Pain in endstage-renal disease:a frequent and neglected clinical problem

Pain is a major health problem in end-stage renal disease (ESRD) affecting half of the dialysis patients; most of them ex- perience a moderate to severe degree of pain. Nevertheless, the impact of chronic pain and its consequences are often underestimated. Sources of pain related to the uremic envi- ronment are renal bone disease (osteitis fi- brosa cystica, amyloidosis, osteomalacia), osteoarthritis, calcific uremic arteriolopathy and peripheral neuropathy. Moreover, co- morbid conditions such as ischemic periph- eral artery disease, diabetic neuropathy, os- teopenia/osteoporosis (due to long-standing hypertension, diabetes, or old age) result in various kinds of pain. Also the primary kid- ney disease (e.g. autosomal dominant poly- cystic kidney disease (ADPKD)) as well as performance of hemodialysis or peritoneal dialysis are important causes of pain. Po- tential consequences of persistent pain are disturbed sleep, weakened memory/atten- tion, altered mood (anxiety and depressive disorder), impotence, poorer physical state, less social activities and consideration of withdrawal from dialysis. Consequently the health-related-quality of life (HRQOL) is di- minished, associated with a higher morbid- ity and mortality. In the therapy of pain the WHO three-step analgesic ladder adapted for ESRD, was shown to be effective in dialy- sis patients. Of fundamental importance are various forms of non-pharmacological strat- egies including electrotherapy. Recently the so-called high tone external muscle stimu- lation (HTEMS) was very effective in the management of neuropathic pain in ESRD patients