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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 985-988
Cramps during Hemodialysis: Are They Always Innocent?


1 Hemodialysis Unit Kyanos Stavros, Patras, Greece
2 Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
3 Department of Internal Medicine, University Hospital of Patras, Patras, Greece
4 Division of Nephrology, Ageing Biology Unit, Italian Hospital of Buenos Aires, Buenos Aires, Argentina

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Date of Submission13-Aug-2018
Date of Acceptance19-Sep-2018
Date of Web Publication27-Aug-2019
 

   Abstract 


Cramps are very common in hemodialysis (HD) patients. A high ultrafiltration rate and volume contraction have been implicated in the pathogenesis, but the underlying mechanism is not yet fully elucidated. We present a male HD patient with cramps during his session, attributed to acute limb ischemia due to thrombosis of a common femoral artery aneurysm (CFAA). The true CFAAs are extremely rare, but the pseudoaneurysms (or false aneurysms) are less uncommon resulting after femoral catheterization for diagnostic and therapeutic procedures. This aneurysm was eccentric in shape which in conjunction with the patient’s history of femoral catheterization strongly suggests us to consider it a pseudoaneurysm. Although the patient was operated with the clinical suspicion of arterial embolism due to atrial fibrillation and the subtherapeutic anticoagulation, no embolus was found in the aneurysm. We want to emphasize that the presence of cramps is not always innocent, simply attributed to HD. Rarely, it may result from or mask severe and devastating acute leg ischemia caused by thrombosis of a CFAA. Notably, the thrombosis of a CFAA (true or false) is an extremely rare condition. We suggest all the HD patients with a history of femoral cannulation to undergo a vascular ultrasound in the related femoral artery at least once, to manage and to prevent the complications.

How to cite this article:
Dousdampanis P, Trigka K, Ntouvas I, Assimakopoulos SF, Musso CG, Papadoulas S. Cramps during Hemodialysis: Are They Always Innocent?. Saudi J Kidney Dis Transpl 2019;30:985-8

How to cite this URL:
Dousdampanis P, Trigka K, Ntouvas I, Assimakopoulos SF, Musso CG, Papadoulas S. Cramps during Hemodialysis: Are They Always Innocent?. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Sep 21];30:985-8. Available from: http://www.sjkdt.org/text.asp?2019/30/4/985/265480



   Introduction Top


Painful muscle cramps are a common complication during hemodialysis (HD). They usually occur in the second half of HD, affect the lower extremities, and are preceded by hypo-tension.[1] Rapid ultrafiltration (UF), volume contraction, and tissue ischemia have been implicated in the pathogenesis of cramps; but, in some cases, they can occur without any clear underlying mechanism.[1]

Common femoral artery aneurysms (CFAAs) are extremely rare,[2],[3] but they can be found in HD patients.[4] They are separated into true aneurysms if they involve all the three wall layers (intima, media, and adventitia) and pseudoaneurysms which comprise an outpou-ching of one or two layers of the vessel wall and result after arterial wall trauma, most commonly due to iatrogenic puncture (post-traumatic).[5],[6] True aneurysms tend to be fusiform, while pseudoaneurysms are saccular or eccentric in shape.[7] Femoral pseudoaneurysms in HD patients can be caused by both frequent attempts to place femoral HD catheters or by femoral cannulation for percutaneous coronary or peripheral vascular interventions.[4],[5],[6]

CFAAs are subject to thrombosis, rupture, and embolization of thrombus from within the aneurysm sac to more distal arteries.[3] Acute limb ischemia can occur after thrombosis or distal embolization which may jeopardize leg viability mandating urgent revascularization.[3] Otherwise, delay of severe ischemia treatment will inevitably lead to limb amputation.[3]

We present a case of a patient complaining of leg cramps during HD caused by acute ischemia due to thrombosis of a CFAA. Our intension is to promote awareness in HD patients with a previous history of femoral artery cannulation or HD femoral catheter to prevent the complications of CFAA.


   Case Report Top


A 70-year-old man has been under a three-time weekly HD schedule in our unit over the past six years. His medical history was significant for end-stage renal disease due to vascu-litis, atrial fibrillation (under acenocoumarol, 1 mg per os, q.d), and ischemic heart disease. He was a heavy smoker and underwent percutaneous coronary intervention through femoral cannulation 12 years ago.

The patient attended his normal HD schedule (HD prescription: 4 h session with an UF rate of 700 mL/min and sodium profiling 143–138 mEq/L). His predialysis blood pressure was 130/70 mm Hg. The patient complained of left leg muscle cramps halfway through his HD session. At that time, his blood pressure dropped to 100/60 mm Hg. Immediately, the UF was ceased, and 250 mL of saline solution (N/S 0.9%) was administrated intravenously. In addition, we modified the sodium dialysate from 140 to 142 mEq/L. A nurse massaged the patient’s limb to relieve the symptoms. Despite these maneuvers, the patient’s symptoms worsened resulting in constant and severe leg pain, although his blood pressure increased to 120/70 mm Hg. On physical examination, the leg was cold, pale, and paralyzed with loss of sensation. Femoral pulses were present, but no pulses were palpated in popliteal and posterior tibial and dorsalis pedis arteries.

Immediately, the HD session was interrupted, and the patient was transferred urgently to the university hospital with the clinical diagnosis of acute limb ischemia. In the emergency room, the vascular surgeon strongly suspected arterial embolism based on the presence of atrial fibrillation with subtherapeutic anticoa-gulation, the palpation of normal pulses in the contra lateral limb, and the absence of previous intermittent claudication in the affected limb. The patient was transferred urgently to the operating theater without undergoing duplex ultrasound or other imaging modalities, because of the severity of ischemia and to avoid any delay, which would jeopardize leg viability. It is well known that on these occasions, revascularization must be completed within 6 h, especially when the patient presents leg paralysis. On operation, an eccentric CFAA nearly 2.5 cm in diameter was revealed. The aneurysm was no pulsatile due to thrombosis and stiff in the bifurcation area due to an underlined atherosclerotic plaque. The superficial femoral artery was also stiff due to atherosclerosis. Conversely, the profound femoral artery was elastic. No embolus was found in the aneurysm. A calcified atherosclerotic plaque was lining the lumen while the aneurysm was full of the chronic wall thrombus and a newly created fresh thrombus [Figure 1]. The aneurysm sac was resected apart from the posterior segment; the atheromatous plaque was partially removed and a polytetrafluoroethylene (PTFE) 6-mm ringed tube graft was interposed to restore the arterial continuity [Figure 2]. After the operation, the pulses reappeared and leg function was restored. In addition, no other aneurysms were detected in other locations. The patient was discharged on postoperative day 2 without any further complications. He continued statins and was prescribed tinzaparin sodium as bridging therapy until adequate anticoa- gulation be achieved with acenocoumarol.
Figure 1: An eccentric common femoral artery aneurysms nearly 2.5 cm in diameter was revealed. The aneurysm was no pulsatile due to thrombosis (white arrow) and stiff in the bifurcation due to an underlined atherosclerotic plaque. The superficial femoral artery (black arrow) was also stiff due to atherosclerosis. Conversely, the profunda femoral artery was elastic (yellow arrow).

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Figure 2: The aneurysm sac was resected apart from the posterior segment, the atheromatous plaque was partially removed, and a poly- tetrafluoroethylene 6-mm ringed tube graft was interposed to restore the arterial continuity.

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   Discussion Top


Muscle cramps are the second common complication (5%–20%) after hypotension during HD. It is well known that they occur after the second half of HD and they primary affect the low extremities.[1] The exact etiology and mechanism of muscle cramps remain obscure.

Muscular cramps more often occur in the setting of hypovolemia due to volume contraction, and they are the result of the imbalance between UF and vascular refilling rate.[1] Usually, they occur when the UF rate is high and/or the used sodium dialysate is low.[8] In support of this theory is the fact that administration of hypertonic solution with concomitant restoration of volume often brings relief to HD patients. Volume contraction may activate several vasoconstrictor mechanisms, which in turn mediate the reduced muscle blood flow[1]. In this regard, it could be speculated that the basis of the underlying mechanism is tissue hypoxia. It should be noted that cramps may persist even when the blood pressure has been restored. Electrolyte disturbances including hypomagnesemia, hypo- calcemia, and hypokalemia are predisposing factors for muscular cramps during HD.[8]

Isolated CFAA is uncommon and can be associated with aortic and popliteal aneu-rysms.[3] Atherosclerosis, advanced age, and smoking are common risk factors for CFAA. Isolated CFAA can be seen in HD patients both due to atherosclerosis and to femoral catheterization (percutaneous cardiac intervention via femoral artery and/or HD catheter placement).

CFAA is usual clinical silent, but pain of the inferior limb can occur. Notably, occlusive arterial disease leading to acute ischemia of the inferior limb can occur as the result of thrombosis and/or distal embolization. If the occlusive arterial disease remains untreated, it leads to local tissue necrosis with amputation of the limb and death. Notably, thrombosis of a CFAA is extremely rare.[2]

Our patient in the middle of his HD session complained about muscular cramp of the left foot while his blood pressure dropped to 100/60 mm Hg. Despite our efforts to relieve the cramps, he continued to complain for an increasing pain in his lower left extremity. He was admitted to the hospital with the diagnosis of acute ischemia of the inferior limb. The vascular surgeon found an isolated thrombotic common aneurysm of the left common femoral artery resulting in acute limb ischemia and proceeded to aneurysmectomy with interposition grafting (PTFE) successfully.

It could be assumed that despite the heparin used in HD (10,000 UI) and acenacoumarol 1 mg for atrial fibrillation, it was the dehydration resulting in increased plasma viscosity that triggered or aggravated the formation of thrombus with concomitant acute ischemia of the limb.

In conclusion, the teaching points in our case are the following: (1) cramps are not always attributed to HD and although rarely, they may hide an underlying disease which needs to be clarified, (2) CFAA is uncommon in general population, but it could be found in HD patients due to atherosclerosis and to femoral artery or venous cannulation.

It is worth noting that in clinical practice, when there is no other well-functioning vascular access to perform HD, the nephrologists are required to place HD femoral catheters. In this case, the possibility of the formation of a CFAA (and its complication) should be taken in consideration.

Finally, we suggest all the HD patients with a history of femoral cannulation or femoral HD catheter to undergo a vascular ultrasound in the related femoral artery at least once, to manage and to prevent the complications.

Conflict of interest: None declared.



 
   References Top

1.
Mujais SK. Muscle cramps during hemodialysis. Int J Artif Organs 1994;17:570-2.  Back to cited text no. 1
    
2.
Piffaretti G, Mariscalco G, Tozzi M, Rivolta N, Annoni M, Castelli P. Twenty-year experience of femoral artery aneurysms. J Vasc Surg 2011;53:1230-6.  Back to cited text no. 2
    
3.
Pappas G, Janes JM, Bernatz PE, Schirger A. Femoral aneurysms. Review of surgical management. JAMA 1964;190:489-93.  Back to cited text no. 3
    
4.
Sirvent AE, Enríquez R, Martínez D, Reyes A. Delayed presentation of a femoral pseudo-aneurysm after venous hemodialysis catheter insertion. Nefrologia 2008;28:654-5.  Back to cited text no. 4
    
5.
Haas K, Quinlan B. Preventing pseudoaneu-rysms following femoral cannulization. Dimens Crit Care Nurs 1999;18:24-8.  Back to cited text no. 5
    
6.
Borioni R, Garofalo M, De Paulis R, Albano P, Chiariello L. Iatrogenic pseudoaneurysms of the peripheral arteries. Chir Ital 2008;60:103- 11.  Back to cited text no. 6
    
7.
Corriere MA, Guzman RJ. True and false aneurysms of the femoral artery. Semin Vasc Surg 2005;18:216-23.  Back to cited text no. 7
    
8.
Daugirdas JT, Blake PG, Ing Todd S. Handbook of Dialysis. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.  Back to cited text no. 8
    

Top
Correspondence Address:
Periklis Dousdampanis
Hemodialysis Unit, Kyanos Stavros, Patras
Greece
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DOI: 10.4103/1319-2442.265480

PMID: 31464261

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