A Review of Treatments to Relieve Muscle Cramps in Patients with Chronic Kidney Disease on Dialysis

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Muscle cramps (involuntary muscle contraction associated with severe pain) occur frequently in patients receiving dialysis. Muscle cramps can involve the legs, most commonly in the feet, but can also involve arms and hands, as well as abdominal muscles. It is estimated that 33% to 86% of patients receiving dialysis have experienced cramps. In a study from 2001, 25% of hemodialysis patients reported two or more cramps weekly.

Muscle cramps begin with muscle twitches, and can be very painful in any circumstances. As you are likely recall, cramps can be so painful you can hardly move. Unfortunately, this can occur during hemodialysis treatment. It is not unusual for the cramp to lead to the dialysis session being terminated earlier than planned, leading to a less effective dialysis for that treatment, something that should be avoided for long-term health.

There are numerous factors that directly contribute to muscle cramps in Chronic Kidney Disease (CKD) patients receiving dialysis including a decrease in body fluid volume, abnormally low blood pressure (hypotension), changes in electrolyte-water balance, low levels of sodium, inadequate oxygen, low magnesium in blood, carnitine (an amino acid) deficiency, and elevated serum leptin (a hormone that regulates appetite and energy). Patients who experience cramps associated with dialysis have been reported to have lower parathyroid hormone levels than patients who do not experience cramps. Low concentrations of sodium in the dialysate bath, and increased ultrafiltration required to remove excess fluid are factors related to the dialysis procedure itself, which increase the risk of muscle cramps.

Non-pharmacological strategies can be employed in order to prevent cramps in dialysis patients. Volume contraction and hyponatremia are the most common factors that cause cramping in relation to the hemodialysis procedure itself. In order to prevent these problems, and the resulting hypotension you should regularly evaluate your appropriate dry weight including minimize your weight gains between dialysis treatments. Also, increasing the frequency of hemodialysis, or switching to peritoneal dialysis have been effective in reducing the frequency of cramping. If cramps occur during dialysis, it is important to assess your hypotension. Dialysis-related hypotension may be treated through slowing or stopping ultrafiltration, lying in the Trendelenberg (flat on back) position, or reducing your blood flow rate.

Local massage of the affected muscle and the application of moist heat may provide some comfort. Other low-risk strategies include performing stretching exercises before dialysis, performing mild exercise such as riding a stationary bicycle during dialysis or prior to bedtime, minimizing alcohol and caffeine, and keeping bed covers loose and not tucked in to prevent cramps. Local heat (including showers or baths) or ice, massage, walking or leg jiggling followed by leg elevation, are other methods reported to help relieve muscle cramps.

If non-pharmacological treatments do not relieve your cramps then you should discuss with your healthcare team some pharmacotherapy options. Quinine is a medication that has been used for many years for the treatment of cramps both in the general population and in the dialysis population. Quinine was approved only for the treatment of malaria, and is used off- label to treat cramps. Quinine reduces leg cramps by decreasing excitability of the nerve stimulations, which increases the muscle refractory period and, subsequently, prevents prolonged muscle contractions. Quinine does not require a dose reduction for reduced renal function, but has a delayed onset of action, so it must be administered one to two hours prior to starting hemodialysis.

Yet, there is some debate as to the risk-benefit ratio of the above treatment because Quinine has considerable, potentially dangerous, side effects. Studies suggest that vitamin E may be an alternative therapy for the management of leg cramps for CKD patients receiving dialysis. Results showed that there was a 68.3% reduction in the number of attacks across the board, with no trends relating to age or gender, nor hemodialysis duration. It has been found that short-term treatment with vitamin E is a safe and effective treatment for patients suffering from cramps during and after dialysis. KidneyBuzz.com advises that you check with your doctor to ensure that there are no long term adverse effects from the vitamin E regiment.

Patient education about the available evidence for benefit and potential for harm of pharmacotherapy, is an important aspect of treatment. If a trial of Quinine is considered, you should be aware of the potential for harm associated with the therapy. Careful monitoring for the effectiveness and toxicity are warranted. If the drug is ineffective, or if there is any evidence for adverse effects, you should insist that it be discontinued. A short-term trial of vitamin E can be considered. However, interactions with anticoagulants (i.e warfarin or heparin), and a concern for adverse effects for risk of bleeding may limit its use in dialysis patients.



Treatment of Leg Cramps in Patients with Chronic Kidney Disease Receiving Hemodialysis. CANNT Journal

" Vitamin E and Muscle Cramps during Dialysis." Kidney Dialysis Information.

Recommended Readings:

CKD Patients improve Dialysis Outcomes by Exercising During Session
Is Use of Heparin in Dialysis as Safe as Dialysis without Heparin?
Lower Extremities Impaired Performance Associated with Death in CKD Patients