Pain Management in End Stage Renal Disease: A Case Study

Running head: CASE STUDY
Pain management
Name of the Student
Name of the University
Author Note

1CASE STUDY
Introduction- Pain management refers to the specialty medicine that has originated
from the need of treating different types of pain namely, spinal, musculoskeletal and
neuropathic pain (Macintyre and Schug 2014). Chronic or end stage kidney disease most
commonly encompasses a range of pathophysiologic mechanisms that are associated with
abnormal functions of the kidney and result in a progressive decline in the rate of glomerular
filtration (Jha et al. 2013). The assignment will elaborate on a case study of an older adult,
diagnosed with end stage renal disease and will provide an insight into the pain management
techniques that can be adopted for treatment.
Case Study- A 78 year old female X (pseudo name) had been admitted to the
nephrology department for her end-stage renal disease and reports signs of poorly controlled
pain, vascular dementia and peripheral vascular disease. The patient had been diagnosed with
ESRD in 2017, and needs dialysis every week for survival. Her family ruled out the option
for a kidney transplant. Although haemodialysis is not a permanent cure for her condition, it
has been considered as an effective strategy in increasing the life span of an affected patient.
The patient has been diagnosed with musculoskeletal pain based on the symptoms reported
such as, stiffness and aching in her legs, sleep disturbances, burning sensation in the lower
limb muscles, and widespread pain that gets worsened with her movement. Furthermore, she
also reported a swelling in the joints after minor movement and stiffness after resting for a
considerable period of time. She was diagnosed with osteoarthritis by blood tests, analysis of
the joint fluids and X-ray imaging. The patient has a body weight of 65 kilograms and was
under the prescribed medication of angiotensin receptor blockers. Assessing her joints during
a physical examination further confirmed the presence of swelling, redness and tenderness.
Pathophysiology- Pain is commonly defined as feelings of distress that are caused due
to the action of some damaged stimuli. It is also referred to an unpleasant, emotional and
sensory experience that is related with potential or actual damage to cells and/or tissues.

2CASE STUDY
Musculoskeletal pain are caused due to injury to the joints, bones, tendons, muscles, and
ligaments (Mayer and Bushnell 2015). Although osteoarthritis had earlier been categorised as
a non-inflammatory form of arthritis, there is mounting evidence to suggest that the
inflammation occurs as a result of release of metalloproteinase and cytokines, into the joints.
These compounds are primarily involved in excessive degradation of the matrix, which in
turn characterises the degeneration of cartilage in osteoarthritis. A fine balance of the water
content present in a healthy cartilage is maintained due to the compressive force that drives
out water, and osmotic and hydrostatic pressure that draw in water (Arden et al. 2014). The
collagen matrix is shows a disorganised state during the onset of the condition, along with a
subsequent decrease in the content of proteoglycan in the cartilage. Increase in water content
occurs due to breakdown of the collagen fibres (Hoff et al. 2013).
Failure of the proteoglycans to exert a protective effect increase susceptibility of the
collagen to get degraded, thereby exacerbating degeneration. Further changes include
thickening and fibrosis of the ligaments present in the joints and damage or wear of the
menisci. Research evidences have also established strong correlation between enhanced
quadriceps strength and reduction of pain (Herrero-Beaumont et al. 2017). Furthermore, a
growing body of evidences have also emphasised on the fact that chronic pain is quite
common in patients with ESRD and creates a virtual impact on different facets of health-
related quality of life (Santoro et al. 2013). There occurs an exponential increase in in the
challenges to treat chronic pain in an ESRD patient, who is on haemodialysis. All of these
changes might have resulted in the onset of osteoarthritis in the patient X, undergoing
haemodialysis for ESRD.
Bio-psychological and social impact- Time and again chronic pain has been
recognised as a main public health issue that produces a significant social and economic
burden on the sufferer and his/her family members. Severe chronic pain has been associated

3CASE STUDY
with increased risks of major mental disorders that commonly encompass anxiety, depression
and post-traumatic stress disorder (Turk et al. 2016). With a subsidisation in the pain
symptoms, the stressful response associated with mood alterations also show a marked
reduction. However, in this case scenario, the patient X was found to be constantly stressed
and tense about her health and inability to move. Over time, this stress aggravated her
emotional problem and resulted in the onset of a depressed mood that was characterised by a
reduced self-esteem, fatigue, confused thinking, social isolation and a fear of injury.
Furthermore, another major biological impact created by osteoarthritis is an impairment in
functional mobility (Bunzli et al. 2013). Research evidences have illustrated the fact that
patients with osteoarthritis commonly experience major functional limitations in their hands
and legs compared to individuals without the disease (Neogi 2013).
Additionally, depression also plays a crucial role in modifying the association
between functional mobility and knee pain (Holmes, Christelis and Arnold 2013). In this case
scenario, in addition to suffering from a persistent low mood, the patient X could not move
on her own, without assistance, which in turn can be attributed to the stiffness in her joints
and leg muscles. The subsequent disability also prevented her from participating in activities
of daily living such as, doing household chore, dressing, feeding and fulfilling certain social
roles in the context of the community or family. Behaviour and lifestyle modifications and
several psychosocial attributes have been identified imperative for accommodating to daily
activities and reducing the severity of impairment (Kjeken et al. 2013). However,
osteoarthritis has often been found to create a negative impact on the health outcomes and
daily functioning of affected people, thereby making them travel less distance or use more
transportation.
The fact that depression in the patient X influenced the relationship between her
functional mobility and knee pain is further illustrated by low mood and poor self-esteem due