Does this patient have muscle cramping?
What tests to perform?
Laboratory tests that may identify cause and assess severity:
Serum magnesium (exclude hypomagnesemia)
Serum calcium (exclude hypocalcemia)
Serum creatinine kinase (may be elevated in severe form) (optional)
Electromyography – increased tonic muscle electrical activity (optional)
Bioelectrical impedance analysis (BIA) for better estimation of dry weight
How should patients with muscle cramping be managed?
Reduce or stop (if severe) ultrafiltration rate
Infuse hypertonic solution, e.g., 23.5% hypertonic saline (15-20 mL), or 50% dextrose in water (25-50 mL)
Hypertonic saline may result in post-dialysis thirst, interdialytic weight gain and fluid overload.
Adjusted estimated dry weight (increase by 0.5 kg if no edema or adjust according to BIA)
Dietary counseling on minimal interdialytic weight gain
Biofeedback program (blood volume monitoring, BVM) (optional)
Blood temperature monitoring (BTM) (optional)
Dialysate sodium profile (optional
Ultrafiltration profile (optional)
Combined dialysate sodium and ultrafiltration profile (optional)
Isolated ultrafiltration or sequential ultrafiltration followed by dialysis (optional)
More frequent (short daily or nocturnal) hemodialysis (optional)
Quinine sulfate (250-300 mg) given 2 hours before dialysis (optional), not approved for use in United States
Oxazepam (5-10 mg) given 2 hours before dialysis (optional)
L-carnitine (20 mg/kg) given intravenously after dialysis (optional, some studies shown benefit and marginal significance in meta-analysis)
Gabapentin 300 mg given before each dialysis session (optional
Vitamin E (400 mg) and vitamin C (250 mg) daily (optional)
What happens to patients with muscle cramping?
Poor quality-of-life measures
Recurrent episodes may induce inadequate dialysis from poor compliance
Chronic fluid retention from poor compliance
How to utilize team care?
Nurses – Monitor closely high-risk patient.
Pharmacists – Review and check compliance with prescribed medications and monitor for side effects.
Dietitians- Counsel patient to adhere to low sodium diet (< 2 g/day) diet and fluid restriction
Specialists – Neurology consultation may be required to perform electromyography and nerve conduction studies to rule out other causes of muscle cramping (e.g., neuropathy)
Are there clinical practice guidelines to inform decision making?
Applications – no
ICD-10 CM diagnosis code M62.83: Muscle spasm
What is the evidence?
Lynch, KE, Feldman, HI, Berlin, JA, Flory, J, Rowan, CG, Brunelli, SM. “Effects of L-carnitine on dialysis-related hypotension and muscle cramps: a meta-analysis”. Am J Kidney Dis. vol. 52. 2008. pp. 962-971.
El-Hennawy, AS, Zaib, S. “A selected controlled trial of supplementary vitamin E for treatment of muscle cramps in hemodialysis patients”. Am J Ther. vol. 17. 2010. pp. 455-9.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- Does this patient have muscle cramping?
- What tests to perform?
- How should patients with muscle cramping be managed?
- What happens to patients with muscle cramping?
- How to utilize team care?
- Are there clinical practice guidelines to inform decision making?
- Other considerations