ASN's Mission

ASN leads the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005


The Latest on Twitter

Kidney Week

Abstract: SA-OR039

Opiate Analgesics and Adverse Outcomes in Hemodialysis Patients

Session Information

Category: Dialysis

  • 607 Dialysis: Epidemiology, Outcomes, Clinical Trials - Non-Cardiovascular


  • Ishida, Julie H., UCSF, San Francisco, California, United States
  • McCulloch, Charles E., UCSF, San Francisco, California, United States
  • Steinman, Michael, UCSF, San Francisco, California, United States
  • Grimes, Barbara A., UCSF, San Francisco, California, United States
  • Johansen, Kirsten L., UCSF, San Francisco, California, United States

Pain is a highly prevalent symptom in hemodialysis patients and has been associated with worse quality of life and survival. Hemodialysis patients may be particularly vulnerable to adverse events from the use of opiate analgesics, but studies evaluating their risk are scare and have not examined associations with dose or specific agents.


From the USRDS, we identified 140,899 Medicare-covered adults on in-center hemodialysis with Part D coverage in 2011. Using Cox regression models in which we adjusted for demographics, comorbidities, number of medications, and use of potentially confounding concomitant medications (e.g., sedatives/hypnotics), we investigated the association between receipt of opiate analgesics, modeled as a time-varying exposure, and time to first emergency room visit or hospitalization for altered mental status (AMS), fall, and fracture defined by ICD-9 and CPT codes. We evaluated risk according to average daily dose (high >60 mg, low <=60 mg, and per 10 mg) and specific agents (hydrocodone, oxycodone, tramadol, codeine, hydromorphone, fentanyl, morphine, methadone per 10 mg). Doses are expressed in standardized oral morphine equivalents (OME), and exposure was time-lagged (i.e., ascertained from the prior day) for fall and fracture to account for the possibility of effect/cause.


There were 90,124 (64%) patients who received opiate analgesics and 39,173 (28%) who had an episode of AMS, fall, or fracture in 2011. Opiate use was associated with risk of AMS, fall, and fracture in a dose-dependent manner (Table). Agents were associated with significantly higher rates of adverse outcomes (hazards per 10 mg OME): all agents for AMS (2-22% higher hazard); hydromorphone, hydrocodone, oxycodone, tramadol, and morphine for fall (2-7% higher hazard); and hydrocodone, oxycodone, and tramadol for fracture (3-10% higher hazard).


Opiate analgesics are associated with a high risk of adverse outcomes in hemodialysis patients, even at lower doses and for agents recommended by guidelines. Future research intended to predict and mitigate risks of opiate use in this population is warranted.

Adverse Outcomes by Opiate Dose
 Hazard Ratio (95% Confidence Interval)
<=60 mg vs. none1.30 (1.24-1.35)1.30 (1.22-1.38)1.50 (1.38-1.62)
>60 mg vs. none1.79 (1.68-1.90)1.51 (1.37-1.65)1.75 (1.54-1.99)


  • NIDDK Support