Can dialysis (renal replacement therapy) cause muscle jerking and twitching in patients due to electrolyte imbalances such as hypocalcemia (low calcium levels), hypomagnesemia (low magnesium levels), or hypokalemia (low potassium levels)?

Muscle Jerking and Twitching in Dialysis Patients

Yes, dialysis treatment directly causes muscle jerking and twitching through multiple mechanisms, most importantly through electrolyte fluctuations—particularly magnesium, calcium, and potassium—that occur during and after dialysis sessions. 1

Primary Mechanisms

Electrolyte fluctuations are the dominant cause of neuromuscular irritability in dialysis patients. The intermittent nature of hemodialysis creates wide swings in potassium, ionized calcium, magnesium, and other divalent ions between treatments 1. These fluctuations are driven by:

• Dialysate composition used during the treatment session 1
• Rapid correction of acidosis during dialysis, which causes potassium to shift from extracellular to intracellular space, potentially causing severe hypokalemia even when dialysate contains adequate potassium 2
• Variable dietary adherence affecting calcium-phosphate product control 1

Critical Electrolyte Abnormalities to Evaluate

Hypomagnesemia

Check serum magnesium immediately—this is the most commonly overlooked cause of refractory muscle twitching. 3

• Occurs in 60-65% of critically ill patients on continuous kidney replacement therapy 3
• Target serum magnesium should be ≥0.70 mmol/L (approximately 1.7 mg/dL) 3, 4
• Hypomagnesemia causes refractory hypokalemia and hypocalcemia that cannot be corrected without magnesium replacement 4, 5, 6
• If using regional citrate anticoagulation, magnesium losses are dramatically increased through chelation 3

Hypocalcemia and Hypokalemia

These often coexist with hypomagnesemia and will not respond to replacement unless magnesium is corrected first. 4, 7, 6

• Hypomagnesemia occurs in 42% of patients with hypokalemia 7
• Magnesium is essential for PTH secretion and inhibits urinary potassium excretion 6
• Rapid potassium shifts during dialysis can cause life-threatening hypokalemia despite adequate dialysate potassium 2

Aluminum Toxicity (Less Common but Serious)

If muscle twitching is accompanied by speech disturbances, personality changes, or occurs shortly after dialysis, consider aluminum neurotoxicity. 1

• Dialysis encephalopathy presents with twitching, myoclonic jerks, and motor apraxia 1
• Symptoms characteristically worsen shortly after dialysis 1
• Plasma aluminum levels are typically 150-350 µg/L in dialysis encephalopathy 1
• Acute aluminum neurotoxicity causes agitation, confusion, myoclonic jerks, and major motor seizures with plasma aluminum 400-1,000 µg/L 1

Arrhythmogenic Risk

These same electrolyte fluctuations that cause muscle twitching also create a dysrhythmogenic state. 1

• 76% of maintenance dialysis patients demonstrate varying degrees of ventricular dysrhythmias 1
• Arrhythmias often occur during hemodialysis sessions and for 4-5 hours afterward 1
• Risk factors include compromised myocardium, increased QTc interval, electrolyte abnormalities, intradialytic hypotension, and LVH (present in 80% of dialysis patients) 1

Immediate Management Algorithm

1. Check electrolytes immediately: magnesium, calcium (ionized if possible), potassium, phosphate 1, 3
2. Assess dialysate composition: Determine current magnesium, calcium, and potassium concentrations in dialysate 3, 8
3. Correct magnesium FIRST if low:
   • Use dialysis solutions containing magnesium rather than IV supplementation 3
   • Commercial dialysis solutions enriched with magnesium can be safely used 3
   • Avoid exogenous IV supplementation during dialysis—it carries severe clinical risks 3, 4
4. Then address calcium and potassium after magnesium correction 4, 6
5. Monitor timing: Check electrolytes 24 hours post-dialysis to assess for rebound abnormalities 8

Critical Pitfalls to Avoid

• Do not treat hypokalemia or hypocalcemia without checking and correcting magnesium first—these will be refractory to replacement 4, 5, 6
• Do not give IV magnesium supplementation to patients on dialysis—adjust dialysate composition instead 3
• Do not assume post-dialysis electrolytes are stable—fluctuations continue for hours after treatment 1, 8
• Do not overlook aluminum toxicity if symptoms worsen after dialysis or include speech/cognitive changes 1