Muscle cramps in dialysis patients
- Jean L Holley, MD, FACP
Jean L Holley, MD, FACP
- Clinical Professor of Medicine
- University of Illinois, Urbana-Champaign
Muscle cramps are a common complication of hemodialysis treatments, occurring in 33 to 86 percent of patients [1,2]; they often result in the early termination of a hemodialysis session and are therefore a significant cause of underdialysis. The exact etiology of cramps in dialysis patients is unknown. Since cramps tend to occur most frequently near the end of hemodialysis treatments, changes in plasma osmolality and/or extracellular fluid volume have been implicated.
The pathophysiology, clinical features, and treatment of cramps occurring in association with dialysis will be reviewed here. A general overview of muscle cramps and other acute complications of dialysis are presented separately. (See "Nocturnal leg cramps" and "Acute complications during hemodialysis".)
A cramp is a prolonged involuntary muscle contraction that occurs in a muscle that voluntarily contracts when it is already in its most shortened position . The increased frequency of cramps at rest and during the night may be caused by the placement (by the plantar-flexed foot) of the calf and ventral foot muscles in the most shortened and vulnerable position during sleep .
Electromyography reveals that cramps begin with fasciculations in various muscle parts that subsequently progress to high-frequency action potentials. The origin of a cramp is therefore neural, not muscular .
The etiology of hemodialysis-associated cramps may include contributions from one or more of the following factors [1,3,4]:
- Canzanello VJ, Burkart JM. Hemodialysis-associated muscle cramps. Semin Dial 1992; 5:299.
- Kobrin SM, Berns JS. Quinine--a tonic too bitter for hemodialysis-associated muscle cramps? Semin Dial 2007; 20:396.
- McGee SR. Muscle cramps. Arch Intern Med 1990; 150:511.
- Hung CY, Chen YL, Chen CS, et al. Association of leptin with hemodialysis-related muscle cramps: a cross-sectional study. Blood Purif 2009; 27:159.
- Noordzij M, Boeschoten EW, Bos WJ, et al. Disturbed mineral metabolism is associated with muscle and skin complaints in a prospective cohort of dialysis patients. Nephrol Dial Transplant 2007; 22:2944.
- Hernando P, Caramelo C, López Garcia D, Hernando L. Muscle cramps: a cause of elevated creatine kinase levels in hemodialysis patients. Nephron 1990; 55:231.
- Kaji DM, Ackad A, Nottage WG, Stein RM. Prevention of muscle cramps in haemodialysis patients by quinine sulphate. Lancet 1976; 2:66.
- Roca AO, Jarjoura D, Blend D, et al. Dialysis leg cramps. Efficacy of quinine versus vitamin E. ASAIO J 1992; 38:M481.
- Khajehdehi P, Mojerlou M, Behzadi S, Rais-Jalali GA. A randomized, double-blind, placebo-controlled trial of supplementary vitamins E, C and their combination for treatment of haemodialysis cramps. Nephrol Dial Transplant 2001; 16:1448.
- El-Hennawy AS, Zaib S. A selected controlled trial of supplementary vitamin E for treatment of muscle cramps in hemodialysis patients. Am J Ther 2010; 17:455.
- Chang CT, Wu CH, Yang CW, et al. Creatine monohydrate treatment alleviates muscle cramps associated with haemodialysis. Nephrol Dial Transplant 2002; 17:1978.
- Serrao M, Rossi P, Cardinali P, et al. Gabapentin treatment for muscle cramps: an open-label trial. Clin Neuropharmacol 2000; 23:45.
- Hinoshita F, Ogura Y, Suzuki Y, et al. Effect of orally administered shao-yao-gan-cao-tang (Shakuyaku-kanzo-to) on muscle cramps in maintenance hemodialysis patients: a preliminary study. Am J Chin Med 2003; 31:445.
- Sherman RA, Goodling KA, Eisinger RP. Acute therapy of hemodialysis-related muscle cramps. Am J Kidney Dis 1982; 2:287.
- CLINICAL FEATURES
- Interventions to reduce the frequency of cramps
- - Minimize interdialytic weight gains
- - Prevention of dialysis-associated hypotension
- - Higher dialysate sodium concentration
- - Carnitine supplementation
- - Quinine sulfate
- - Vitamin E
- - Others
- - Approach to treatment
- Treatment of cramps during hemodialysis
- - Hypertonic saline versus dextrose
- - Mannitol
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS