Weighing the pros and cons of opioids in renal patients with protein-energy wasting: the triaging potential of frailty

Protein-energy wasting (PEW) denotes the pathologic combination of undernutrition and excessive catabolism observed mainly in patients with chronic kidney disease (CKD). The risk of PEW increases progressively during the trajectory of renal function decline, so does that of another progeric syndrome “frailty” which describes the rising susceptibility to various insults during chronological or biological aging. Patients with CKD and PEW are at higher risk of having chronic uncontrolled pain, for which the treatment of choice is frequently limited. Under-treatment of pain is a common scenario in renal patients with PEW. Opioids and their derivatives carry therapeutic potential in these patients, but their use is associated with an increased probability of consciousness change, falls and fractures over time, followed by a surge in short- and long-term mortality due to pharmacokinetic issues. This condition poses an ethical dilemma for physicians who wish to optimize pain management for renal patients with PEW based on opioids. Our prior investigation showed that frailty assisted in stratifying patients into groups without or with opioid-related mortality risk. Opioid users with CKD may have progressively diminished mortality risk from opioid use compared to never-users following frail severity increases, and the risk disappeared among those with severe frailty. The use of frailty as a simple triaging approach may play a potential role in the shared decision making course, with regard to who will not be harmed by opioid use among patients with CKD and PEW. [Display omitted]