Multidisciplinary management of chronic refractory pain in autosomal dominant polycystic kidney disease

BACKGROUND: chronic pain is often difficult to manage in ADPKD patients and sometimes even leads to nephrectomy. We analyzed long-term efficacy of our innovative multidisciplinary protocol to treat chronic refractory pain, and that aims to preserve kidney function by applying among other sequential nerve blocks. METHODS: patients were eligible if pain was present ≥ 3 months with a score on a visual analogue scale (VAS) of ≥ 50 out of 100, was negatively affecting quality of life, and if there had been insufficient response to previous therapies, including opioid treatment. Treatment options were in respective order analgesics, cyst aspiration and fenestration, nerve blocks and nephrectomy. RESULTS: 101 patients were assessed in our clinic, mean age 50 ± 11 years and 65.3% were females. Eight patients were treated with medication, 6 by cyst aspiration or fenestration, 63 by nerve blocks, whereas 6 received surgery as first treatment option. Overall, 76.9% experienced a positive effect on pain complaints shortly after treatment. VAS score was reduced from 60/100 to 20/100 (p < 0.001) and patients lowered their number of non-opioid and opioid analgesics significantly (p < 0.001, p = 0.006 respectively). A substantial part of the patients (32.6%) needed additional treatment. At the end of follow-up only in 13 patients (12.9%) surgical intervention was necessary: 11 nephrectomies (of which 10 in patients already on kidney function replacement treatment), 1 liver transplantation, 1 partial hepatectomy. After a median follow-up of 4.5 [2.5-5.3] years, 69.0% of the patients still had less pain complaints. CONCLUSIONS: these data indicate that our multidisciplinary treatment protocol appears effective in reducing pain in the majority of patients with chronic refractory pain, while postponing or even avoiding in most patients surgical interventions as nephrectomy

Novel treatment protocol for ameliorating refractory, chronic pain in patients with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) patients can suffer from chronic pain that can be refractory to conventional treatment, resulting in a wish for nephrectomy. This study aimed to evaluate the effect of a multidisciplinary treatment protocol with sequential nerve blocks on pain relief in ADPKD patients with refractory chronic pain. As a first step a diagnostic, temporary celiac plexus block with local anesthetics was performed. If substantial pain relief was obtained, the assumption was that pain was relayed via the celiac plexus and major splanchnic nerves. When pain recurred, patients were then scheduled for a major splanchnic nerve block with radiofrequency ablation. In cases with no pain relief, it was assumed that pain was relayed via the aortico-renal plexus, and catheter-based renal denervation was performed. Sixty patients were referred, of which 44 were eligible. In 36 patients the diagnostic celiac plexus block resulted in substantial pain relief with a change in the median visual analogue scale (VAS) score pre-post intervention of 50/100. Of these patients, 23 received a major splanchnic nerve block because pain recurred, with a change in median VAS pre-post block of 53/100. In 8 patients without pain relief after the diagnostic block, renal denervation was performed in 5, with a borderline significant change in the median VAS pre-post intervention of 20/100. After a median follow-up of 12 months, 81.8% of the patients experienced a sustained improvement in pain intensity, indicating that our treatment protocol is effective in obtaining pain relief in ADPKD patients with refractory chronic pain