Kidney disease and massage

Ask Our Experts Dr. John Agar, Nephrologist
1

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

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.

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

4

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

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…

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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.

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:slight_smile: thank you :slight_smile: 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 :wink:

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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.

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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

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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Hi

Massage is one of the oldest, simplest forms of therapy and is a system of stroking, pressing and kneading different areas of the body, which can help to relieve pain, relax, stimulate, and tone the body.

It is reported that massage is not only helpful for patients, but also beneficial for healthy people. In our body, there are more than 1000 acupoints and by pressing them, our immune system can be strengthened and immunity can be increased.

The benefits of massage for the kidney failure people are as follows:

-Almost all the kidney failure patients have digestive problems, sleep problems, blood circulation problems, and emotional problems and so on. These problems become more and more serious and always become the real factors that affect their daily life. Under such a condition, massage can be applied to help them alleviate these symptoms.

-Besides that, massage stimulates blood circulation and increase kidney failure patients’ immunity to against bacterium and viruses, which can help them avoid cold and infection easily. Cold and infection are the leading two aggravating factors of chronic kidney failure. With effective prevention, acute kidney failure can be avoided remarkably to kidney failure patients.

Furthermore, clinic applications have proved that more than 95% chronic diseases occur due to the poor immunity. So massage is very health-beneficial to chronic kidney failure patients.

If you want to avail the massage, then you can visit http://instituteofeastwestwellness.com/

12

I’m a massage therapist for ten years and a massage instructor for five years. Massage therapists are trained to protect themselves from liability and repetitively reminded we are not doctors and cannot diagnose our clients. We do follow Hippocrates quote “Do No Harm.” Therefore, we cannot determine if it is safe or not for individuals to get a massage. That being said, we follow certain guidelines and established contraindications. As time goes on and more research develops contraindications can/may change. I have noticed a change what is taught now, compared to last decade when I was a student. I would like to share a bit about contraindications for massage.

There are three types of contraindications. Absolute or general, local and medical. Absolute contraindications are conditions they may be temporary, but cannot be a present condition for massage. This could include fever or CHF (congestive heart failure). A local contraindication will allow someone to get a massage, but you would avoid a specific area involved. A broken bone could be massaged above or below the break, but not on the site of the break. The medical contraindication is where kidney disease would fall into. Ironically, this just happened with me yesterday. I had a client arrive, whose husband had scheduled a massage for her as a Christmas present. During her intake I learned she was born with one kidney and since her pregnancy, it is only working at 50%. As a massage therapist, she is medically contraindicated. This means I cannot massage her without consent from her physician. I am not medically trained to determine if her kidney will withstand the effects massage has on kidneys or in her case a kidney. I informed her that if her doctor says it is fine, then I would be more than happy to massage her. However, if her kidneys could not withstand a massage, I would not want to harm her in any way.

The way it was explained to me in school as far as the reason massage could affect a kidney is because massage is encouraging the system and everything is moving through the system faster; therefore at concentrated levels. It’s the same reason massage is contraindicated while someone is under the influence of alcohol. If someone is drinking, I believe the norm is one hour for a drink to go through the system, so if a person had three drinks, I believe it should take three hours for the alcohol to go through their system. (I’m not sure how this changes with multiple drinks, but I will use one hour per drink.) If the person was to get a massage, it may quicken the process and instead of the body processing one drink per hour it will process it all within an hour. My numbers of processing may not be correct, but I believe you can get the gist of what I am saying; the toxins are concentrated. The fear is that someone with kidney disease may not be able to withstand the concentration of toxins going through their kidney. Whether or not a person’s kidney(s) could withstand the effects of massage is out of a massage therapists scope of practice and therefore must be determined by their doctor, preferably their nephrologist.

I hope this helped clarify why massage therapists state and should state that kidney disease is contraindicated. They should be specific in that it is medically contraindicated; simply meaning it is out of our scope of practice to determine if your individual case of kidney disease is indicated for massage therapy - have your qualified physician make this determination, so we do no harm.

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My son as of 4/23/19 is 6-years post transplant. During his 4.5 years of dialysis, andshortly before, he received massages from myself or my daughter-both licensed massage therapists-every day and especially after hemodialysis.

We discussed his muscle cramps, fatigue, etc with his nephrologist, and he indicated “good to go!” We used a medium pressure and sunflower oil for his massages so that we avoided ny chemical additives. Yes, there were times that his creatinine was slightly elevated but had dissipated prior to the next dialysis session.

Potassium levels were taken care of by cutting out processed foods and those with preservatives. Read labels…His worst enemy was phosphorus from cheese products-we are “cheeseaholics”!

But back to massage pre and post-dialysis…it is good to discuss all types of complementary processes with all doctors. A good relaxing massage; however, will normally make a dialysis patients “life of hell” more livable. I know it did for my son! He continued to work his job and an automotive tech 50-55 hrs per week, 12 hrs of dialysis and weekend work as a lumberjack throughout that 4.5 years and he gives all the credit to receiving his daily massages!

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Hi Cindy! I’m Angel…just stopped by to read your post as I too am a massage therapist.I loved reading that your son is doing well and crediting massage! That always makes me smile. I’d like to share something that may make you smile too.
My dad’s,86, on PD for a little over a month now, just started on the machine version at home. He hasn’t had too many cramp issues, mainly at the start with trying to figure out fluid levels ok for him to drink but not swell up. He was never much for massage, in fact all the years I’ve been a professional and lived with him and he’s barely let me work on him a dozen times. But, he was having, and I guess still is having, some drain issues. Now, in PD, they put fluid in their abdominal cavity so it surrounds all the intestines and above/below. So it can get into pockets of areas that have to then be “motivated” to make their way to the catheter to drain out. One night, I’m firmly but gently pressing about four knuckles of my right hand into his right lower abdomen, and he says, “I can see why people fall asleep during massages. It’s so relaxing.” …I about peed myself laughing so hard. I explained that this type of deep abdominal massage is typically not relaxing for many people and certainly not the type that comes to mind for a relaxation session! Of course, the laughter that ensued helped the drain a lot too. He has had me work on his legs when they’ve cramped in the past and he does doze off then too, he just doesn’t remember.
Best wishes and laughter…Angel

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Hi Angel! I am so glad to see someone is reading the blog as it was rather old message! I am also glad to hear that your dad is doing well on PD! My son did not do well on PD as an adult. When he was 15 mos old he was in renal failure from the MMR vaccine and they over filled his diaphragm making it too thin as an adult to use PD. However after 30 days of dialysis he was fine again.

He was declared free and clear of damage at 15 years but it came back with a vengeance at 25. He tried PD again only to go into congestive heart failure and on to hemodialysis, was a lot better for him! He will definitely swear by massage for all dialysis patients, even if lightest Swedish…just the touch and caring that it brings is terrific!

My daughter and I now work home healthcare working with individuals who have CP and other disabilities and love it thanks to being introduced to this side of the fence. Massage is great for simple relaxation and tension relief for the “normally healthy” individuals but when you can touch the lives of those in pain like this…it is very rewarding!

Thanks for sharing your story as well!

Best wishes and prayers for your dad and family!

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Hello Dr.Agar.
I am an in center dialysis patient with a fistula on my left forearms. I run a 5.5 hours treatment. My dry weight is 137. Question is. Can I get a massage after treatment on the same day?
Thank you

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Absolutely. Of course you can. Just avoid the fistula area. Enjoy.

NB: I replied similarly to a post about massage some years ago … see earlier on in this massage thread!

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I am a massage therapist and was an instructor. The correct answer, from a massage position, is that it is contraindicated without consent from a doctor. Therefore, any massage therapist in the US, should have been taught that a doctor’s permission is required. Many doctor’s will agree to the massage, which relieves you if the liability. You wouldn’t want to harm your family members, friend or clients, nit would you want that responsibility. It should be listed in your Massage Book under contraindications. Once you have the doctors permission in writing, on file; you are cleared of any results pertaining to the kidneys.

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I never thought a gentle massage can harm any dialysis patient who goes through lot of after dialysis pain on feet ,backache and weakness . After going through this thread, got to realise that I was doing it right for my wife who is undergoing Dialysis twice a week.
As far as respective countries guidelines are concerned to do it or not to do it without consent of Nephrologist, I would say based out of my observation that during dialysis session many patients were.accompanies by their attendant and in times of cramps it’s the attendant does the massage to the patient instead of going back to doctor for taking the consent first. With all respect , I hope common sense.prevail in regulations where it’s due.