Neuropathy In Patients With Kidney Disease

That "pins and needles" sensation in your feet could be neuropathy

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Neuropathy, which literally means "disease of the nerves" is a relatively common problem in patients with advanced kidney disease, or end-stage kidney disease patients who are on dialysis.  You might be familiar with the term diabetic neuropathy, that typical tingling and numbness that happens in hands and feet in a poorly-controlled diabetic patient.  However, diabetes is not the only reason to have neuropathy.

Depending on the nerve affected, symptoms could vary vastly.  For instance, the well-known carpal tunnel syndrome is also a common form of neuropathy in dialysis patients.  Let's try to understand this disorder.

WHY DO KIDNEY DISEASE PATIENTS TEND TO DEVELOP NEUROPATHY

Patients with advanced kidney disease or those on dialysis do have a higher risk for neuropathy. However, the exact cause is not clearly known. Here are a few speculations:

  • We do know that nerves tend to degenerate in kidney failure.  There is some speculation that deficiencies of essential nutrients like thymine or zinc might contribute to this.
  • Other coexistent disease states in dialysis patients, like hyperparathyroidism (excess production of parathyroid hormone) have been blamed.
  • Interestingly, certain kinds of neuropathy states like carpal tunnel syndrome seem to occur more frequently in the arm which has the dialysis access (fistula or graft), in hemodialysis patients.  The reasons for neuropathy in those situations have also not been well understood. However it is speculated that drop in blood supply to the further-off nerves because of the dialysis access acting as a "shunt" which bypasses the blood away from the hand, might be a contributing factor.
  • Additionally, increase in pressure in the dialysis access can lead to infiltration of fluid or blood into the surrounding tissues which might compress a nerve.
  • Patients whose phosphorus level tends to run high can actually see calcium phosphate deposits form which could contribute to neuropathy.
  • Not receiving an adequate dose of dialysis is a frequent cause (which could worsen some of the above mentioned issues). Yes, just like any other medication, there is a dose of dialysis as well, and if you don't get the minimum prescribed, your risk of developing neuropathy could be higher. 

    ​HOW COMMON A PROBLEM IS THIS

    Extremely.  Over half of dialysis patients could have signs of a nerve problem on objective testing but not everyone will necessarily experience symptoms. Patients also don't necessarily need to be on dialysis. Patients with advanced kidney disease not yet on dialysis have also been found to develop neuropathy because of their kidney disease.

    WHAT DO PATIENTS EXPERIENCE

    Once neuropathy advances far enough, most patients will complain of tingling or numbness, or a pricking sensation in the hands or feet.  Sometimes the pain is described as "burning", or even the textbook "pins-and-needles". It is not just about these sensory problems though. As the disease advances, it can lead to muscle weakness and eventual loss of muscle mass in the muscles that are enervated by the affected nerve. This is called "muscle atrophy".  

    HOW DO YOU DIAGNOSE NEUROPATHY IN PATIENTS WITH KIDNEY DISEASE OR THOSE ON DIALYSIS

    The way to confirm the problem is pretty much the same as it would be in anyone else.

    It is often based just on the "clinical judgment" of your nephrologist. However, if the diagnosis is in doubt, something called "nerve conduction studies" might need to be done.

    HOW DO YOU TREAT NEUROPATHY IN KIDNEY DISEASE PATIENTS 

    Since neuropathy could be a sign of inadequate dialysis in kidney failure patients, the first step is for your nephrologist to make sure that you're receiving an adequate dose.  There are tests done when you are on dialysis setting to confirm that.  If the dose is insufficient, consideration can be given to increasing that, perhaps by increasing the time spent on dialysis. Other risk factors that might be identified, like an elevated parathyroid hormone level or high phosphorus level should be addressed.  If these measures fail, medications like gabapentin might be helpful.

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