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Abstract
Opioid analgesics are useful in the management of moderate to severe pain. A number of patients taking opioids have compromised kidney function, guidelines and recommendations exist, however at the time of review the evidence backing recommendations for analgesic choice in kidney disease was unclear. In this systematic review we examine the available evidence on the safety and analgesic effect of opioid use in adults with kidney disease. Eight electronic databases were searched from inception to January 2023. Articles in English, reporting on opioid use and pharmacokinetic data among adults with kidney dysfunction were included. Article screening, data extraction, and quality assessment were conducted by at least two investigators independently. This review was registered prospectively on PROSPERO (ID: CRD42020159091). 32 observational studies included, 14 of these reported on morphine, 3 related to fentanyl, two hydromorphone use and 13 articles reported on other opioids including codeine, dihydrocodeine, and buprenorphine.
We found there is limited and low-quality evidence to inform the safety and analgesic effect of opioid use in kidney disease. Morphine remains the opioid for which there is the most evidence available on safety and analgesic effect in this context. Caution and consideration of potential risks and benefits should be applied when using all opioids, beyond that we suggest the context of dose, half-life and pain or non-pain indication (eg breathlessness) must be considered for each individual. Further at opioids at low to moderate doses, morphine may be a safer option than non-morphine especially if increased dosing interval or short duration of treatment is appropriate. Further high-quality studies examining clinical outcomes associated with the use of different opioids and opioid doses in kidney disease are warranted.
