Muscle wasting & pain is a common complication reported in most patients with Chronic Kidney Disease, worldwide. Speaking from personal experience, this is also one of those “visibly apparent” physical changes in the course of CKD, which can have a negative impact on our already complicated quality of life.

So, can you prevent this from happening? Well, that’s the million-dollar (research) question, isn’t it?

In our previous article in this category, we covered the whole bunch of causes that conspire together in CKD to make your muscles gradually “lose themselves” over time. Fortunately, medical research has offered us effective solutions to keep muscle wasting in CKD at bay for as long as possible. In addition, some approaches can also partially restore muscle bulk and strength after muscle wasting has already started.

Let’s explore these treatments then, shall we?

Muscle wasting & pain in CKD are a mixed consequence of the kidney disease process itself, the dialysis technique, a side-effect of taking certain BP-lowering medicines in the long-term and sometimes, the root condition that caused kidney disease. Hence, quite understandably, strategies to deal with CKD-induced muscle loss tend to target these specific mechanisms.

While most of these strategies are applicable to all kidney patients with muscle wasting irrespective of whether they are on Dialysis or not, some are specific for members on Dialysis as discussed below:

STRATEGIES COMMON FOR ALL ADVANCED CKD PATIENTS WHETHER ON DIALYSIS OR NOT

 EXERCISE  

And it’s that E-word again!

Every time we exercise, we infuse our body, and skeletal muscles in particular with loads of fresh nutrient-rich, oxygen-laden blood. This fresh oxygen supply fuels increased muscle metabolism, boosts the repair process of injured muscles and triggers the formation of new muscle fibers.

These beneficial effects of exercise on muscle mass & strength extend to both healthy individuals and those with Chronic Kidney Disease. However, if there is a difference, it’s in the pace at which these benefits set-in. Unwell kidneys in CKD are incapable of flushing-out toxic wastes from the blood adequately. Blood levels of such wastes overshoot beyond permissible limits. So, exercising during CKD circulates the same waste-burdened blood although with enough oxygen, throughout the body.  Wastes “drag down the enthusiasm oxygen brings with it”.  As a result, muscle strength and bulk do revive, but understandably, at a slower pace than healthy individuals.

Both resistance exercises (weight-training) and Endurance exercises (aerobics/cardio) have been found to be beneficial in terms of preventing muscle wasting and retaining healthy muscle mass for as long as possible during your CKD journey.

• ENDURANCE TRAINING (AEROBICS)

Aerobics and cardio-exercises or more technically, Endurance Training work well as a preventive tactic for the onset of muscle wasting. It is best adopted by members who have been diagnosed with kidney disease early on. This implies the subset of patients with GFR number not below 40 ml/min. Endurance training basically improves blood circulation throughout the body, ensures muscles receive a good blood supply and keeps your heart healthy. This, in turn, reduces the need for starting multiple Blood Pressure-lowering meds at a time or even paves way for reducing the dose of these meds during your CKD journey. However, always consult with your medical team and get assessed for your heart health status before joining an Endurance Exercise training programme.

• RESISTANCE TRAINING

Resistance training is a good option to restore muscle mass for members with advanced CKD who have limited exercise capacity. A Resistance Exercise regimen in this subset of patients has proven to effectively reduce muscle wasting and boost new muscle-fibre-growth. In addition, blood levels of muscular pain-causing substances have also been reported to decrease after 12 weeks of resistance exercise. But as always, there’s a catch. Studies have reported that positive effects yielded from these exercise programs weren’t permanent. Muscle wasting resumed  2 months after training ceased. (ref) And this is hardly surprising, considering the circulation of blood with a progressively increasing waste-load during CKD.

Now that we have a clear understanding of how exercise works to preserve & restore muscle health in CKD, let’s take a look at the what makes for globally accepted norms to keep your muscles stronger for longer.

To delay the onset of muscle wasting in early-stage pre-dialysis CKD patients, it is advisable to do moderate-intensity exercises for 30 minutes per day 5 days per week. This should be easy to adopt for members who already follow an exercise regimen. However, for patients with advanced CKD (GFR value below 30 ml/min), if you’ve not been on an active lifestyle before CKD hit, and extreme weakness / fatigue has been getting the better of you, please still try to continue to walk for 20-25 mins 3-4 times a week.

We completely understand how in such stages our body just refuses to even carry us out of our bed at times. We’ve been there! But being sedentary has been tied to making your heart more vulnerable to the damage that fibrosed kidneys in CKD unleash on our body, as compared to that in patient-groups who continue with daily light activity. Poor heart health is undesirable, both in terms of muscle health and your overall clinical outcome for CKD.

Team ATK strongly recommends that you consider talking to your medical team to decide on exercise intensity and plan that is appropriate to your individual health status.

 CORRECTION OF METABOLIC ACIDOSIS

Our previous article explained in detail how acidic blood in advanced CKD (Metabolic Acidosis) is the chief perpetrator of muscle wasting, weakness & pain.

To assess how acidic or alkaline your blood is at a point, your medical team tests “bicarbonate” (HCO3-) levels in your blood work. Ideally, the level should range from 24 to 28 mM. In CKD, your bicarbonate level continues to fall, and blood acidity increases with time. In fact, research shows that muscle protein loss doubles-up once your bicarbonate levels fall below 16 mM as compared to when the level stands at 22.6 mM.

So, quite naturally, restoring the right pH of your blood is of prime importance in the medical management of CKD. To achieve this, doctors prescribe all CKD sojourners, Sodium Bicarbonate tablets. The usual prescription is for a strength of 500 mg, one to three times daily. The aim is to increase serum bicarbonate level approximately above 22 mM and curb abnormal muscle protein loss & wasting.

 TREATMENT OF INSULIN RESISTANCE

Insulin resistance in muscles as a result of metabolic acidosis in CKD is another significant contributor to muscle wasting in advanced kidney disease.

Insulin Resistance is also what causes blood glucose levels to rise abnormally in Type2 Diabetics. So, Insulin resistance is more pronounced in members who got chronic kidney disease due to kidney damage from Type 2 Diabetes.

We have looked at how Insulin – the hormone normally associated with blood sugar control helps increase muscle bulk. Plus, the article looked at how high blood acidity in CKD makes muscles “resist” Insulin from strengthening muscles. To recall the detail on this topic, click here.

Therefore, reversing insulin resistance allows muscles to retain their bulk and strength for a longer duration. This is what makes it a crucial approach in treating muscle wasting in CKD.

Medicines belonging to a class called “Thiazolidine-diones” come to the rescue right away. These are the meds which have generic names ending with the suffix “-glitazone”. Examples include “Rosi-glitazone”, “Pio-glitazone” etc.

These meds act as Insulin “sensitizers” for “insulin-resistant” skeletal muscles in CKD. They do so by re-activating the muscle-bulking insulin signals, otherwise masked by advanced CKD.

Research evidence supports a major role of these medicines to curb muscle wasting in patients on Hemodialysis.

As written above, this class of drugs also forms an important part of treatment in patients with Type2 Diabetes irrespective of whether kidney disease has advanced or not.

A noteworthy point is that “thiazolidinediones” are metabolized in the liver. So, these are safe for use in CKD patients without any simultaneous liver disease. However, side effects on the heart and urinary bladder mean doctors need to actively monitor all CKD patients on this group of drugs.

PROPER NUTRITION

Among other things, advanced CKD brings about high blood-load of Urea (waste), metabolic acidosis & insulin resistance. These factors act in tandem to prevent the release of “hunger-enhancing” chemicals from specific areas of your brain, which, otherwise regulate your appetite in normal health. Hence, an overall undernourished state sets-in, which further propels muscle-loss, weakness & pain.

TREATING THE ROOT CAUSE OF POOR APPETITE

Until a donor organ is available, Dialysis can help reduce the excess load of wastes like urea in your blood. Additionally, treating acidic blood and insulin resistance in CKD as explained above, can keep poor appetite at bay for a longer time, thereby significantly slowing down the pace at which muscles undergo physical changes.

APPETITE-RESTORATION — DIRECT APPROACHES

Nutritional Supplements:

It is common practice for medical teams to prescribe nutritional supplements such as Protein powders to patients with advanced CKD. These have been found to help patients (especially those on dialysis) to overcome the muscle-weakness & wasting plus improve body mass index. The chief aim of this approach is to improve the general quality of life.

However, please make it a point to not go overboard with these protein powders beyond what your doctors prescribe.

That’s because once protein from food is done helping with any tissue repair & bodybuilding activities, it forms a toxic waste product called Urea. This is one of the major wastes that our kidneys eliminate via urine. In the event of chronic kidney disease, unwell kidneys are already unable to flush Urea out in adequate quantities. Over-enthusiastic usage of protein powders will only burden your weak kidneys with an excess of Urea to deal with. As a result, your blood urea levels will shoot up abnormally. And this will in-turn hasten the process of kidney failure. Hence, it is imperative that you religiously stick to the specific protein powder intake allowances as set by your medical team.

Appetite enhancers:

Medical scientists have artificially synthesized brain chemicals that can potentially enhance appetite. Some of these such as “Cyproheptadine” (generic name) syrup may be used in children because poor nutrition hurts their overall growth & development much more than in adults.

However, for adult patients, these are usually reserved for dire cases. The refers to patients who skip meals for days at a stretch due to loss of appetite & under-nutrition gets the better of their health.  And this is for good reason! If you think about it, these are like a short term boost to your appetite just to get you going for a single meal or maybe a day at best. Moreover, these are likely to make you psychologically dependent on them even when you really don’t need them.  Add to that, the list of side effects they pack with them in case of overuse. The list includes impotence and blood clot formations which are dangerous for the heart. Would you rather risk all these side effects to gain muscle instantly? Perhaps not.

STRATEGIES RESERVED FOR CKD PATIENTS ON DIALYSIS

For all CKD sojourners on Dialysis, muscle wasting and sudden, acute cramps during and right after a dialysis session are a known development.

But the greatest news is, this “dialysis-induced” muscle loss is actually preventable and easily reversible! Yes, you read that right!

The following approaches are available with regards to combating dialysis-induced muscle loss:

HORMONAL THERAPY FOR MUSCLE WASTING

Hemodialysis helps get rid of excess waste load in the blood of CKD patients. However, we are yet to upgrade to dialysis machines that can prevent uncontrolled loss of various hormones circulating in the blood during this “blood-cleansing” procedure.

This means patients on hemodialysis tend to “freely” lose Testosterone hormone during their dialysis sessions over time. In addition, advanced CKD slows down the natural production of this hormone in the body. This leaves dialysis patients with Low testosterone levels in their bloodwork.

Now, Testosterone is a major natural contributor to muscle bulk & strength in normal health. Its deficiency due to Dialysis directly impacts this aspect which presents as Muscle Weakening & Wasting. Weak muscle fibers are unable to bear our body weight and “complain” about this with muscle pain.

Quite understandably, this segment of muscle loss needs restoration of normal levels of Testosterone hormone in the patient’s blood. To address this, doctors can prescribe a course of “Nandrolone Acetate” (a synthetic Testosterone-like molecule) at a strength of 100 mg for 6 months. Clinical research studies have reported an improvement in lean muscle mass by 2-fold with this regimen. However, this medicine requires that patients undergo regular follow-ups with the medical team. This is to allow for timely intervention should any of its serious side effects on heart, blood flow or cross-reaction with other hormones takes place.

FOR MUSCLE CRAMPS

Episodes of debilitating Muscle Cramps especially along the calf (legs) during or right after a session of hemodialysis are common. This results from a rapid outflow of the mineral — Sodium from blood towards the low-sodium dialysate fluid. Read how exactly this impacts muscles, here

As a solution:

The mineral levels in the dialysate fluid can be adjusted as per individual patient requirement. So current norms favour adjusting Sodium levels in the dialysate to slightly higher than the usual. This is to allow for more controlled removal of excess sodium overload from the blood of CKD patients.

If muscle cramps have become a constant & debilitating complaint, clinics may prescribe Muscle Relaxant tablets/capsules, sprays or ointments. One such common muscle relaxant is Baclofen which works efficiently by relaxing the dialysis-induced muscle spasms. But again, just like any medicine, it is essential to not go overboard with it. This is especially in light of recent evidence that muscle relaxants like Baclofen molecules are absorbed across the skin into your bloodstream; These molecules are small enough to reach the brain and its overuse can cause an altered mental status.

The lead author of this study Dr. Diana Mina put it beautifully. She said, “Providing the best care to our patients is not limited to providing the best dialysis prescription. Pain is common among our patients and the risks and benefits of each treatment we provide must be carefully considered for each patient”.

And we at Team ATK agree with a resounding “Absolutely”!

On that note, here’s concluding this detailed article on the CKD treatments aimed at combating muscle wasting and pain. Hope we could instill the sense of responsible medication with our explanation-article today.

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