Tendinopathy in Hemodialysis Patients (The Hidden Face of CKD-MBD) - Dr. Gawad
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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
57. 7th
International Hemodialysis Course, Mansoura UNC, December 22-26, 2014
Take Home Messages
Most affected tendons: Quadriceps,
Patellar and Achilles tendon
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
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