In a patient with end‑stage renal disease on long‑term dialysis presenting with finger locking, what interventions are recommended?

Management of Finger Locking in ESRD Patients on Dialysis

For ESRD patients on long-term dialysis presenting with finger locking (trigger finger), surgical release with wide tenosynovectomy is the definitive intervention, as this condition is most commonly caused by β2-microglobulin amyloidosis affecting the flexor tendons and typically occurs after 5-10 years of dialysis. 1

Understanding the Underlying Pathology

Finger locking in dialysis patients is fundamentally different from idiopathic trigger finger in the general population:

• β2-microglobulin amyloidosis (A2M) is the primary cause, affecting joints and periarticular structures including flexor tendon sheaths 1
• This occurs because β2-microglobulin accumulates to 15-30 times normal levels in dialysis patients, as the kidney is the principal site of metabolism and conventional dialysis membranes cannot adequately clear this 11,800 Da protein 1
• Clinical manifestations typically appear 2-10 years after dialysis initiation, with 90% of patients showing pathological evidence at 5 years 1
• Trigger finger occurs in approximately 25% of patients with carpal tunnel syndrome related to dialysis-associated amyloidosis 2

Immediate Interventions

Conservative Management (Limited Efficacy)

Conservative approaches have poor long-term outcomes in this population but may be attempted initially:

• Volar wrist splinting at night can be tried in early cases 3
• Steroid injection into the flexor tendon sheath may provide temporary relief in 90% of cases, though recurrence is common 3
• Avoid activities that precipitate triggering 3

Critical caveat: Unlike idiopathic trigger finger, conservative management rarely provides durable relief because the underlying amyloid deposition is progressive and unaffected by these interventions 2, 4

Definitive Surgical Intervention

Surgical Technique

The recommended surgical approach includes: 2, 4

• A1 pulley release (standard trigger finger release)
• Wide tenosynovectomy of flexor tendons to remove amyloid-laden synovium 2
• In severe or recurrent cases (especially after 20-30 years of dialysis), resection of thickened flexor digitorum superficialis tendons may be necessary 4

Surgical Considerations Specific to ESRD Patients

Anesthesia approach: 4

• Local anesthesia is preferred
• Tourniquet use should be avoided in limbs with arteriovenous fistulas or prosthetic shunts 2
• Can be performed safely under local anesthesia without tourniquet in most cases 4

Expected histopathology: 2, 3

• Tenosynovial amyloid deposits are found in 84% of operated cases 2
• Histological confirmation of β2-microglobulin amyloid should be obtained 5, 3

Outcomes and Prognosis

Short-term Results

• Pain relief occurs in the majority of patients after initial surgery 2, 4
• Finger mobility improvement is seen in approximately one-third of patients when tendon resection is performed 4

Long-term Challenges

Recurrence is common and progressive: 4

• First recurrence occurs after an average of 6.1 years (SD 2.8)
• Second recurrence after 4.6 years (SD 3.1)
• Third recurrence after 3.8 years (SD 1.9)
• 20% of patients experience decreased digital mobility postoperatively due to extension of tenosynovitis to the fingers 2

Management of Recurrences

Algorithmic approach to recurrent trigger finger: 4

1. First recurrence: Repeat A1 pulley release with synovectomy is usually sufficient
2. Second recurrence: Consider more aggressive synovectomy; tendon resection may be needed
3. Third recurrence: Resection of flexor digitorum superficialis tendons is recommended, as simple synovectomy alone rarely provides relief at this stage 4

Systemic Interventions to Slow Disease Progression

Dialysis Modifications

Switch to high-flux dialyzers: 1

• In patients with evidence of or at risk for β2-microglobulin amyloidosis, non-cuprophane, high-flux dialyzers should be used 1
• This may slow but not stop disease progression 1

Definitive Treatment

Kidney transplantation is the only intervention that stops disease progression: 1

• Transplantation should be considered to halt progression or provide symptomatic relief in patients with β2-microglobulin amyloidosis 1
• No other currently available therapy can stop disease progression 1

Critical Pitfalls to Avoid

1. Do not treat this as simple idiopathic trigger finger – the underlying amyloid pathology requires more aggressive surgical debridement 2, 4

2. Do not delay surgical intervention in symptomatic patients, as conservative management rarely provides durable relief and the disease is progressive 3, 4

3. Protect the arteriovenous access – avoid tourniquet use on the limb with vascular access 2

4. Anticipate recurrence – counsel patients that multiple procedures may be needed over time, particularly in those on dialysis for >20 years 4

5. Do not assume the side of trigger finger correlates with the AV fistula side – no precise relationship exists between the two 2

6. Screen for associated conditions – 21% of patients with trigger finger also have amyloid arthropathy, and many have concurrent carpal tunnel syndrome requiring simultaneous treatment 2