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Tendinopathy in Hemodialysis Patients (The Hidden Face of CKD-MBD) - Dr. Gawad

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Tendinopathy in Hemodialysis Patients (The Hidden Face of CKD-MBD) - Dr. Gawad

  1. 1. 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
  2. 2. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  To download the presentation please contact me on drgawad@gmail.com  For ore lectures and presentations visit: www.NephroTubeCNE.com
  3. 3. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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)
  4. 4. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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.
  5. 5. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Case History Physical examination  Inspection: There was swelling around left posterior ankle joint. Archived, identical image (not the patient own image)
  6. 6. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Case History Physical examination  Palpation:  Tenderness above the insertions of the Achilles tendon.  There was a gap in the Achilles tendon site. Archived, identical image (not the patient own image)
  7. 7. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Case History Physical examination  Palpation:  The Thompson calf squeeze test was positive for a subcutaneous Achilles tendon rupture. Normal Abnormal (tendon rupture)
  8. 8. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Case History Ultrasonography Archived, identical image (not the patient own image)  A complete disruption of the fibrillar structure of the tendon  The gap between the ruptured tendon ends was filled by a hematoma
  9. 9. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Diagnosis of Rupture Tendo- Achilles was confirmed Case History Diagnosis
  10. 10. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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
  11. 11. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Tendinopathy in Hemodialysis First Case Report Steiner CA and Palmer LH. Am J Surg 1949; 78: 752–755.
  12. 12. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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
  13. 13. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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
  14. 14. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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
  15. 15. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  16. 16. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture Hemodialysis - Talk Outline  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention
  17. 17. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture Hemodialysis - Which Tendon? Quadriceps tendon Achilles tendon Patellar tendon The most frequently affected tendons
  18. 18. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Ho LC et al. Clin Nephrol. 2009 Apr;71(4):451-3. Spontaneous Tendon Rupture Hemodialysis - Which Tendon?
  19. 19. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  20. 20. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  21. 21. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Spontaneous Tendon Rupture 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
  22. 22. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Spontaneous Tendon Rupture 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
  23. 23. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Tendinopathy in Hemodialysis The Hidden Face of CKD-MBD MBD + MVD
  24. 24. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Tendinopathy in Hemodialysis The Hidden Face of CKD-MBD MBD + MVD + MSD
  25. 25. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Case History Risk Factors
  26. 26. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism β-2 microglobulin associated amyloidosis Fluoroquinolone use Corticosteroid use Malnutrition / Chronic inflammation Chronic Acidosis Case History Risk Factors
  27. 27. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism Yes: β-2 microglobulin associated amyloidosis Fluoroquinolone use Corticosteroid use Malnutrition / Chronic 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
  28. 28. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism Yes: β-2 microglobulin associated amyloidosis Yes: Serum β-2 microglobulin: 460 mg/L Fluoroquinolone use Corticosteroid use Malnutrition / Chronic inflammation Chronic Acidosis Case History Risk Factors
  29. 29. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism Yes: β-2 microglobulin associated amyloidosis Yes: Serum β-2 microglobulin: 460 mg/L Fluoroquinolone use No Corticosteroid use No Malnutrition / Chronic inflammation Chronic Acidosis Case History Risk Factors
  30. 30. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism Yes: β-2 microglobulin associated amyloidosis Yes: Serum β-2 microglobulin: 460 mg/L Fluoroquinolone use No Corticosteroid use No Malnutrition / Chronic inflammation Not sever Chronic Acidosis Lab Variable Result Hb 11g/dl Serum Albumin 3.7 g/dl Case History Risk Factors
  31. 31. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Known Risk Factor Is it present in our patient? Long-term hemodialysis Yes: 12 years old HD 2ry hyperparathyroidism Yes: β-2 microglobulin associated amyloidosis Yes: Serum β-2 microglobulin: 460 mg/L Fluoroquinolone use No Corticosteroid use No Malnutrition / Chronic inflammation Not sever Chronic Acidosis Yes Case History Risk Factors
  32. 32. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  33. 33. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  34. 34. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture 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.
  35. 35. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture Hemodialysis - Diagnosis 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
  36. 36. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture Hemodialysis - Diagnosis Simultaneous, spontaneous, bilateral ruptures may occur Jones N, Kjellstand CM. Am J Kidney Dis 1996; 28:861-6.
  37. 37. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  38. 38. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  39. 39. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Spontaneous Tendon Rupture Hemodialysis Which Part of the Tendon?
  40. 40. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Spontaneous Tendon Rupture Hemodialysis Which Part of the Tendon?
  41. 41. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  42. 42. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  43. 43. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Trobisch PD et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88. Spontaneous Tendon Rupture Hemodialysis - Treatment Early treatment of ruptured tendons results in better outcomes than delayed treatment Early surgical repair
  44. 44. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Trobisch PD et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88. Spontaneous Tendon Rupture Hemodialysis - Treatment Early surgical repair Leg Cast Control of 2ry Hyperparathyroidism Physiotherapy
  45. 45. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Archived, identical image (not the patient own image) 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
  46. 46. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Archived, identical image (not the patient own image) Non absorbable mono-filamentous sutures Tear at the lower 1/3 of the tendon Case History Treatment
  47. 47. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Early surgical repair Leg Cast Case History Treatment A short leg cast was postoperatively applied with foot in gravity equinus (non bearing cast)
  48. 48. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Early surgical repair 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
  49. 49. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Early surgical repair Leg Cast Case History Treatment Control of 2ry Hyperparathyroidism Physiotherapy The patient almost completely regained his normal ankle function 2 months after surgical repair
  50. 50. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  51. 51. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014  Which Tendon?  Risk Factors  Diagnosis  Which part of the tendon?  Treatment  Prevention Spontaneous Tendon Rupture Hemodialysis - Talk Outline
  52. 52. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Spontaneous Tendon Rupture 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
  53. 53. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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. Spontaneous Tendon Rupture Hemodialysis - Prevention
  54. 54. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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 Spontaneous Tendon Rupture Hemodialysis - Prevention
  55. 55. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages
  56. 56. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages ESRD is a risk factor for tendon rupture
  57. 57. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Most affected tendons: Quadriceps, Patellar and Achilles tendon
  58. 58. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages The most important risk factor is 2ry hyperparathyroidism
  59. 59. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Up to 50% of quadriceps tendon rupture may be misdiagnosed
  60. 60. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Don’t misdiagnose High suspicion → MRI
  61. 61. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Early surgical repair of ruptured tendons results in better outcomes than delayed treatment
  62. 62. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Physiotherapy is mandatory
  63. 63. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Take Home Messages Control risk factors especially 2ry hyperparathyroidism
  64. 64. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 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
  65. 65. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 KDIGO Update Project
  66. 66. 7th International Hemodialysis Course, Mansoura UNC, December 22-26, 2014 Mohammed Abdel Gawad www.NephroTubeCNE.com Thank You
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