Pain Coping Skills Training Aids Pain Management for Dialysis-Dependent Kidney Failure

Pain coping skills training (PCST) may offer a viable approach to addressing and managing chronic pain in patients with kidney failure receiving maintenance hemodialysis, according to findings from a recent study.1

Results from the HOPE Consortium Trial showed 24 weeks of a PCST intervention improved pain interference, quality of life, and several other patient-reported outcomes in patients receiving hemodialysis with self-reported chronic pain, suggesting the cognitive behavioral intervention may provide a low-risk, scalable approach for pain management in this patient population.1

According to the American Kidney Fund, an estimated 35.5 million people in the US have kidney disease and about 808,000 are living with kidney failure. There are not enough donor kidneys available for everyone with kidney failure to receive a transplant. As a result, most people who develop kidney failure will require treatment with dialysis, which is frequently associated with burdensome side effects leading to an impaired quality of life.2

“Behavioral approaches for chronic pain such as cognitive behavioral therapy are appealing alternatives or complements to pharmacologic therapies but have not been well studied among people with dialysis-dependent kidney failure,” Laura Dember, MD, a professor of medicine and epidemiology at the University of Pennsylvania, and colleagues wrote.1

To evaluate the effectiveness of PCST on pain interference, investigators conducted a multicenter randomized clinical trial across 16 academic centers and 103 outpatient dialysis facilities in the US. For inclusion, patients were required to be ≥ 18 years of age; receive in-center treatment with maintenance hemodialysis for ≥ 90 days; be fluent in English or Spanish; and self-report moderate or severe chronic pain, defined as pain on most days or every day during the past 3 months and a score of ≥ 4 on the Pain, Enjoyment of Life, and General Activity scale.1

A total of 643 participants were included in the study. Among the cohort, the mean age was 60.3 (Standard deviation [SD],12.6) years, 44.8% of patients were female, and 47.9% self-identified as Black.1

Participants were randomly assigned to PCST or usual care in a 1:1 ratio using random permuted blocks of 2, 4, and 6 with stratification by enrolling site and presence or absence of opioid use. Participants randomized to PCST (n = 319) had weekly coach-led sessions lasting 45-50 minutes via video or telephone conferencing for 12 weeks, followed by an additional 12 weeks of automated interactive voice response (IVR) sessions. Participants randomized to usual care (n = 324) had no trial-driven pain intervention.1

Investigators followed trial participants for 36 weeks, with in-person or telephone visits conducted every 4 weeks. The primary outcome was pain interference measured with the Brief Pain Inventory (BPI) Interference subscale. Secondary outcomes included pain intensity, pain catastrophizing, quality of life, depression, and anxiety.1

The median number of coach-led PCST sessions attended by the 319 participants randomized to PCST was 12.0 (interquartile range [IQR], 10.0 to 12.0) out of a maximum of 12. Most (61.9%) were conducted by video conferencing and took place during dialysis (63.2%). Of the 21,034 daily automated telephone contacts initiated during the 12-week IVR intervention period, 11,206 (53.3%) were accepted by the participants, and the per-participant median completion was 59.8% (IQR, 19.1% to 86.9%).1

At week 12, the PCST group had a larger reduction in the BPI Interference score than the usual care group (between-group difference, −0.49; 95% CI, −0.85 to −0.12; P = .009). The effect persisted at week 24 (between-group difference, −0.48; 95% CI, −0.86 to −0.11) but was diminished at week 36 (between-group difference, −0.34; 95% CI, −0.72 to 0.04).1

Investigators noted a larger proportion of participants in the PCST group, compared with the usual care group, had a decrease in BPI Interference score > 1 point at week 12 (50.9% vs 36.6%; odds ratio [OR], 1.79; 95% CI, 1.28 to 2.49) and at week 24 (55.0% vs 42.8%; OR, 1.59; 95% CI, 1.13 to 2.24) but not at week 36 (48.2% vs 42.4%; OR, 1.26; 95% CI, 0.89 to 1.79).1

Positive changes with PCST were also evident for secondary outcomes of pain intensity, quality of life, depression, and anxiety at weeks 12 and/or 24, as well as for pain catastrophizing at weeks 24 and 36.1

Investigators acknowledged multiple limitations to these findings, including the fact that participants and members of the site research teams were not masked to treatment assignments; ascertainment of the PROs could not be performed for approximately 10% of participants at week 12 and approximately 20% of participants at later time points, largely due to participant death; and the lack of a cost-effectiveness analysis to assess the economic implications of adopting the intervention.1

“This randomized clinical trial of PCST showed benefits on pain interference, quality of life, and several other PROs among individuals undergoing maintenance hemodialysis and experiencing chronic pain,” investigators concluded.1 “Centrally administered PCST may provide a low-risk, scalable approach for people with dialysis-dependent kidney failure, a population with limited options for managing pain.”

References

1. Dember LM, Hsu JY, Mehrotra R, et al. Pain Coping Skills Training for Patients Receiving Hemodialysis: The HOPE Consortium Randomized Clinical Trial. JAMA Intern Med. doi:10.1001/jamainternmed.2024.7140
2. American Kidney Fund. Quick kidney disease facts and stats. July 19, 2024. Accessed January 8, 2025. https://www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats