Meier Kristen M, Ha Darren, Sevick Carter, Blanchette Eliza D, Brockel Megan A, Vemulakonda Vijaya M, Rove Kyle O
Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA; Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Children's Mercy Hospital, Kansas City, MO, USA.
Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA.
J Pediatr Urol. 2025 Apr;21(2):460-469. doi: 10.1016/j.jpurol.2024.11.015. Epub 2024 Dec 6.
Significant efforts have been undertaken to decrease opioid prescribing, but there is little research into patient-specific factors presenting as barriers in the pediatric surgical population. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be a safe and effective alternative to opioids for pain control, however, concerns about their impact on renal function limit their use in patients with chronic kidney disease (CKD). Data is limited on the interplay of CKD on opioid prescribing.
We hypothesized that opioid reduction efforts were successful, but patients with CKD would be more likely to receive an opioid prescription than those without CKD.
A retrospective cohort study of patients ≤18 years old undergoing urologic surgery from 2014 to 2022 was performed. Patients were stratified by CKD diagnosis, determined by chart diagnosis and confirmed with CKiD U25 eGFR calculations, excluding those with normal eGFR or Stage 1 CKD. Patients without a documented CKD diagnosis and without preoperative renal function testing were presumed not to have CKD. Patients were propensity matched using the optimal full algorithm across 12 different variables. Outcomes of interest were discharge opioid prescriptions, non-opioid analgesic prescriptions, and unscheduled healthcare encounters (urology clinic visits within 5 days, emergency department visits, readmissions, or reoperations within 30 days).
10,604 patients were included. 603 patients (5.7 %) had a pre-existing CKD diagnosis; the majority were CKD stage 2 (77.8 %, 466 patients). A significant decrease in discharge opioid prescriptions was seen for patients with and without CKD. Patients with CKD had greater opioid exposure prior to surgery (17.2 %, 104 versus 2.8 %, 280, p = 0.04). Those with CKD were equally likely to be prescribed NSAIDs (p = 0.36) and opioids (p = 0.09) at discharge. Patients with CKD were more likely to present to the emergency department (ED) within 30 days of surgery (17.6 % versus 7.9 %, p = 0.007).
Similar proportions of patients with and without CKD received an opioid prescription at discharge. Patients with CKD were more likely to be exposed to opioids in-hospital earlier than non-CKD counterparts.
Multiple interventions and a dedicated postoperative opioid reduction protocol worked well, even in patients with CKD where there is concern about safely receiving NSAIDs. All-cause unplanned healthcare encounters did not differ significantly within groups with introduction of these interventions.
为减少阿片类药物的处方量已付出巨大努力，但针对小儿外科患者中构成障碍的患者特异性因素的研究却很少。非甾体类抗炎药（NSAIDs）已被证明是用于控制疼痛的阿片类药物的安全有效替代品，然而，对其对肾功能影响的担忧限制了它们在慢性肾脏病（CKD）患者中的使用。关于CKD对阿片类药物处方的相互作用的数据有限。
我们假设减少阿片类药物的努力是成功的，但CKD患者比无CKD患者更有可能接受阿片类药物处方。
对2014年至2022年接受泌尿外科手术的18岁及以下患者进行了一项回顾性队列研究。患者根据CKD诊断进行分层，通过病历诊断确定并经CKiD U25估算肾小球滤过率（eGFR）计算确认，排除eGFR正常或CKD 1期的患者。没有记录CKD诊断且未进行术前肾功能检查的患者被假定没有CKD。使用最优全算法对12个不同变量进行倾向匹配。感兴趣的结果是出院时的阿片类药物处方、非阿片类镇痛药处方以及非计划医疗就诊（5天内的泌尿外科门诊就诊、急诊就诊、30天内的再入院或再次手术）。
共纳入10,604例患者。603例患者（5.7%）有既往CKD诊断；大多数为CKD 2期（77.8%，466例患者）。有CKD和无CKD的患者出院时阿片类药物处方均显著减少。CKD患者术前阿片类药物暴露率更高（17.2%，104例对2.8%，280例，p = 0.04）。CKD患者出院时开具NSAIDs（p = 0.36）和阿片类药物（p = 0.09）的可能性相同。CKD患者在术后30天内更有可能前往急诊科就诊（17.6%对7.9%，p = 0.007）。
有CKD和无CKD的患者出院时接受阿片类药物处方的比例相似。CKD患者比无CKD的患者更早地在医院内暴露于阿片类药物。
多种干预措施和专门的术后阿片类药物减少方案效果良好，即使在担心安全使用NSAIDs的CKD患者中也是如此。引入这些干预措施后，各组间全因非计划医疗就诊无显著差异。
