Table 1.

Common causes of hand pain in HD patients and their differentiating featuresa

DHISIMNCTSDA
Predominant featureCold hand with pain on or off dialysisWeakness and paralysis of muscles with prominent sensory lossHand weakness and pain with numbness of fingersPain localized to phalangeal joints mainly
PresentationAcute and chronicAcuteChronicChronic
Access typeCommon with upper arm but also seen with forearm accessesOnly with upper arm accessesNo impact of access typeNo impact of access type
Tissue involvedSkin > muscle > nerveNervesNervesJoints and phalangeal bones
CauseVascular insufficiency leading to distal hypoperfusionVascular insufficiency causing nerve damageAccumulation of β2-microglobulin amyloidosisPoorly understood
Radial pulseUsually diminishedUsually presentPresentPresent
Diagnostic evaluationThorough history, physical examination, and arteriographyHistory and the clinical featuresHistory, physical examination, and NCVSHistory, physical examination, and hand x-ray
More prevalent inPatients with diabetes, peripheral vascular disease, smokersPatients with diabetes, peripheral vascular diseaseLong-term HD patientsLong-term HD patients
Management strategiesPercutaneous and surgical interventionsAccess ligationSupportive management and surgeryNo specific therapy
  • a CTS, carpal tunnel syndrome; DA, destructive arthropathy; DHIS, distal hypoperfusion ischemic syndrome; HD, hemodialysis; IMN, ischemic monomelic neuropathy; NCVS, nerve conduction velocity studies.