Musculoskeletal Manifestation of Renal Failure Thomas Bardin Fédération de Rhumatologie Hôpital Lariboisière Université Paris Diderot Paris
Septic arthritis in hemodialysis patients
Incidence is increased # 100 fold Gloomy prognosis Mono or polyarticular Coexisting amyloid arthropathy Fever, increased ESR or CRP may be missing or attributed to other cause Joint fluid aspiration before antibiotics +++ inflammatory WBC microorganism identification antimicrobial sensitivity
Septic arthritis in hemodialysis patients AURA dialysis Center, Paris (389 patients) 15 septic arthritides in 15 years incidence: 1.1/100 patient-years Amyloid arthropathy: 11/15 No association with diabetes Portal of entry: fistula 2, articular injection 2, cutaneous 2, lung 1, biliary 1 Staphylococcus +++, Streptococcus + 2 death, 3 sequellae (1 amputation)
Crystal -induced arthropathies in renal failure patients • Gout seen in renal failure before dialysis very rare in dialysis patients
• CPPD same as population at large
• BCPs very common
• Calcium
oxalate
primary or secondary oxalosis in dialysis patients
Periarticular BCP deposits in dialysis patients
Calcium phosphate periarticular deposits
Paraarticular calcification with adjacent bone erosion (ABD + Ca CO3)
Uremic tumoral calcinosis
Frequent multiple Bone scan : increased uptake Palpable mass Joint motion limitation Nerve or vein compression Rarely inflammatory
CALCIFIED TENDINITIS IN CKD PATIENTS MANAGEMENT
Curative : short course of NSAIDs (full dosage) Preventive : low dose NSAIDs (colchicine is contra indicated) Correction of etiological disorder (hyperphosphatemia, secondary HPP,stop calcium and vitD derivates)
Calcium oxalate crystals in dialysis patients Primary oxalosis Secondary oxalosis Decreased renal excretion: End-stage renal disease and dialysis Increased ingestion of oxalate precursors: Ascorbic acid Methoxyflurane Ethyleneglycol Increased absorption:
Small bowel resection
Increased production:
Thiamine or pyridoxine deficiency
Calcium oxalate crystals in SF
Dihydrate : weddelite
Monohydrate : whewellite
Calcium oxalate chondrocalcinosis
Oxalosis : Finger flexor involvement
Beta2 microglobulin amyloid: Main deposits : joints May also be systemic Pathophysiology Lack of renal catabolism Insufficient elimination by dialysis Increased synthesis due to cytokine release in contact with dialysis membranes and/or dialysate Risk factors Length of dialysis therapy Age Dialysis technique
β 2m Amyloidosis: a Vanishing Complication? Schwalbe et al. Kidney Int 1997;52:1077-1083
•1988
•1996
•Age
•50.9 ± 12.3
•50.7 ± 12.5
•HD duration
•71.2 ± 49.4
•71.0 ± 49.7
•CTS
•7/43
•1*/43
•Amyloid cysts
•13/34 •33/272 sites
•3/34 •7/272 sites
•* After 2 years of HD, diabetes
β 2M amyloidosis: clinical features CTS (≈ 50% of CTS of dialysis patients) Chronic artropathy •
predominant involvement of shoulders and hands
•
bursa and tendon involvement
•
less than 1000 cells in SF
Subchondral bone erosions Destructive arthropathy Still seen in very long trem dialysis patients
DIALYSIS SHOULDER Calcified tendinitis: acute inflammatory flares Amyloid arthropathy: chronic shoulder pain frequently worsened by dialysis session usually bilateral - amyloid synovitis - bursal involvement - rotator cuff thickening: impigement syndrome
Destructive spondylarthropathy in dialysis patients (Kuntz et al, 1984)
Intervertebral space narrowing Erosions of adjacent vertebral plates No osteophytosis
Frequency of destructive spondylarthropathy in hemodialysis patients Auteurs
Population Age moyen étudiée (ans)
Durée HD (ans)
% spondylarthropathies
Hardouin 1987
80
53
6,1
9
Fardelone 1988
84
53,7
> 10
12
Kessler 1992
171
49
> 10
14
Maruyama 1992
405
51,9
8,2
9,1
Destructive arthropathies in 50 patients under hemodialysis with histologically proven amyloidosis
Site of destructive arthropathy Spine Small joints of the hands Large peripheral joints
No pts 19 10 8
Differential features between dialysis spondylarthropathy and infectious discitis
Level involved
Infection
Dialysis
Usual. single
Often xple
rare
frequent
no
frequent
Vertebral subluxation Vacuum phenomenon Soft tissue mass T1 weighted
yes
no
Low signal
Low signal
T2 weighted
Low
Low/intermediate
IRM : T2, fat sat
Destructive arthropathy of large limb joints in dialysis patients
- hip, knee, shoulder, wrist - frequently multiple involvement - subchondral bone erosion precede JS narrowing, which is frequently rapid -traitement : total joint prothesis - pathology : amyloidosis
Destructive amymoid arthropathy of the wrist
Trapezo-metacarpal arthropathy in dialysis patients
Management of β 2m amyloid arthropathy Standard analgesics NSAIDs : increased risk of gastric ulcer complications COXIBs : vascular risk Prednisone : 0.1 mg/kg/day Steroid injections : contraindicated (sepsis) Radiation synovectomy Highly permeable and biocompatible membranes
Management of β 2m amyloid arthropathy Carpal tunnel syndrome: early release of median nerve Destructive spondylarthropathy with neurological compromise: interbody fusion of instable levels Destructive arthropathy of the hip and knee: total joint prosthesis
Dialysis amyloidosis Renal transplantation Rapid pain improvement Subchondral erosions persist but do not progress Destructive arthropathy may worsen Amyloid deposists persist
EROSIVE ENTHESOPATHY IN CKD
Etiology Severe (primary or) secondary HPT Clinical features Pain on use Tendon rupture Management correction of HPT (PTX or Mimpara)
Tendon Rupture in CKD Patients
Secondary hyperparathyroidism Corticosteroids Fluoroquinolones
Bone Fissures in Dialysis patients Symptom • •
Pain on use, usually of the lower limb Triggered by weight bearing
Value of bone scan Etiology • • •
Osteomalacia due to vit D deficiency Fluorosis Osteoporosis
Fractures in Dialysis Patients Age and sex adjusted relative risk of hip fracture in a national US register: • •
4.44 in men 4.40 in women
Alam et al. Kidney Int 2000; 58:366-9
Risk Factors for Osteoporotic Fractures in Renal Failure Patients Age Female sex Caucasian Early menopause Steroids Denutrition Low DMO
Duration of survival upon dialysis Peripheral arteriopathy Vascular calcification Al intoxication Other types of renal osteodystrophy
Effect of PTH levels on fracture Coco & Rush. Am J Kidney Dis 2000
Vertebral fractures and vascular calcifications in dialysis patients
Rodriguez-Garcia Nephrol Dial Transpl 2009;24:239-46
Treatment of osteoporosi in CKD patients Prevention and treatment of osteodystrophy Estrogens in early menopause General measures exercise, correct nutrition Other treatments are contraindicated Raloxifene increases BMD
Muskuloskeletal Manifestations of Renal Failure Frequent and diverse, especialy in dialysis patients Septic arthritis is increased and severe BCP deposition is favoured by renal osteodystrophy Beta-2 amyloid is still observed in long term dialysis patients IA steroid injections should be avoided Osteoporosis is frequent and remains a therapeutic challenge