Dialysis: Muscloskeletal ManifestationsDz

Synonym: Hemodialysis-related arthropathy.

ICD-9 Code: Amyloid arthropathy, 713.7.

Definition: These are syndromes related to muscles and joint structures seen in patients undergoing long-term renal dialysis.

Etiology: The cause of most hemodialysis-associated syndromes is unknown. Secondary hyperparathyroidism can lead to development of bone abnormalities. 132-Microglobulin amyloidosis and crystal deposition arthritis result from abnormalities of renal clearance.

Pathology: Arthritic syndromes associated with dialysis show erosive bone changes in <25%. Most synovial fluids are noninflammatory, except those associated with crystals. 132-Microglobulin deposits are observed in bone cysts and soft tissues such as those within the carpal tunnel.

Cardinal Findings: Arthralgias are common. A minority of patients show erosive changes in small joints of the hands. Amyloid deposition most commonly presents as CTS or characteristic bone cysts seen on radiographs.

Uncommon Findings: Myelopathy with paresis caused by amyloid deposition has been reported.

Diagnostic Tests: Biopsies of affected tissues are required to establish a diagnosis of amyloidosis. Radiographs of affected joints show bone cysts, erosions, or subperiosteal resorption of bone. Synovial fluid analyses are required to evaluate crystal deposition diseases.

Keys to Diagnosis: Persistent symptoms referable to joints or periarticular tissues in the setting of hemodialysis should prompt further investigation.

Differential Diagnosis: Hyperparathyroidism, idiopathic CTS (not related to amyloid deposition), and other metabolic disorders should be considered.

Therapy: Amyloid deposition in some patients may be slowed by changing the membrane used for dialysis. Symptomatic CTS may require surgical intervention. Nonspecific arthralgias and other joint complaints may be treated symptomatically, with use of analgesics dictated by the underlying medical condition and the drugs mode of clearance or half-life. Treatment of crystal arthritis may also be limited by the underlying condition.

Prognosis: Patients with amyloid are difficult to treat and have a more limited prognosis than those with other dialysis-related syndromes, which probably do not significantly alter the patient’s course.

BIBLIOGRAPHY

Menerey K, Braunstein E, Brown M, et al. Musculoskeletal symptoms related to arthropathy in patients receiving dialysis. J Rheumatol 1988;15:1848–1854. PMID:3230570