Hemodialysis: Acute Complications – Muscle Cramping

Does this patient have muscle cramping?

Symptoms

Muscle cramping

Restlessness

Agitation

Anxiety

What tests to perform?

• Clinical diagnosis

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• Laboratory tests that may identify cause and assess severity:

  Serum magnesium (exclude hypomagnesemia)

  Serum calcium (exclude hypocalcemia)

  Serum creatinine kinase (may be elevated in severe form) (optional)

  Electromyography – increased tonic muscle electrical activity (optional)

  Bioelectrical impedance analysis (BIA) for better estimation of dry weight

How should patients with muscle cramping be managed?

Acute management

Reduce or stop (if severe) ultrafiltration rate

Infuse hypertonic solution, e.g., 23.5% hypertonic saline (15-20 mL), or 50% dextrose in water (25-50 mL)

Hypertonic saline may result in post-dialysis thirst, interdialytic weight gain and fluid overload.

Prevention

Nonpharmacologic

• Adjusted estimated dry weight (increase by 0.5 kg if no edema or adjust according to BIA)

• Dietary counseling on minimal interdialytic weight gain

Dialysis prescription

• Biofeedback program (blood volume monitoring, BVM) (optional)

• Blood temperature monitoring (BTM) (optional)

• Dialysate sodium profile (optional

• Ultrafiltration profile (optional)

• Combined dialysate sodium and ultrafiltration profile (optional)

• Isolated ultrafiltration or sequential ultrafiltration followed by dialysis (optional)

• Hemodiafitration (optional)

• More frequent (short daily or nocturnal) hemodialysis (optional)

Pharmacologic

• Quinine sulfate (250-300 mg) given 2 hours before dialysis (optional), not approved for use in United States

• Oxazepam (5-10 mg) given 2 hours before dialysis (optional)

• L-carnitine (20 mg/kg) given intravenously after dialysis (optional, some studies shown benefit and marginal significance in meta-analysis)

• Gabapentin 300 mg given before each dialysis session (optional

• Vitamin E (400 mg) and vitamin C (250 mg) daily (optional)

What happens to patients with muscle cramping?

Poor quality-of-life measures

Recurrent episodes may induce inadequate dialysis from poor compliance

Chronic fluid retention from poor compliance

How to utilize team care?

• Nurses – Monitor closely high-risk patient.

• Pharmacists – Review and check compliance with prescribed medications and monitor for side effects.

• Dietitians- Counsel patient to adhere to low sodium diet (< 2 g/day) diet and fluid restriction

• Specialists – Neurology consultation may be required to perform electromyography and nerve conduction studies to rule out other causes of muscle cramping (e.g., neuropathy)

Are there clinical practice guidelines to inform decision making?

Applications – no

Other considerations

ICD-10 CM diagnosis code M62.83: Muscle spasm

What is the evidence?

Lynch, KE, Feldman, HI, Berlin, JA, Flory, J, Rowan, CG, Brunelli, SM. “Effects of L-carnitine on dialysis-related hypotension and muscle cramps: a meta-analysis”. Am J Kidney Dis. vol. 52. 2008. pp. 962-971.

El-Hennawy, AS, Zaib, S. “A selected controlled trial of supplementary vitamin E for treatment of muscle cramps in hemodialysis patients”. Am J Ther. vol. 17. 2010. pp. 455-9.

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