This document summarizes rheumatological aspects in hemodialysis patients. It discusses musculoskeletal disorders that are related to dialysis, chronic renal failure, or crystal deposition. Key points include: dialysis related amyloidosis involving beta2-microglobulin deposition; tendon disorders like tendonitis and rupture; olecranon bursitis from repeated arm friction during dialysis; infection risks from impaired immunity and vascular access; and crystal-associated arthropathies involving hydroxyapatite, calcium pyrophosphate, urate, or calcium oxalate crystals. Treatment focuses on improving dialysis, managing underlying bone disease or infection, and using NSAIDs, colchicine, or steroids for crystal-associated joint

1. By
Samar Tharwat Radwan
Lecturer of Internal Medicine
(Rheumatology & Immunology)
Mansoura University
12th International Hemodialysis
Course for African Countries
Rheumatological Aspects in Hemodialysis

2. Introduction
• The number of patients with CKD stage 5 is
• Life expectancy has improved
• So, musculoskeletal disorders become a major
problem in long term hemodialysis patients (50%)
• However, the studies are limited

3. Rheumatic Disorders in HD patients
Related to Dialysis
• Dialysis related amyloidosis
Related to chronic renal failure
Non-crystalline–associated disorders
• Tendon disorder
• Olecranon bursitis
• Uremic myopathy
• Nephrogenic systemic fibrosis
• Infection
• Hemodialysis related Aluminium toxicity
• Renal osteodystrophy
Crystalline-associated disorders
• Arthropathy associated with carbonate apatite crystals
• Pseudogout
• Gout
• Calcium oxalate

4. Dialysis related amyloidosis
Tissue deposition of beta2-microglobulin (beta2-m)
Risk factors
• Increasing age and dialysis duration
• Use of low-flux dialysis membranes
• Use of bioincompatible dialysis membranes
• Lack of residual renal function

5. Dialysis related amyloidosis : C/P
Carpal tunnel
syndrome (CTS)
Scapulohumeral
periarthritis
Flexor
tenosynovitis
Bone cysts
Destructive
spondyloarthropathy
Visceral
involvement:
gastrointestinal tract

6. Dialysis related amyloidosis: Diagnosis
• Conventional radiography
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Ultrasonography
• Scintigraphy
• Biopsy : the "gold standard“

7. Dialysis related amyloidosis:Treatment
No specific treatment
• Hemodialysis: highly biocompatible, high-flux
membrane ..increase the dialysis
duration and/or frequency
• Peritoneal dialysis: no sufficient data
• Other therapies: Doxycline
• Surgery and analgesia:
─ removal of synovium infiltrated by amyloid in the shoulder
─ Carpal tunnel surgery
─ Curettage and bone grafting of amyloid cysts
─ Replacement of a diseased joint with a prosthesis

8. Circuit diagram
Lixelle treatment improved symptoms of dialysis-related amyloidosis in most patients

9. Rheumatic Disorders in HD patients
Related to Dialysis
• Dialysis related amyloidosis
Related to chronic renal failure
Non-crystalline–associated disorders
• Tendon disorder
• Olecranon bursitis
• Uremic myopathy
• Nephrogenic systemic fibrosis
• Infection
• Hemodialysis related Aluminium toxicity
• Renal osteodystrophy
Crystalline-associated disorders
• Arthropathy associated with carbonate apatite crystals
• Pseudogout
• Gout
• Calcium oxalate

10. Tendon disorders
•Tendonitis
•Tendon rupture

11. Tendonitis
TTT: analgesic, immobilization, and physical therapy
Soyupek, Feray, et al. "The upper extremity musculoskeletal complications in dialysis patients: comparison between hemodialysis and peritoneal dialysis."
Journal of back and musculoskeletal rehabilitation 26.3 (2013): 267-271.
Due to:
2ry hyperparathyroidism
use of fluoroquinolones
calcium deposition at these sites

12. Spontaneous tendon rupture
Diagnosis
• Ultrasonography
• MRI
Moerenhout, Kevin, et al. "Simultaneous Ipsilateral Quadriceps and Triceps Tendon Rupture in a Patient with End-Stage Renal Failure." Case reports in orthopedics 2018 (2018).

13. Olecranon bursitis
Dialysis elbow/ Uremic bursitis
• 3.3 episodes per 100 person-year
• long-term hemodialysis
• at the same side of AVF
• repeated friction during HD practice
• with arm resting upon hard surface
Vilbar, R. M., et al. "Treatment of dialysis elbow by simple aspiration." Journal of dialysis 3.4 (1979): 327-330.

14. Uremic myopathy
• Weakness ,aching of muscles, especially the shoulder or
pelvic girdles (e.g., climbing or descending stairs, cleaning
windows, and reaching for objects on a high shelf)
• 50% of HD patients.
• Multifactorial: Vitamin D deficiency, hyperparathyroidism
• Must be differentiated from uremic neuropathy by NCS
• TTT: adequate dialysis, Vit D , ttt of hyperparathyroidism
Sarraf, Pasha, Jonathan Kay, and Anthony M. Reginato. "Non-crystalline and crystalline rheumatic disorders in chronic kidney disease." Current rheumatology
reports 10.3 (2008): 235-248.

15. Nephrogenic systemic fibrosis
Dialysis associated systemic fibrosis.
• gadolinium-containing agents (recent or remote)
• thickening of the skin
• May affect deeper structures:muscle,fascia,lung &heart
TTT:
• prophylactic
• kidney transplantation
• extracorporeal photopheresis
• ultraviolet a phototherapy
• plasmapheresis
Endrikat, Jan, et al. "10 Years of Nephrogenic Systemic Fibrosis: A Comprehensive Analysis of Nephrogenic Systemic Fibrosis Reports Received by a
Pharmaceutical Company from 2006 to 2016." Investigative radiology 53.9 (2018): 541.

16. Nephrogenic systemic fibrosis

17. Hemodialysis related Aluminum toxicity
Due to:
• exposure to aluminum in dialysis fluid
• aluminum-containing phosphate binders
C/P:
• bone and muscle pain, fracture, proximal muscle
weakness, osteomalacia
Diagnosis
• serum aluminum concentrations
• deferoxamine stimulation test
• bone biopsy
Cannata‐Andía, Jorge B., and Jose L. Fernández‐Martín. "The clinical impact of aluminium overload in renal failure." Nephrology Dialysis Transplantation
17.suppl_2 (2002): 9-12.

18. Now uncommon(KDOQI) guidelines for aluminum testing
• annually in all HDpatients
• / 3ms in patients on aluminum-containing
medications
Treatment
• removal of all sources of aluminum
• intensive (six days per week) dialysis with high-flux
dialysis
• deferoxamine
Hemodialysis related Aluminum toxicity

19. Infection
Direct extension or hematogenous spread
Risk factors :
• immue defense
• AVF
• coexisting diseases: DM,CVDs
• concomitant inflammatory or degenerative arthritis
Septic
arthritis/bursitis
Discitis
Osteomyelitis

20. Septic arthritis
• Staphylococcus aureus
Diagnosis is challenging
• synovial fluid WBCs:not reliable
• crystal-induced can coexist
• ESR& CRP may be elevated without infection
• Difinite diagnosis: synovial fluid culture &
polarized light microscopy
McGillicuddy, Daniel C., et al. "How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis?." The American journal of emergency
medicine 25.7 (2007): 749-752.

21. Osteomyelitis
• A high index of suspicion is appropriate
Dudareva, Maria, et al. "Osteomyelitis of the Pelvic Bones: A Multidisciplinary Approach to Treatment." Journal of bone and joint infection 2.4 (2017): 184.

23. Rheumatic Disorders in HD patients
Related to Dialysis
• Dialysis related amyloidosis
Related to chronic renal failure
Non-crystalline–associated disorders
• Tendon disorder
• Olecranon bursitis
• Uremic myopathy
• Nephrogenic systemic fibrosis
• Infection
• Hemodialysis related Aluminium toxicity
• Renal osteodystrophyCrystalline-associated disorders
• Arthropathy associated with carbonate apatite crystals
• Pseudogout
• Gout
• Calcium oxalate

24. Arthropathy associated with hydroxy apatite
crystals
• HA extraskeletal calcification late-stage CKD
• may deposit in the small joints of the hands, wrists,
elbows,hips, and ankles
• shoulders are the joints most commonly affected.
Schoppet, M., et al. "Exploring the biology of vascular calcification in chronic kidney disease: what's circulating?." Kidney international 73.4 (2008): 384-390.

25. Pseudogout
• Calcium Pyrophosphate Dihydrate crystals
• large or medium-sized joints knees,wrists, hips,
and shoulders, metacarpophalangeal joints..
• Accelerated spinal osteoarthritis
• 43% among HD patients
Due to:
• hypercalcemia
• hyperphosphatemia
• vitamin D deficiency
• hyperparathyroidism
• iron overload
Menerey, K., et al. "Musculoskeletal symptoms related to arthropathy in patients receiving dialysis." The Journal of rheumatology 15.12 (1988): 1848-1854.

26. Gout
• hyperuricemia.
• small joints as the first metatarsophalangeal
• Hyperparathyroidism enhances urate absorption
hyperuricemia
• However, hyperuricemia is attenuated by urate
removal, especially with high-flux hemodialysis.

27. Calcium oxalate
Due to:
─Inefficient removal of oxalate by hemodialysis
─Vitamin C
• Deposits of oxalate crystals have been in synovium,
tendon sheaths, articular cartilage, and bone
• Polyarticular pain
• Polarizing light microscopy
• Positive alizarin red S staining of CaOX

28. Treatment of Crystal-Induced Arthropathies
• Infection must be excluded
• Synovial fluid crystals by polarizing light microscopy
The mainstay of therapy
• NSAIDs
• Colchicine :not dialyzable, granulocytopenia,
reversible neuropathy, myopathy...low-dose regimen
(0.15–0.3 mg) or an alternate day dosing regimen
(0.3–0.6 mg)
• Corticosteroids
• Adrenocorticotropic hormone (ACTH)
• Hydroxychloroquine

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