerular filtration rate [8].

Stage 2 60–89 Mild/asymptomatic Stage 3 30–59 Moderate/mild symptoms

Murtagh et al., in a cross-sectional survey of symptoms prevalence in stage 5 chronic kidney disease managed without dialysis, found that pain was present in 53% (42–63%) of total 66 patients with a mean age of 82 ± 6.6 years [1].

Davison et al. have analyzed publications from 1992 to 2009 and concluded that 58% of CKD patients are suffering from pain, 49% of those patients rated their pain as moderate to severe [2].

As quality of life is greatly diminished by any kind of pain, it has been studied in CKD patients as part of symptom burden, for example [3], older patients found musculoskeletal symptoms, including pain in bones/joints (69% of 283 CKD Stage 1–5 patients), are more disturbing and bothersome, while younger patients found that reduced concentration is more intrusive. Perlman et al. also demonstrated that the presence of pain was associated with lower qualityof-life scores in a multicenter cross-sectional analysis of 634 patients with CKD [4].

Additionally, in prospective cohort study of 205 Canadian hemodialysis (HD) patients, 50% of them reported pain which was related to those who was on longer HD therapy, 52.5 months with pain versus 37.7 months for those without pain.

The etiology of pain was multiple in 18.4% of patients with pain, among which musculoskeletal was the most frequent (50.5%); same study found that almost one third of all patients with pain were not on any painkillers, and authors concluded that pain management was ineffective in 74.8 of patients [5].

Pain in CKD patients is an important factor, which immensely affects quality of life. Weisbord et al. showed clear correlation between symptom excess and severity with diminished quality of life. If they had considered pain-related symptoms such as muscle cramps, headache, and chest pain in pain group, the prevalence would have increased to 50–85% [6].

Moreover, CKD patients with pain tend to decide to withdraw from HD more often; as shown by Davison and Jhangri, they also were more depressed and suffered sleep disturbances [7].
