Tendinopathy in Hemodialysis Patients

7th
International Hemodialysis Course, Mansoura UNC, December 22-26, 2014
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
Tendinopathy in
Hemodialysis Patients
The Hidden Face of
CKD-MBD

7th
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Case History
Patient Medical History
 70 years old male patient.
 On maintainenance hemodialysis (3 times per
week) since 12 years.
 The main cause of ESRD is
APKD.
Archived, identical image
(not the patient own image)

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Case History
Presenting Complaint
 This patient presented to us with a sudden
onset of painful disability in the left posterior
ankle.
 This occurred while he was climbing the
stairs.

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Case History
Physical examination
 Inspection:
There was swelling around left posterior
ankle joint.

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Case History
 Palpation:
 Tenderness above the insertions of the Achilles
tendon.
 There was a gap in the Achilles tendon site.

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Case History
 Palpation:
 The Thompson calf squeeze test was positive for
a subcutaneous Achilles tendon rupture.
Normal Abnormal (tendon rupture)

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Case History
Ultrasonography
 A complete disruption of the fibrillar structure
of the tendon
 The gap between the ruptured tendon ends
was filled by a hematoma

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Diagnosis of Rupture Tendo-
Achilles was confirmed
Case History
Diagnosis

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Tendinopathy in Hemodialysis
First Report
Tendinopathy
(Inflammation & Spontaneous rupture)
Mao-Feng Gao et al. Journal of International Medical Research. 41(4) 1378–1383. 29 March 2013.
Prominent in Hemodialysis patients

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First Case Report
Steiner CA and Palmer LH. Am J Surg 1949; 78: 752–755.

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Tendinopathy - Tendon Rupture
Causes
 Tendon rupture has been described as a
complication of:
 ESRD [1]
 SLE [2]
 Gout [3]
 Rheumatoid arthritis [4]
 Diabetes mellitus [5]
 Obesity [6]
 Sports activity and Trauma .
1.Loehr J (1983). Can Med Assoc J 129:254–256
2.Wener JA (1974). J Bone Joint Surg Am 56:823–824
3.Levy M et al (1971). J Bone Joint Surg Br 53:510–513
4.Razzano CD (1973). Clin Orthop Relat Res 91:158–161
5.Bhole R (1985). South Med J 78:486
6.Kelly BM et al (2001). Arch Phys Med Rehabil 82:415–418

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Tendinopathy - Tendon Rupture
Causes
 Tendon rupture has been described as a
complication of:
 ESRD [1]
 SLE [2]
 Gout [3]
 Rheumatoid arthritis [4]
 Diabetes mellitus [5]
 Obesity [6]
 Sports activity and Trauma .
1.Loehr J (1983). Can Med Assoc J 129:254–256
2.Wener JA (1974). J Bone Joint Surg Am 56:823–824
3.Levy M et al (1971). J Bone Joint Surg Br 53:510–513
4.Razzano CD (1973). Clin Orthop Relat Res 91:158–161
5.Bhole R (1985). South Med J 78:486
6.Kelly BM et al (2001). Arch Phys Med Rehabil 82:415–418
And its risk factors

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 Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture
Hemodialysis - Talk Outline

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Hemodialysis - Talk Outline
 Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention

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Hemodialysis - Which Tendon?
Quadriceps
tendon
Achilles
tendon
Patellar
tendon
The most frequently affected tendons

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Ho LC et al. Clin Nephrol. 2009 Apr;71(4):451-3.
Hemodialysis - Which Tendon?

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Known Risk Factor Is it present in our patient?
Long-term hemodialysis
2ry hyperparathyroidism
β-2 microglobulin
associated amyloidosis
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
Hemodialysis – Risk Factors
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
Luis Marcelo A. Malta. Injury , In Press: September 23, 2014
Vellani G et al. Chir Organi Mov. 48:15-18, 1993

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β-2 microglobulin
Fluoroquinolone use
Corticosteroid use
inflammation
Chronic Acidosis
Hemodialysis – Risk Factors
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
Luis Marcelo A. Malta. Injury , In Press: September 23, 2014
Vellani G et al. Chir Organi Mov. 48:15-18, 1993
The most important
risk factor
The most important
risk factor

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The Hidden Face of CKD-MBD
MBD
+
MVD

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The Hidden Face of CKD-MBD
MBD
+
MVD
+
MSD

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β-2 microglobulin
Fluoroquinolone use
Corticosteroid use
inflammation
Chronic Acidosis
Case History
Risk Factors

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Long-term hemodialysis Yes: 12 years old HD
β-2 microglobulin
Fluoroquinolone use
Corticosteroid use
inflammation
Chronic Acidosis
Case History
Risk Factors

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2ry hyperparathyroidism Yes:
β-2 microglobulin
Fluoroquinolone use
Corticosteroid use
inflammation
Chronic Acidosis
Lab Variable Result
Calcium 9.7mg/dl
Phosphorus 5.5mg/dl
PTH 450 pg/ml
Alkaline Phosphatase Not available
Case History
Risk Factors

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β-2 microglobulin
Yes:
Serum β-2 microglobulin: 460 mg/L
Fluoroquinolone use
Corticosteroid use
inflammation
Chronic Acidosis
Case History
Risk Factors

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β-2 microglobulin
Yes:
Fluoroquinolone use No
Corticosteroid use No
inflammation
Chronic Acidosis
Case History
Risk Factors

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β-2 microglobulin
Yes:
inflammation
Not sever
Chronic Acidosis
Lab Variable Result
Hb 11g/dl
Serum Albumin 3.7 g/dl
Case History
Risk Factors

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β-2 microglobulin
Yes:
inflammation
Not sever
Chronic Acidosis Yes
Case History
Risk Factors

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Hemodialysis - Diagnosis
Ultrasonography
good sensitivity (96–100%)
and specificity (83–100%)
MRI
Hartgerink P et al (2001). Radiology 220:406–412
Mao-Feng Gao et al. Journal of International Medical Research. 41(4) 1378–1383. 29 March 2013.

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Up to 50% of quadriceps
tendon rupture may be misdiagnosed
Trobisch PD, Bauman M, Weise K, et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88.
consider the possibility of a quadriceps tendon
rupture in any patient who presents with:
•acute knee pain
•an inability to extend the leg
•a palpable soft-tissue depression proximal to the
superior pole of the patella
MRI of both thighs may be helpful when the
diagnosis remains unclear

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Simultaneous, spontaneous,
bilateral ruptures may occur
Jones N, Kjellstand CM. Am J Kidney Dis 1996; 28:861-6.

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In the tendon itself
due to degenerative
changes
secondary
hyperparathyroidism →
increased osteoclastic cortical
bone resorption at the tendon
insertion site
At the tendon
insertion site
(Enthesitis )
Muratli HH et al (2005). J Orthop Sci 10(2):227–232
Shiota E et al (2002). Clin Orthop Relat Res 394:236–242
Hemodialysis
Which Part of the Tendon?

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In the tendon itself
due to degenerative
changes
secondary
hyperparathyroidism →
increased osteoclastic cortical
bone resorption at the tendon
insertion site
At the tendon
insertion site
(Enthesitis )
Our patient
Muratli HH et al (2005). J Orthop Sci 10(2):227–232
Shiota E et al (2002). Clin Orthop Relat Res 394:236–242
Hemodialysis
Which Part of the Tendon?

7th
Trobisch PD et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88.
Hemodialysis - Treatment
Early treatment of ruptured tendons
results in better outcomes than delayed
treatment
Early surgical repair

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Trobisch PD et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88.
Hemodialysis - Treatment
Leg Cast
Control of 2ry
Hyperparathyroidism
Physiotherapy

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During exploration:
1.The colour of the tissue stump
is dark brown due to poor blood
2.Signs of chronic inflammatory
infiltration
3.Degenerative weak tendon
fibers
Case History
Treatment

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Non absorbable
mono-filamentous
sutures
Tear at the lower 1/3
of the tendon
Case History
Treatment

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Leg Cast
Case History
Treatment
A short leg cast was
postoperatively
applied with foot in
gravity equinus
(non bearing cast)

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Leg Cast
Case History
Treatment
Sequential change of the cast
shape and foot position with
more dorsiflextion each time till a
90 degree position cast
3 wks 3 wks 2 wks

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Leg Cast
Case History
Treatment
Control of 2ry
Hyperparathyroidism
Physiotherapy
The patient almost
completely regained his
normal ankle function 2
months after surgical repair

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Hemodialysis - Prevention
Control Risk Factor
2ry hyperparathyroidism Control
β-2 microglobulin associated amyloidosis !!
Avoid Fluoroquinolone use
Avoid Corticosteroid use
Malnutrition / Chronic inflammation Control
Chronic Acidosis Control

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Statins prescribed for treatment of
dyslipidemia in renal transplant
recipients may rarely cause
tendonitis/tendon rupture.
Marie I, Delafenetre H, Massy N et al. Arthritis Rheum 2008; 59:367-72.

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Renal transplanted patients especially at
early stages after transplantation when they
receive high dose of steroids are at risk of
tendon rupture
Basic-Jukic N et al. Kidney Blood Press Res. 2009;32(1):32-6.
So correct 2ry hyperparathyroidism before
transplantation first

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Take Home Messages

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Take Home Messages
ESRD is a risk factor for tendon rupture

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Take Home Messages
Most affected tendons: Quadriceps,
Patellar and Achilles tendon

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Take Home Messages
The most important risk factor is 2ry
hyperparathyroidism

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Take Home Messages
Up to 50% of quadriceps
tendon rupture may be misdiagnosed

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Take Home Messages
Don’t misdiagnose
High suspicion → MRI

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Take Home Messages
Early surgical repair of ruptured tendons
results in better outcomes than delayed
treatment

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Take Home Messages
Physiotherapy is mandatory

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Take Home Messages
Control risk factors especially 2ry
hyperparathyroidism

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Take Home Messages
Take care of statin use in renal
transplanted patients
Correct 2ry hyperparathyroidism before
transplantation to decrease risk of
tendon rupture due to steroid use

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KDIGO Update Project

7th
Mohammed Abdel
Gawad
www.NephroTubeCNE.com
Thank You

Tendinopathy in Hemodialysis Patients

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