Key Point

• The benefits massage therapy has to offer this population are substantial: Our work may help with pain, fatigue, muscle cramping, sleep quality, and much more.

Take a moment and turn your attention inward to your two fist-sized kidneys located on either side of your anterior spine, from about T11 to L2 or 3. You might remember your right kidney is a bit lower than your left. The kidneys are in the retroperitoneal space. They are protected by thick layers of muscle and a bit of lumbodorsal fascia, but because they are only partially shielded by the rib cage, kidneys can be injured with a sharp blow to the torso where the 12th rib emerges from the spine. In boxing, a “kidney punch” is illegal. 

Kidneys are hardworking organs. They filter our entire blood volume over 30 times every day. But that’s not all—they also help us maintain an appropriate pH balance in the blood, they secrete hormones to maintain healthy blood pressure and blood volume, and they help maintain bone density through the production of vitamin D. And, amazingly, we have about twice as much kidney function as we need, so we can give one away if necessary.

But when things go wrong with the kidneys, big problems can develop, and that is the focus of this article: the progression from chronic kidney disease to renal failure to dialysis to renal transplant—and what those situations mean for decisions about massage therapy. Because diabetes is a major contributing factor to chronic kidney disease, this piece is closely connected to two articles in the November/December 2023 issue of Massage & Bodywork, “Deconstructing Diabetes” and “Diabetes Complications.”

To fully grasp the importance of renal failure, we need to do a brief review of kidney structure and function. You may remember that the main functional unit of the kidney is the nephron, a delicate epithelial duct that connects with a blood capillary in the renal cortex at a junction called the glomerular capsule. Each nephron extends a long loop down into the renal medulla and then comes back into the cortex. Nephrons eventually drain into the renal pelvis (Image 1).

Plasma from the cardiovascular system is forced by blood pressure to cross from the capillary to the nephron at the glomerular capsule. As that fluid travels along the long and convoluted nephron, much of it is reabsorbed into the bloodstream, and the remainders—mainly water, salts, excess hormones, drug leftovers, and other wastes, travel into the renal pelvis, down the ureters, into the urinary bladder, and finally out of the body; this is urine.   

An amazing amount of fluid passes through healthy kidneys; a normal glomerular filtration rate (GFR) is 120 mL per minute, which means we process nearly 180 liters of fluid every 24 hours. We need this high volume of turnover to stay healthy and to prevent the accumulation of toxins and waste products in the bloodstream.

But the kidneys are vulnerable to a few problems. Bacteria from the urinary tract may travel up the ureters to cause kidney infections, or pyelonephritis. Polycystic kidney disease is a genetic disorder that causes cysts to grow, and they interfere with function. And imbalances between water and mineral levels can promote the growth of sharp crystals within the kidneys that excoriate the ureters as they travel downward; these are kidney stones. But the focus of this article is on what happens when chronic wear and tear affects the delicate kidney tissues and eventually leads to renal failure.

Chronic Renal Failure

Renal failure describes a situation where the kidneys cannot keep up with a person’s needs. It can have a sudden onset or be the result of some kind of trauma, which would be acute renal failure. But silently progressive chronic renal failure is much more common, and it’s something massage therapists are more likely to encounter in their practice. 

Chronic kidney disease occurs on a continuum, determined by the GFR (see “The Continuum of Renal Failure”). Early stages are often silent, and many people may not know they are at risk. In later stages, we see the consequences of a low filtration rate: retention of fluid, accumulation of toxins and excessive minerals, and the loss of important renal hormones—this is the transition from chronic kidney disease to renal failure.

Advanced renal failure can affect many organ systems. Damaged kidneys lead to decreased urine output, edema in the lungs and in the extremities from salt and water retention, arrhythmia from potassium retention, anemia, and bone thinning related to the suppression of important hormones. Rashes and skin discoloration appear from retention of toxins in the blood. Failing kidneys can cause easy bruising and bleeding, muscle weakness, and cramps. Fatigue, headaches, peripheral neuropathy, tremors, seizures, and changes in mental and emotional states are the result of toxins that cross the blood-brain barrier. 

Given how serious chronic kidney disease is, it’s shocking to learn how many people in this country have it. About 14 percent of Americans (about 37 million) are affected, and that number is growing by some 8 percent per year. More than 800,000 people are in late-stage renal failure, and about 130,000 people are diagnosed with a new case every year.¹

The consequences of untreated kidney disease are not evenly distributed throughout society. Compared to White Americans, Black Americans are 4.2 times more likely to develop renal failure, Hispanic Americans are 2.3 times more likely, Native Americans are 1.9 times more likely, and Asian Americans are 1.5 times more likely to end up with late-stage renal disease.² This may reflect the consequences of socioeconomic standing and systemic barriers to health care based on race and ethnicity more than on any specific genetic predisposition to kidney disease. 

Only two treatments for chronic renal failure are available: dialysis and kidney transplant.

Dialysis

Kidneys can go through a lot, but when they go from a GFR of 180 mL per minute to 30 mL per minute, it’s time to look for external help. This is where hemodialysis and peritoneal dialysis come in (see “Kidney Heroes,” page 66).

Hemodialysis is typically offered in an outpatient clinic and requires a minimum of three sessions per week, each lasting 3–5 hours. A home version of hemodialysis is available; this one is used more frequently for shorter periods.

Peritoneal dialysis is an alternative to hemodialysis and can be done at home rather than in a clinic. This process uses the capillaries of the peritoneum to filter blood with a dialysis solution. A permanent catheter is inserted in the peritoneum. During a session, the dialysis solution flows into the peritoneal cavity, where it absorbs waste and excess fluid from the body, which takes 60–90 minutes. Then it is drained out of the body. This must be done four times each day, and it can be done during sleep.  

Dialysis is an intervention that can prolong the lives of people with end-stage renal failure, but it can have some serious side effects and complications. With hemodialysis, the person may develop an infection or a blockage in the affected blood vessels, or the needle may become dislodged during treatment. With peritoneal dialysis, the person may develop skin infections, peritonitis, and weakened abdominal muscles and hernia. Since a major ingredient of the dialysis solution is dextrose, they may also absorb a lot of sugar and have weight gain—which doesn’t help factors like diabetes or high blood pressure that contribute to renal failure.

Any kind of dialysis may also involve severe fatigue, painful muscle cramps, and the accumulation of aluminum in the bloodstream, which might need to be treated with chelation therapy. (For context, aluminum poisoning is less of a problem than it used to be, but people who have been on dialysis for a long time may be at risk.) These problems can be addressed, but for most people, dialysis is a stop-gap measure while they wait for the prospect of receiving a donated kidney. The mortality rate for people on dialysis is sobering—the five-year survival rate is about 35 percent.³  

Kidney Transplants

Kidney transplants work better and longer than dialysis to treat renal failure. However, they are complex and not always successful. And the longer a person is on dialysis, the weaker and less capable they are of receiving a transplant. 

At this time, about 90,000 people in the US are on the waiting list for a new kidney, and about 25,000 transplant surgeries are performed each year. The average amount of time on the kidney donor waiting list is just short of two years, but that is a national average, and actual times vary depending on location and availability. That said, Black patients on average wait a year longer than others to receive a new organ. The costs of kidney transplants are also daunting, and one factor in selecting who receives a new organ is whether they can afford the thousands of dollars per month it costs to use antirejection drugs.⁴ 

A new kidney can come from a deceased organ donor or from a carefully matched live donor who is healthy enough to lose half of their filtering capacity. If a recipient’s kidneys are free from infection, necrosis, or other problems, they are left in place and the new kidney is connected to the urinary bladder in the pelvis. A kidney from a deceased donor typically lasts 10–15 years, and from a living donor, that time is 15–20 years. However, those numbers can vary, and kidney transplant protocols are always under development for better access and survival rates. 

Does Massage Have a Role in Kidney Disease?

Considering how common chronic kidney disease is and how severe it can become, there is surprisingly little reliable information about massage therapy in this context. A couple of reviews have looked at manual therapies to help improve sleep for this population, and they found mixed results. A handful of small studies looked at massage during dialysis sessions for fatigue and between-session muscle cramping, with more consistently positive results. But the idea of massage therapy as part of a whole-person coping strategy during a very challenging time has not been researched.

Given all this, is massage therapy appropriate for someone with chronic kidney disease? The answer is, it depends. To figure out what it depends on, let’s put this decision through a critical-thinking process.

• Identify the key question: What does the client want that massage therapy might help them achieve?
• Identify the variables that must inform that question: How severe is their disease? What treatments are they using? What symptoms and side effects are bothering them? What daily activities do they tolerate well? What activities make them feel better? Worse? (There are a lot of other possible questions, but these provide a good start.)
• Look for assumptions about this situation: What have you missed? Are you focused on treating the kidney problem rather than the reason the client came to see you?
• Find what others have done in similar situations: Look at the research, consult with peers, and if appropriate, reach out to the client’s medical providers with specific questions about goals and safety.
• Plan and execute the session: Use what you’ve learned to work with your client. Consider the risks, benefits, and appropriate accommodations.
• Evaluate the results: How will you determine if your work is successful? What will you do differently next time you work together?

Risks, Benefits, and Accommodations

We know people with chronic kidney disease have a hard time managing fluid flow, and we can surmise that to challenge that with deep, fast, draining strokes is probably not a good idea. Other risks that inform our work include bone thinning, skin rashes, itching that thoughtless massage might make worse, and general malaise that is not appropriate for rigorous bodywork. Organ transplant recipients often have complex health situations, and they use tissue-rejection drugs that make them vulnerable to infections.

The benefits that massage therapy has to offer this population are substantial: Our work may help with pain, fatigue, muscle cramping, sleep quality, and much more. In a recent episode of the podcast “I Have a Client Who . . .” (Episode 377), I spoke about doing massage for a person undergoing dialysis. As long as the work is gentle and doesn’t challenge the client’s general energy levels, there is no reason to withhold treatment. 

The accommodations for clients with renal disease or renal failure must be led by their tolerance—some days they may be too tired to receive massage—and by their physical resilience. Obviously, the access site is a local caution, and it may be best to offer shorter sessions while you and your client evaluate how things go for them. Finally, let’s bear in mind that clients with renal failure may seek massage for other issues—musculoskeletal injuries, for instance. And while we must accommodate for their limitations, their kidney disease might not be the centerpiece of their goals. 

Clients who have received transplanted kidneys may have extensive scar tissue and a new organ in their pelvis. Also, these clients use immune-suppressant drugs, so they require us to be especially careful about infection risk along with whatever other challenges they have.

People with chronic kidney disease, those with renal failure, those who use dialysis, and those who have received a transplant all need us to adapt our work to their needs. But knowledgeable massage therapists can offer safe, educated, and caring touch in ways that might help with pain, stress, fatigue, and much more. 

Notes

1. National Institute of Diabetes and Digestive and Kidney Diseases, “Kidney Disease Statistics for the United States,” accessed October 9, 2023, www.niddk.nih.gov/health-information/health-statistics/kidney-disease.

2. American Kidney Fund, “Quick Kidney Disease Facts and Stats,” accessed October 6, 2023, www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats.

3. University of California, San Francisco, “The Kidney Project,” accessed October 12, 2023, https://pharm.ucsf.edu/kidney/need/statistics.

4. National Foundation for Transplants, “Get Informed,” accessed October 12, 2023, https://transplants.org/get-informed.

Resources

Association of American Medical Colleges. “How Our Organ Transplant System Fails People of Color.” Accessed October 12, 2023. www.aamc.org/news/how-our-organ-transplant-system-fails-people-color. 

American Kidney Fund. “Deceased Donor Kidney Transplants.” Accessed October 12, 2023. www.kidneyfund.org/kidney-donation-and-transplant/deceased-donor-kidney-transplants.

American Kidney Fund. “Quick Kidney Disease Facts and Stats.” Accessed October 6, 2023. www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats.

Centers for Disease Control and Prevention. “Chronic Kidney Disease in the United States, 2023.” Accessed October 9, 2023. cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html.

Çeçen, S., and D. Lafcı.  “The Effect of Hand and Foot Massage on Fatigue in Hemodialysis Patients: A Randomized Controlled Trial.” Complementary Therapies in Clinical Practice 43, (May 2021): 101344. https://doi.org/10.1016/j.ctcp.2021.101344.

Chu, S. W. F. et al. “Manipulative and Body-Based Methods in Chronic Kidney Disease Patients: A Systematic Review of Randomized Controlled Trials.” Complementary Therapies in Clinical Practice 48, (August 2022): 101593. https://doi.org/10.1016/j.ctcp.2022.101593.

Chuang, P-H. et al. “Blood Aluminum Levels in Patients with Hemodialysis and Peritoneal Dialysis.” International Journal of Environmental Research and Public Health 19, no. 7 (2022): 3885. https://doi.org/10.3390/ijerph19073885.

Cleveland Clinic. “Dialysis.” Accessed October 6, 2023. https://my.clevelandclinic.org/health/treatments/14618-dialysis. 

Davita Kidney Care. “The History of Dialysis.” Accessed October 10, 2023. www.davita.com/treatment-services/dialysis/the-history-of-dialysis.

Habibzadeh, H. et al. “Effects of Foot Massage on Severity of Fatigue and Quality of Life in Hemodialysis Patients: A Randomized Controlled Trial.” International Journal of Community Based Nursing and Midwifery 8, no. 2 (2020): 92–102. https://doi.org/10.30476/IJCBNM.2020.81662.0.

Home Dialysis Central. “Kidney Disease and Massage.” Accessed September 6, 2023. https://forums.homedialysis.org/t/kidney-disease-and-massage/2745.

Lai, M-Y. et al. “Fever with Acute Renal Failure Due to Body Massage-Induced Rhabdomyolysis.” Nephrology Dialysis Transplantation 21, no. 1 (2006): 233–4. https://doi.org/10.1093/ndt/gfi158.

Lazarus, E. R. et al. “The Effects of an Olive-Oil Massage on Hemodialysis Patients Suffering from Fatigue at a Hemodialysis Unit in Southern India—A Randomized Controlled Trial.” Journal of Complementary and Integrative Medicine 18, no. 2 (2020): 397–403. https://doi.org/10.1515/jcim-2019-0338.

Mastnardo, B. S. et al. “Intradialytic Massage for Leg Cramps Among Hemodialysis Patients: A Pilot Randomized Controlled Trial.” International Journal of Therapeutic Massage & Bodywork 9, no. 2 (2016): 3–8. https://doi.org/10.3822/ijtmb.v9i2.305.

National Foundation for Transplants. “Get Informed.” Accessed October 12, 2023. https://transplants.org/get-informed.

National Institute of Diabetes and Digestive and Kidney Diseases. “Explaining Your Kidney Test Results: A Tool for Clinical Use.” Accessed October 12, 2023. www.niddk.nih.gov/health-information/professionals/advanced-search/explain-kidney-test-results.

National Institute of Diabetes and Digestive and Kidney Diseases. “Hemodialysis.” Accessed October 10, 2023. www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis.

National Institute of Diabetes and Digestive and Kidney Diseases. “Kidney Disease Statistics for the United States.” Accessed October 9, 2023. niddk.nih.gov/health-information/health-statistics/kidney-disease.

National Institute of Diabetes and Digestive and Kidney Diseases. “Kidney Transplant.” Accessed October 5, 2023. www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/kidney-transplant.

National Kidney Foundation. “How Your Kidneys Work.” Accessed October 5, 2023. www.kidney.org/kidneydisease/howkidneyswrk.

National Kidney Foundation. “Transplants For All: Saving Lives, One Kidney at a Time.” Accessed October 12, 2023. www.kidney.org/newsletter/transplants-all-saving-lives-one-kidney-time.

Stanford Medicine. “Kidney Failure Symptoms.” Accessed September 6, 2023. https://stanfordhealthcare.org/medical-conditions/liver-kidneys-and-urinary-system/kidney-failure/symptoms.html.

The Kidney Failure Risk Equation. “Facts & Figures of Chronic Kidney Disease.” Accessed October 5, 2023. http://kidneyfailurerisk.com.

University of California, San Francisco, “The Kidney Project,” accessed October 12, 2023, https://pharm.ucsf.edu/kidney/need/statistics.

Kidney Heroes

The idea of an external machine to filter blood has a fascinating history. The first doctor to explore this possibility was Dutch physician Willem Kolff. His work was interrupted by the Nazi invasion of the Netherlands, during which he illegally sheltered a Jewish colleague and his son. After many failures, he eventually constructed a machine with improvised parts that worked for patients with acute renal failure. He came to the US in the late 1940s and continued to refine his invention. However, dialysis was not considered a long-term solution for people with chronic disease until a solution was found for repeated blood vessel damage. This was accomplished by Dr. Belding Scribner with the invention of a shunt, which allowed repeated access to the vascular system. Scribner opened the first outpatient dialysis center in 1962. The process of choosing who would be given access to this lifesaving intervention led to the formation of the first bioethics committee, a practice that continues to impact health-care accessibility to this day.

Kolff went on to pave the way for the first renal transplant in 1954 and was involved in the creation of the first heart-lung machine, the first artificial heart, and many other innovations in medicine. He died in 2009 at age 97.

The etymology of the term dialysis comes from the Greek dia/luein, which means “to split apart and set free.” For renal failure patients, this “splitting apart” can happen in two ways: as hemodialysis or peritoneal dialysis. 

The process of hemodialysis is complex, but a simplified description looks like this: Blood is removed from the body and passed through a machine that puts it through a filter. At one end of this filter, the blood is forced into many tiny, hollow, semipermeable tubes that resemble capillaries. Dialysis solution passes in the opposite direction, outside these tubules. Waste is sucked out of the blood-carrying vessels and into the dialysis fluid, which is extracted and discarded. The filtered blood re-enters the cardiovascular system.