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A Case of Unpleasant Sensation in The Legs in A CKD Patient: Moderators: Dr. Srikanth Gundlapalli Dr. Sujeeth B. Reddy

The patient, a 29-year-old man with chronic kidney disease and diabetes, experiences an uncomfortable sensation in his legs, particularly in the evenings and during dialysis, that is relieved by movement. This is consistent with restless leg syndrome, a neurological sleep disorder characterized by unpleasant leg sensations that increase with rest and are relieved by movement. Treatment for secondary restless leg syndrome, as caused by the patient's kidney disease and other conditions, may include improving iron levels, treating underlying diseases, dopamine agonists, anticonvulsants, benzodiazepines, opioids, or using a vibrating pad.

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Varun Varn
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64 views23 pages

A Case of Unpleasant Sensation in The Legs in A CKD Patient: Moderators: Dr. Srikanth Gundlapalli Dr. Sujeeth B. Reddy

The patient, a 29-year-old man with chronic kidney disease and diabetes, experiences an uncomfortable sensation in his legs, particularly in the evenings and during dialysis, that is relieved by movement. This is consistent with restless leg syndrome, a neurological sleep disorder characterized by unpleasant leg sensations that increase with rest and are relieved by movement. Treatment for secondary restless leg syndrome, as caused by the patient's kidney disease and other conditions, may include improving iron levels, treating underlying diseases, dopamine agonists, anticonvulsants, benzodiazepines, opioids, or using a vibrating pad.

Uploaded by

Varun Varn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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A case of unpleasant sensation

in the legs in a CKD patient

Moderators: Dr. Srikanth Gundlapalli


Dr. Sujeeth B. Reddy

Presented by: Varun Vankeshwaram


Patient: Y

Age: 29 yrs old

K/c/o: DM type1, HTN, CKD-V, Diabetic Retinopathy

Meds: Insulin, Betacardia20/5, Minipress XL,Revelamir 400,EIDO,Nephro Hp, Inj. Cresp 40mcg, Inj.
Ferrinject

Dialysis(2019): Perm cath to Right arm AV fistula

C/o: Lower extremity discomfort and sleep onset insomnia. The patient reports no pain but
describes uncomfortable sensation in his legs, particularly in the evening or at night and during
dialysis. His symptoms are relieved by leg movement or walking.

.
Restless Leg Syndrome:

Definition: It is a relatively common, neurological sleep disorder characterized by


unpleasant sensations in the legs and a strong urge to move them. The urge increases
during periods of rest, especially in the evenings, and may diminish with movement.

Epidemiology: Sex: ♀ > ♂,

Peak incidence 30–40 years of age


Etiology:
Primary: (common): idiopathic , but is familial in up to 77% of cases

Secondary: Chronic conditions: Iron deficiency


Peripheral neuropathy (i.e., in diabetes mellitus )
End-stage renal disease (uremia)
Inflammatory conditions: celiac disease,rheumatoid arthritis,IBD
Psychiatric illness: depression, anxiety disorders
Neurological : Parkinson disease , polyneuropathies, spinal cord diseases, MS
Drugs: Antihistamines,Antidepressants, Dopamines antagonists, Lithium, BBs
Pregnancy
Clinical features:
A recurrent, uncomfortable urge to move the legs:
Typically, relieved by movement. Begins and/or worsened with rest. Symptoms are worse in the evening and at
night (may occur exclusively at night) Can be accompanied by dysesthesias(e.g., pain, pins and needles, itching, tickling,
or crawling sensations).
Pathophysiology: The pathophysiology of RLS remains unclear. Studies suggest that
abnormal dopamine pathways in the brain and impaired iron homeostasis (leading to iron
deficiency in the substantia nigra) are the most prominent pathophysiological mechanisms
involved.

Dopamine dysfunction plays a critical role in the pathophysiology of RLS.


Clinically, RLS appears to involve a decreased dopaminergic signal; dopamine
receptor agonists improve symptoms, and dopamine receptor antagonists worsen
symptoms. Additionally, iron is a cofactor for tyrosine hydroxylase, the rate-limiting
enzyme in dopamine synthesis.
Diagnostics:
RLS is mainly a clinical diagnosis but additional testing may be indicated to rule out an underlying disease,
including conducting laboratory tests, nerve conduction studies, polysomnogram, and needle electromyogram.

● Clinical diagnosis (according to DSM V)


○ Clinical features mentioned above
○ Symptoms occur at least 3 times per week and persist for at least 3 months
○ Symptoms cause significant distress or impairment in social, occupational, educational,
academic, behavioral, or other areas of functioning
○ Symptoms cannot be attributed to another medical condition (e.g., leg edema, arthritis, leg
cramps) or behavioral condition (e.g. positional discomfort, habitual foot tapping)
○ Symptoms cannot be explained by drug/medication abuse

● Laboratory tests
○ Iron studies (best initial)
○ Other: CBC, kidney function tests, TSH, vitamin B12, folic acid, Mg2+
RLS IN DIALYSIS PATIENTS:

Studies focusing on treatment:

1)A study conducted by Santos et al. to evaluate the effect of parathyroidectomy on dialysis patients . The study was
conducted on 10 dialysis patients with hyperthyroidism, hyperphosphatemia, and diagnosed with RLS. After
parathyroidectomy, the patients showed significant improvement in RLS severity.

2)Rad et al. reported that using cool dialysate for hemodialysis can help alleviate RLS symptoms by enhancing
toxins removal from the blood and decreasing creatinine and urea levels .

3)A study conducted by Shahgholian et al. compared the effect of reflexology, stretching exercise, and placebo on RLS
severity index in dialysis patients showed significant improvement in RLS severity with reflexology and
stretching exercise compared to placebo.

4)Song et al. conducted a metanalysis on the effect of exercise on RLS, fatigue, depression and sleeping quality in
hemodialysis patients, and he reported that exercise can be effective in improving symptoms of RLS (P < 0.001),
fatigue (P < 0.001) and depression (P < 0.001).
5)Mohammadi et al. performed a single-blind, randomized controlled trial, and he found that near-infrared
light can decrease symptoms of RLS in hemodialysis patients.

6)Kahvecioglu et al. declared that there is an improvement of RLS in hemodialysis patients after renal
transplantation and normalization of the kidney functions.

7)In a clinical trial conducted by Nasiri et al. to assess the effect of massage with olive oil after dialysis
sessions on RLS patients, the study stated that olive oil can be used as a complementary treatment for
RLS since it improves the symptoms significantly.

8)Another study by Hashemi et al. reported improvement with the use of lavender oil for massage.

9)Hosseini et al. studied the effect of vibration on RLS severity and reported that vibration improved RLS
symptoms in hemodialysis patients .
Treatment: Treatment for primary RLS is largely symptomatic. Treatment of secondary RLS depends on
the underlying cause. Intermittent treatment may be necessary for recurrent cases with spontaneous remission.
● General
○ Lifestyle changes: abstinence from coffee, nicotine, and alcohol
○ Discontinue offending agent (e.g., dopamine antagonists).
○ Supplemental iron if serum ferritin < 50 ng/mL.
○ Treatment of underlying conditions
● Medical therapy: indicated in patients with significant functional and sleep impairment
○ Dopamine agonists (first-line drugs): pramipexole, ropinirole, rotigotine, cabergoline
○ For intermittent symptoms: levodopa with carbidopa
○ Anticonvulsants: gabapentin or pregabalin
○ If not responsive to any other therapy: benzodiazepines (e.g., clonazepam) or opioids(e.g.,
codeine)
● Vibrating pad: provides counter stimulation to the patient's legs while lying in bed (improves sleep quality)
Thank you

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