Kidney Disease and the Musculoskeletal System

Renal dialysis — both haemodialysis (HD) and peritoneal dialysis (PD) — is a life-sustaining treatment for patients with end-stage kidney disease, replacing the filtration function of kidneys that have lost sufficient capacity to maintain homeostasis. The kidneys play a critical role in musculoskeletal health far beyond fluid and electrolyte management; they activate vitamin D, regulate calcium and phosphate balance, clear uremic toxins, and produce erythropoietin for red blood cell production. When kidney function fails, all of these processes are disrupted, and the resulting metabolic derangements produce a range of musculoskeletal consequences that are directly relevant to manual therapy practice.

Renal Osteodystrophy

Renal osteodystrophy is the term for the spectrum of bone disorders associated with chronic kidney disease. The principal mechanism involves impaired vitamin D activation (the kidneys convert 25-hydroxyvitamin D to its active form 1,25-dihydroxyvitamin D), leading to reduced intestinal calcium absorption, hypocalcaemia, and compensatory elevation of parathyroid hormone (secondary hyperparathyroidism). Elevated PTH drives osteoclast-mediated bone resorption, depleting bone mineral density and producing high-turnover bone disease (osteitis fibrosa cystica). Elevated serum phosphate (due to impaired renal excretion) independently drives calcification of soft tissues and vasculature.

The clinical consequence for manual therapy is significantly elevated fracture risk — particularly of the femoral neck, vertebrae, and ribs. Dialysis patients should not receive heavy axial loading, high-force joint manipulation, or forceful passive stretching without explicit medical clearance and bone density data. Positioning during treatment requires care to protect fragile skeletal structures.

Arteriovenous Fistulas and Access Sites

The most important practical concern for manual therapists treating dialysis patients is the arteriovenous (AV) fistula — a surgically created connection between an artery and vein, typically in the non-dominant forearm, used for haemodialysis access. The fistula produces a palpable thrill and audible bruit reflecting the high-flow arteriovenous communication; its integrity is critical to the patient's ability to receive dialysis treatment. Direct massage, compression, blood pressure cuffing, venepuncture, or intravenous access must never be performed on the fistula arm. This is an absolute clinical rule, not a guideline. Any pressure, compression, or manipulation that could thrombose or damage the fistula represents a serious risk to the patient's ability to receive ongoing dialysis.

Muscle Weakness, Cramps, and Peripheral Neuropathy

Dialysis patients commonly experience uraemic myopathy — proximal muscle weakness driven by accumulation of uremic toxins, metabolic acidosis, impaired mitochondrial function, and the catabolic effects of chronic inflammation. Muscle wasting is worsened by the loss of amino acids across the dialysis membrane and by the anorexia associated with renal failure. Muscle cramps are a frequent complaint, particularly during and immediately after haemodialysis sessions, related to rapid fluid and electrolyte shifts.

Peripheral neuropathy — a "glove and stocking" pattern of sensory loss and dysaesthesia — is present in a significant proportion of patients with long-standing kidney disease, reflecting the neurotoxic effects of accumulated uremic metabolites. This alters sensory feedback from the periphery and must be considered when applying techniques relying on patient pain response to guide intensity. Beta-2-microglobulin amyloidosis — a complication of long-term dialysis — produces amyloid deposits in periarticular and carpal tunnel structures, causing carpal tunnel syndrome, destructive arthropathy, and tendon rupture.

Essential rule: Never massage, compress, take blood pressure from, or apply any technique to the arm bearing a dialysis fistula or graft. Check which arm before every treatment session, as fistula creation may have occurred since the previous visit.

Exercise and Rehabilitation in Dialysis Patients

Despite the multiple comorbidities, dialysis patients derive significant benefit from appropriately structured exercise. Intradialytic exercise — light to moderate resistance exercise or cycling performed during dialysis sessions — is safe, well-tolerated, and associated with improved dialysis adequacy (Kt/V), reduced muscle wasting, and better functional capacity. Exercise prescription must account for anaemia, cardiovascular disease (highly prevalent in this population), bone fragility, and access site protection. Collaboration with the patient's nephrologist and renal nurse is essential before implementing exercise or rehabilitation programmes.

References & Further Reading

  1. Moe S, et al. Definition, evaluation, and classification of renal osteodystrophy. Kidney Int. 2006;69(11):1945–1953.
  2. Johansen KL. Exercise in the end-stage renal disease population. J Am Soc Nephrol. 2007;18(6):1845–1854.
  3. Strid H, et al. Complications and morbidity of peritoneal dialysis: a clinical review. Semin Dial. 2014;27(3):228–237.
  4. Kalantar-Zadeh K, et al. Malnutrition-inflammation complex syndrome in dialysis patients. Semin Dial. 2003;16(3):213–227.