Rev Dor. São Paulo, 2017 jul-sep;18(3):245-9 ORIGINAL ARTICLE Bone pain assessment in patients with chronic kidney disease undergoing hemodialysis Avaliação da dor óssea em pacientes renais crônicos em hemodiálise Mariana Capelo Vides1, Marielza Regina Ismael Martins2 DOI 10.5935/1806-0013.20170109 ABSTRACT RESUMO BACKGROUND AND OBJECTIVES: The objective of this JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi study was to descriptively evaluate the symptom of pain and its avaliar, de forma descritiva, o sintoma da dor e sua influência na influence on the quality of life in patients with chronic renal qualidade de vida, de pacientes com insuficiência renal crônica failure on hemodialysis treatment. em tratamento de hemodiálise. METHODS: This is a descriptive, cross-sectional exploratory, MÉTODOS: Trata-se de uma abordagem descritiva, transversal, quantitative approach. We evaluated 50 chronic renal failure pa- exploratória e quantitativa. Foram avaliados 50 pacientes renais tients on hemodialysis treatment through the Brief Pain Invento- crônicos em tratamento de hemodiálise, por meio do Inventário ry and the Kidney Disease and Quality of Life Short Form. The de Dor Breve e do questionário especifico de doença renal. Os emotional factors were evaluated by the Toronto Alexithymia fatores emocionais foram avaliados pelas escalas de Alexitimia de and Hospital Anxiety and Depression Scales. Toronto e Hospitalar de Ansiedade e Depressão. RESULTS: The predominant age group was 40 to 60 years. RESULTADOS: A faixa etária predominante foi de 40 a 60 anos. 72% of the patients showed some bone changes and the major- Setenta e dois por cento dos pacientes apresentaram algumas alter- ity interviewed did not have formal jobs at the time of interview. ações ósseas, e a grande maioria entrevistada, não tinha empregos re- There was a noticeable increase in the intensity of pain in pa- munerados no momento da entrevista. Houve um aumento notável tients with bone alterations when compared to those without, na intensidade da dor em pacientes com alterações ósseas, quando as well as an increased ambulation impairment. The Hospital comparado com aqueles sem, bem como um aumento da deficiên- Anxiety and Depression Scale showed a slight increase in both cia de caminhada. Através da escala de Hospitalar de Ansiedade e parameters in those with bone pain. Regarding the quality of life, Depressão, observou-se que houve um ligeiro aumento em ambos physical function and work status were the most affected. There os parâmetros naqueles com dor óssea. Quanto à qualidade de vida, was the absence of alexithymia in most of the interviewees, a a função física e o status de trabalho foram os mais afetados. Houve positive correlation between pain intensity versus physical func- ausência de alexitimia na maioria dos entrevistados, correlação posi- tion (r=-0.14, p=0.03), physical function x work status (r=-0.28, tiva entre a intensidade da dor versus função física (r=-0,14, p=0,03), p=0.04) and a negative correlation between alexithymia versus função física versus status do trabalho (r=-0,28, p=0,04), e correla- anxiety (r=0.03, p=0.62) and moderate pain versus overall health ção negativa entre alexitimia versus ansiedade (r=0,03, p=0,62), dor (r=0.06, p=0.40). moderada versus saúde geral (r=0,06, p=0,40). CONCLUSION: We found worse outcomes in hemodialysis CONCLUSÃO: Encontrou-se resultados piores em pacientes patients who presented bone alterations, regardless of the source. em hemodiálise, que apresentaram alterações ósseas, indepen- Keywords: Affective symptoms, Chronic pain, Chronic renal dentemente da fonte. failure, Metabolic bone disease, Quality of life. Descritores: Doença óssea metabólica, Doença renal crônica, Dor crônica, Qualidade de vida, Sintomas afetivos. INTRODUCTION 1. Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil. Chronic kidney disease (CKD) is a metabolic syndrome that arises from 2. Faculdade de Medicina de São José do Rio Preto, Departamento de Ciências Neurológi- a gradual and usually slow loss of the excretory capacity of the kidneys1. cas, São José do Rio Preto, SP, Brasil. What is most alarming about this disease is its visible spread throughout Submitted in April 26, 2017. the world. The current situation in the USA is that the occurrence of Accepted for publication in August 02, 2017. CKD doubles every 10 years2. The information obtained from the Bra- Conflict of interests: none – Sponsoring sources: PIBIC/CNPq. zilian Nephrology Society (SBN) and the Brazilian Ministry of Health Correspondence to: shows a similar picture, with the number of patients needing kidney Faculdade de Medicina de São José do Rio Preto 3 Av. Brigadeiro Faria Lima, 5416 - Vila São Pedro replacement therapy having doubled over the last 5 years . SBN data 15090-000 São José do Rio Preto, SP, Brasil. also shows that the number of patients has increased by 9.9% per year3. E-mail: [email protected] In Brazil, the total sum spent on the dialysis and kidney transplant pro- © Sociedade Brasileira para o Estudo da Dor gramme stands at approximately 1.4 billion Brazilian Reais per year3. 245 Rev Dor. São Paulo, 2017 jul-sep;18(3):245-9 Vides MC and Martins MR The secondary disorders that come together with CKD are many: low based on the data regarding the number of patients with kidney blood pressure (one of the main disorders), cramp, malaise and vom- disease currently undergoing haemodialysis, admitted in one shift. iting, headaches, chest pains, lumbar pains, itching, fever and chills, These figures vary around 56 people. Based on this datum, a sample diarrhoea, allergic reactions, cardiac arrhythmia, gas embolism, gastro- with a 95% level of confidence (LC), a maximum error equal to intestinal haemorrhage, metabolic problems, convulsions, muscular 5%, and considering a proportion estimate of 50% (maximum spasms, insomnia, restlessness, dementia, infections, pneumothorax or variance), we obtain a sample size equal to 49 patients9. Thus, the haemothorax, ischaemia or oedema in the hand, and anaemia4,5. Out sample studied had 50 people interviewed, in order to meet the sta- of all these, musculoskeletal ailments appear as significant, affecting the tistical requirement to validate the study. These patients underwent quality of life (QoL) of the patient with chronic kidney disease1. haemodialytic treatment at the Base Hospital in São Jose do Rio Disorders in the homoeostasis of calcium, phosphorus, calcitriol and Preto/SP, State of São Paulo, Brazil, between October 2015 and Feb- parathormone occur very early in patients with CKD, and play an im- ruary 2016. The criteria for inclusion were the following: people portant role in the physiopathology of bone diseases that afflict these with CKD undergoing haemodialytic treatment and without any patients, known as mineral and bone disorder (CKD-MBD) and cognitive deficit; also, through consultation made to the electronic CKD6. Among the expressions of CKD-MBD, the most important files, there was verification of comorbidities presented with regard are: joint pain, painful shoulders, carpal tunnel syndrome, and trig- to bone alterations (painful shoulder, cramp, osteodystrophy, bone ger finger, resulting from deposits of the protein B2-microglobulin on deformities, and osteoporosis, among others). tissues, as well as arthritis caused by crystals, avascular necrosis, septic The patients were approached during the sessions of haemodialysis, arthritis, weakness of the muscles, and muscular cramps1,6. in which the researcher gave explanations about the research study Pain accounts for approximately 40% of the universe of complaints and, later, carried out the interview. No patient refused the applica- made by patients with CKD during haemodialysis7, and many of tion of the questionnaire. The instruments used were the following: these painful symptoms have a known physiopathological mecha- Brief Pain Inventory (BPI)10, for appraisal of pain, which consists of nism, being able to be adequately treated during the course of treat- 15 items subdivided into two parts: the first part appraises the inten- ment: the muscular pain which follows cramps, caused by the rapid sity of the pain, while the second assesses how pain interferes with removal of body fluids; headaches, associated with increases in blood daily life (activities in general, mood, walking ability, sleep, work, in- pressure; thoracic pain which occurs in dialyser reaction syndrome, terpersonal relationships, and taking opportunities in life). The inten- formerly known as first-use syndrome6. This situation shows that pain sity and interference of pain were assessed based on a numerical scale in kidney disease reduces physical and professional function, and one’s going from 0 (no pain) to 10 (the worst possible pain). For assessment perception of his or her own health also has a negative impact on of the quality of life, the test used was the Kidney Disease and Quality- levels of energy and vivacity, which could either reduce or limit social of-Life Short-Form (KDQOL-SF)11, a specific instrument that assesse interactions and also seriously jeopardise QoL7. CKD. Emotional factors, in turn, were assessed by the Toronto Alexi- In this context, it is very important to identify the types of pain caused thymia Scale (TAS-20)12, which makes use of 20 statements as being by the changes that occur in patients with CKD. When these are bone an instrument of self-evaluation of the difficulty to identify feelings, alterations, grouped under the general theme of Renal Osteodystro- to describe the feelings of others, and also a style of thought aimed phy, they include skeletal disorders that are secondary to changes in outwards, and also outwards, with the Hospital and Anxiety Depres- the metabolism of calcium and phosphorus, and the resulting bone sion Scale (HADS)13, comprising 14 different statements, of which 7 remodelling that follows1. These can cause diffuse pains, with the in- referring to anxiety and the other 7 to depression, The global point volvement of the spine, knees, ankles and thighs, and could even cause score ranges from zero to 21 points on each subscale.