The Burden of Musculoskeletal Disease in Hemodialysis Patients

Dear Editor, Musculoskeletal complications represent a major contributor to morbidity and reduced quality of life in patients with end-stage kidney disease (ESKD) undergoing maintenance hemodialysis. While renal osteodystrophy is a well-recognized complication in patients with chronic kidney disease (CKD), other forms of musculoskeletal complications also require careful consideration. These complications are multifactorial in origin, arising from chronic metabolic derangements, persistent low-grade inflammation, accumulation of β2-microglobulin, disordered mineral metabolism, and physical deconditioning.[1] The musculoskeletal complications in CKD and ESKD are listed in Table 1.Table 1: Musculoskeletal complications in hemodialysis patientsCommonly reported conditions include CKD – mineral and bone disorder which is characterized by abnormalities in calcium, phosphate, parathyroid hormone, and Vitamin D metabolism. It includes secondary hyperparathyroidism, renal osteodystrophy, and vascular/soft tissue calcifications, causing symptoms such as bone pain, fractures, and skeletal deformities.[2] Other complications include carpal tunnel syndrome and dialysis-related amyloidosis, which are related to long-term β2-microglobulin accumulation. Osteoarthritis (OA), fibromyalgia, and vertebral compression fractures are common in hemodialysis patients, exacerbated by aging, reduced physical activity, chronic inflammation, and uremic toxins. Less frequently recognized complications include uremic myopathy and avascular necrosis. Spontaneous tendon ruptures, particularly of the quadriceps and Achilles tendons, are associated with severe secondary hyperparathyroidism and fluoroquinolone use. Calcific periarthritis and tumoral calcinosis may arise due to chronic disturbances in calcium–phosphate metabolism, leading to painful periarticular soft tissue masses due to deposition of calcium hydroxyapatite.[3] Pseudogout in dialysis patients is caused by the deposition of calcium pyrophosphate crystals in the joints. Restless legs syndrome RLS) is common in hemodialysis patients, affecting about 20%–30% of individuals.[4] Muscle cramps, especially during or postdialysis, are highly prevalent and may be linked to volume shifts and electrolyte imbalances. Finally, many patients experience nonspecific musculoskeletal pain that cannot be attributed to a single etiology but reflects the complex interplay of uremia, inflammation, immobility, and chronic illness. Falls are a common and serious concern in hemodialysis patients, and main risk factors include intradialytic hypotension, sarcopenia, peripheral neuropathy, postural instability, and the use of polypharmacy or sedatives. These falls often result in fragility fractures, particularly hip fractures, and contribute to functional decline and increased mortality. Effective management involves use of fall risk screening tools such as the Tinetti or Berg Balance Scale, along with interventions such as resistance training, Vitamin D supplementation, postdialysis rest, and regular medication review to reduce fall risk and improve patient outcomes.[5] Analgesic management in hemodialysis patients must account for altered pharmacokinetics and increased susceptibility to adverse effects. Paracetamol is safe and effective in mild-to-moderate pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) have serious adverse effects; however, topical NSAIDs may be considered in localized pain. For moderate–to-severe pain, opioids such as fentanyl and hydromorphone are preferred, whereas morphine and codeine are contraindicated. Gabapentinoids (gabapentin and pregabalin) and serotonin–norepinephrine reuptake inhibitors (e.g., duloxetine) are effective for neuropathic and fibromyalgia-associated pain but require dose adjustments to prevent central nervous system toxicity. Nonpharmacological modalities may be used where possible.[6] Through this letter, we emphasize that musculoskeletal pain in CKD has many diverse causes and that it requires a multipronged treatment approach including pharmacological interventions, physical therapy, and dialysis optimization. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.