title: Evidence for Neurotoxicity Due to Morphine or Hydromorphone Use in Renal Impairment: A Systematic Review.
abstract: Opioids are the mainstay of pain control for patients with chronic pain. Often, opioids with reported active metabolites, such as morphine and hydromorphone, are thought to increase the risk of neurotoxicity in renal impairment.
  
  
  
  To identify and assess the quality of evidence for neurotoxic effects in patients with renal impairment receiving morphine or hydromorphone.
  
  
  
  Systematic searches were conducted of the following databases from inception to December 2015: MEDLINE, CINAHL, EMBASE, in addition to hand-searching relevant review articles' citations. Studies were included if they reported neurotoxic effects of either morphine or hydromorphone for chronic or malignant pain in patients with renal impairment. Review articles and case reports were excluded. Narrative review was undertaken. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess study quality.
  
  
  
  Six original articles, three prospective and three retrospective studies were identified and assessed. No relevant randomized clinical trials were identified.
  
  
  
  Although morphine and hydromorphone use may be associated with neurotoxic effects in patients with renal impairment, current evidence consists of very low-quality studies with conflicting findings. Clinicians may consider using either morphine or hydromorphone in mild-to-moderate renal impairment, while closely monitoring for neurotoxic effects, particularly when used in high doses and for extended duration.
authors.affiliation: 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Lee
authors.affiliation: 2 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania.
authors.forename: Niharika
authors.initials: N
authors.lastname: Ganta
authors.affiliation: 3 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.
authors.forename: Jay R
authors.initials: JR
authors.lastname: Horton
authors.affiliation: 3 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.
authors.forename: Emily
authors.initials: E
authors.lastname: Chai
mesh_terms: D000701:Analgesics, Opioid; D006801:Humans; D004091:Hydromorphone / Q000009:adverse effects*; D007674:Kidney Diseases / Q000139:chemically induced*; D009020:Morphine / Q000009:adverse effects*; D011446:Prospective Studies; D012189:Retrospective Studies
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine; D004091:Hydromorphone