Opioid prescribing patterns and the effect of chronic kidney disease in pediatric urology population: A retrospective cohort analysis

Background: 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.

Objective: 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.

Study design: 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).

Results: 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).

Discussion: 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.

Conclusions: 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.