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  1. #1
    Join Date
    11-20-10
    Posts
    142

    Default Kidney disease and massage

    This is probably a mundane question but to me, an interesting one. I don't know if you, Dr. Agar, would have any thoughts, but maybe someone else will.

    There is a new member over on IHD who is pre-dialysis and has a wife who is in training to be a massage therapist. Our IHD member has been enjoying being his wife's guinea pig, but he has noticed that his creatinine tends to spike after he has had a massage. His wife thought this to be most curious, so she made inquiries of her teacher who said that massage was contraindicated for kidney patients.

    In doing a bit of googling, I have found evidence that this seems to be prevailing wisdom. It makes sense, I suppose, as some forms of massage claim to "rid the body of toxins", which is a big red flag for renal patients.

    However, massage is a tremendously valuable stress-reducer, so I'd hate to think that this would be yet one more pleasure denied to renal patients.

    So, my question to you is do you think that massage is contraindicated in renal patients? Would it be safer in a patient who was dialyzing daily? Should it be avoided altogether by pre-d and/or standard D patients?

    Lastly, if you were to devise a massage therapy that is safe for the renal patient, what would it be?

    Thank you, and my apologies if this question is not as interesting to you as it is to me. LOL!

  2. #2
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    407

    Default Re: Kidney disease and massage

    Massage? It is an interesting Q ...

    As one who has been having a weekly massage – a deep tissue, murderous massage – since the mid 1990’s … a sacrosanct hour in my calendar which even the pleasure of answering questions on HDC would fail to interfere with … I cannot but think that massage is good for us – soul and body, regardless of whatever other concurrent problems we might have: including renal disease and CKD.

    So … my short answer is ‘ go for it’.

    However, her observation is likely correct. Massage - especially deep tissue massage – is known to mobilize creatinine (a muscle enzyme after all), and this ‘mobilized’ (i.e. released) creatinine will enter the circulation for subsequent excretion. Thus, a creatinine measured post-massage will be higher – at least for a while – until that mobilized creatinine has been excreted.

    To me? … so what!

    Creatinine is, as we understand it, not particularly toxic in its own right. True, we used to think it might be, but as uraemic toxins go - and for specific ill-effects - it ranks way down the list in comparison to most others. It has some minor effects on platelet factor 3 and a few other (again) minor and non-significant effects on body metabolism but I never get too hung up about creatinine - as a toxin. More importantly, it is a helpful, easy to measure, relatively reliable ‘marker’ to use to measure renal function … but, my view would be that if massage mobilizes and releases a little creatinine into the circulation … so be it. I don't believe that is likely to be in any way harmful or deleterious.

    The only thing I would take into account - especially at lower levels of eGFR - is that a higher creatinine might translate into a lower eGFR calculation that is representative of true baseline renal function and might prompt a decision for earlier dialysis that would otherwise be the case (= a potentially bad outcome) - for who would start dialysis before it's necessary: see the report of the Australian IDEAL trial in the NEJM: 2010. So, while I would build her massage into the decision-making process regarding an appropriate dialysis start date - is it likely to make a material difference? I think not.

    However, there may be potsssium issues - as muscle is also a significant potassium source - this might need to be measured (as a check) post massage to be certain that there is not a 'spike' in the potassium level. It would be easy to measure and be quite simple to either be reassured about - or warned to desist if the serum potassim pre- and post- massage were seen to be significantly different.

    I’d take the massage any time – and hack the briefly higher creatinine. It wont harm here, the degree and duration of rise will be minimal, and the benefit she gets from the massage, the relaxation, the better ‘feel’ to her body and her lifestyle will far outweigh any detriment, if any – and I would contend there is none.

    I think this is one of those ‘debates’ that to me, at least, would best be described as a storm in a tea cup.
    Last edited by John Agar; December 2, 2012 at 05:08 PM.

  3. #3
    Join Date
    11-20-10
    Posts
    142

    Default Re: Kidney disease and massage

    That's the reply I was hoping for, Dr. Agar. Thanks so very much, once again, for your time!

  4. #4
    Join Date
    08-17-04
    Posts
    2,124

    Default Re: Kidney disease and massage

    We cover massage in the Alternative Treatments module of Kidney School (http://www.kidneyschool.org). It's one of the treatments that we view as safe and unlikely to cause any harm.

  5. #5
    Join Date
    12-06-10
    Posts
    48

    Default Re: Kidney disease and massage

    i have a question about it as well. During my husbands 'session' i give him a leg message. It's only 10-20 min each leg, but im wondering this. Should that 'NOT' be done on blood draw days so it doesnt possibly alter the results of his testing?? Thank you So much for your information on this..

  6. #6
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    407

    Default Re: Kidney disease and massage

    To be perfectly honest, I dont think it would make any significant difference.

    It may mobilize a smidge more creatinine - so what ...

    And, it may mobilisze a little more muscle phosphate - all the better as that may allow more to be removed ...

    And, it shouldnt make material difference to the urea levels (for those who care a jot about Kt/V or PRU - which I don't - at least, I don't in the kind of dialysis you are accessing ... which is home dialysis at an already far higher frequency and/or duration than most facility-based patients get and where, arguably, Kt/ or PRU may be more useful subsistance dialysis markers).

    So ... I think this post - though a good question that needs an answer - is really a storm in a tea-cup about nothing.

    Massage helps patients. It makes them feel better. It makes their muscles, their joints, their bodies feel better. It helps to relieve cramp .. though I would contend that cramp, in good dialysis, should be a minimal, if any, problem.

    I really don't have an issue with it - bloods or no bloods - and if the minimal effect of massage on bloods were to be significant in changing dialysis interpreatation, then it is not the massage that is wrong but the dialysis prescription and the dialysis delivery.

    My view? ... massage with neither fear nor anxiety.

    If it helps - and it usually does (in many ways) ... do it.

  7. #7
    Join Date
    12-06-10
    Posts
    48

    Default Re: Kidney disease and massage

    thank you I really appreciate your quick responce. I was massaging him for comfort first, then thought about those 'medical' stockings helping circulation and thought, well if i pressure his legs in a nice way, i can help get some fluid more available to be taken, and even a small amt of toxins.. Either way, hes got a win win

  8. #8
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    407

    Default Re: Kidney disease and massage

    My pleasure!

    Sadly there is much fear, much misinformation and a sad lack of common sense in dialysis circles.

    I am glad this little weight is lifted for you and you can now make your hubby feel better from your massages without guilt and with a little pleasure that you are actually likely doing him good, and certainly not harm.

  9. #9
    Unregistered Guest

    Question Re: Kidney disease and massage

    Hi There,

    I am very interested in your information regarding massage for renal patients. My brother in law is having a lot of difficulty getting the needle in his arm for home dialysis. Last week it took an hour and a half and lots of pain for him to get through the scar tissue.

    I am a sports massage therapist and was wondering if it was ok for me to break down this scar tissue to make it easier for him to insert the needle repeatedly in the same place?

    You advise would be much appreciated!

    Many Thanks

    Tanya

  10. #10
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    407

    Default Re: Kidney disease and massage

    Dear Tanya

    I can sympathize with your brother in law, though an hour and a half sounds an awful ordeal and a very long time to access a fistula. But, without knowing exactly what his fistula looks like, its actually quite hard to answer your question.

    The vein in most fistulae is quite close under the skin and often is tethered there (as you rightly note) by quite a lot of thickened scar tissue from previous needling. While massage has the potential to increase the suppleness of the scar tissue in the subcutaneous (underneath the surface of the skin) space between the skin and the vein wall, it may also - if handled too energetically - cause damage to the vein wall ... especially if the recent puncture site(s) have not yet fully healed and blood is allowed or encouraged by manipulation of the puncture site to leak/seep out from the vessel into the tissues.

    A fistula, used at least 3 time weekly, does need a little time to heal - post-dialysis - and early 'manipulation' might promote a re-bleed or blood leak. Yet, in under 48 hrs, he's got to get back into it again, for another set of needlings. So, I guess what I am saying is, too early and there's risk .. but, too late, and its the next dialysis.

    I wonder if he might be a good candidate for the creation of a buttonhole. We use buttonholes in the majority of our home patients .. probably in more than 30 of our home HD patients .. and, increasingly, in both our nurse-needled and self-needled facility patients. Yes ... we actively encourage and train patients to self-needle in our facilities as well as at home ... especially for those who, for some reason, can't or won't consider home but would be capable of home self-care if they would train for it.

    Buttons are also useful when fistula 'ladder' access is difficult .. perhaps the case with here ... and, once a button is made, it works well and sustainedly in most patients - allowing needling with great ease and without pain. Clealry, a button should be made according to the buttonhole guidelines: same nurse, same site, same angle, same track, same everything ... and by a nurse skilled at fashioning a good button. indeed, as the button-making process switches from sharp to blunt needles, this would be the ideal time for the patient-hands-on-transfer of needling care from nurse to brother-in-law.

    While subcutaneous tissue conditioning through massage or gentle manipulation may have a role to play in keeping an AVF 'nice' and 'supple' .. it is something that would need to be done with great care and with direct knowledge and supervision of his renal team. This is not to call into question your clear skills in this area ... but the renal team should be involved and know that this process is happening.

    For me, however, deciding and advising on this without intimate knowledge of the state of his access would be dangerous indeed!

    1. He should put this question to his team.

    2. He should at least discuss the potential for buttonholing with his team.

    3. He is a lucky guy to have you by his side to help, where and however you can.

    That is the best I can offer, from afar .. but I hope it may have been of some help.

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