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Dermatological manifestations in patients with chronic kidney disease on regular hemodialysis.

Byline: Asma Nasir and Atif Shehzad

Abstract

Objective

To determine the frequency of different dermatological manifestations in patients of chronic kidney disease on regular hemodialysis.

Methods

In this descriptive cross-sectional study, 160 patients were included from October, 2014 to April, 2015. Dermatological examination was performed and investigations were carried out where required to diagnose. Data was stratified for age, gender and duration of disease. Poststratification chi square test was applied. P value a$? 0.05 was considered significant.

Results

Mean age of the patients was 43.93+-12.12 years. Out of 160 cases, 90 (56.2%) patients were males while remaining 70 (43.8%) patients were females. Mean duration of chronic kidney disease was 2.54 years with minimum 3 months and maximum 14 years. Patients were on hemodialysis, duration ranging from 3 months to 9 years. Distribution of dermatological lesions were as follows: pallor was present in 119 (74.4%) patients, hyperpigmentation in 115 (71.9%) patients, xerosis in 96 (60%), pruritus in 91 (56.9%), ecchymosis and petechiae in 28 (17.5%), fissured tongue in 18 (11.3%), angular cheilitis in 3 (1.9%), ulcerative stomatitis in 22 (13.8%), half-and-half nails in 55 (34.4%) and koilonychia was present in 5 (3.1%) patients. Other manifestations seen were reactive perforating collagenosis in 4 (2.5%) and onychomycosis in 6 (3.7%) patients.

Out of 91 (56.87%) pruritic patients, mild pruritus was observed in 27 (16.9%) patients, moderate in 36 (22.5%), intractable and severe pruritus in 14 (8.8%) patients. Out of total 96 xerotic patients, xerosis was mild in 35 (21.8%) patients, moderate in 38 (23.8%), severe in 23 (14.4%) patients.

Conclusion

Pallor, hyperpigmentation and xerosis were most common in CKD patients on hemodialysis, so early recognition of cutaneous signs can relieve suffering and decrease morbidity.

Key words

Chronic kidney disease, hemodialysis, dermatological manifestations.

Introduction

Chronic kidney disease (CKD) is a progressive, usually irreversible loss of renal function through months or years classified into five stages from 1 (mild) to 5 (severe) and is identified from estimated glomerular filtration rate (eGFR). 1,2

The incidence of CKD is higher in Indo-Asians than in European populations. The number of patients with end-stage renal disease (ESRD) in Pakistan is continuously increasing with estimated annual incidence of 100 per million populations. 3

Cutaneous examination of patients with end stage renal disease (ESRD) have shown that 50-100 percent patients have at least one dermatologic disorder, this disorder may be the result of uremia, underlying etiology or various treatment modalities.4,5

Xerosis, pruritus, half-and-half nails, cutaneous hyperpigmentation, pallor and perforating disorders are common manifestations of ESRD.6

The dermatological findings can precede or follow initiation of hemodialysis and there are more chances to develop newer cutaneous findings with hemodialysis, as this treatment modality increases life expectancy in ESRD.7,8

Very few regional studies were conducted to evaluate the skin changes in CKD patients on hemodialysis. The purpose of this study was to determine the frequency of different dermatological findings in CKD patients on regular hemodialysis in a developing country, who are not on renal replacement therapy secondary to renal transplant dysfunction and do not have coexisting chronic liver disease. The later two factors can cause many new, unrelated manifestations, as well as, increase the severity and frequency of many dermatological manifestations known to occur in CKD9,10,11 a factor which is not clearly stated in previous studies. Physicians if aware of the cutaneous findings can significantly decrease the morbidity associated with the disease by reassurance, education and proper treatment. Consequently, it will improve the quality of life. Further, for preventive measures accurate knowledge of dermatological problems in uremic patients in local circumstances is a pre-requisite.

Methods

This descriptive, cross-sectional study was done in the Department of Dermatology, Department of Urology and Dialysis Centre of Lahore General Hospital, Ameer-Ud-Din Medical College/Post Graduate Medical Institute, Lahore. Study was carried out over a period of six months from October, 2014 to April, 2015.

Total of 160 patients were enrolled through nonprobability purposive sampling technique. Patients undergoing regular hemodialysis at least twice a week for a minimum of three months. Individuals with ages 25-60 years, from both genders were included. However females who were pregnant, patients with chronic liver disease and patients undergoing hemodialysis secondary to ESRD following graft dysfunction were excluded.

Chronic kidney disease was defined as a glomerular filtration rate (GFR) < 60ml/min/1.73m2 for three months. End stage renal disease was stage 5 (severe) of CRF with GFR 40 years age groups. In our study, pruritus, pallor, xerosis, hyperpigmentation, ulcerative stomatitis and nail changes did not differ in two groups (P>0.05). Ecchymosis/petechiae, angular cheilitis were more frequent in a$?40 years patients (P40 years (P40###value

Pruritus###36###55###11.324###0.023

Pallor###48###71###0.890###0.346

Xerosis###37###59###7.139###0.068

Hyperpigmentation###46###69###1.046###0.306

Ecchymosis/petechiae###17###11###4.608###0.032

Fissured tongue###2###16###8.177###0.004

Angular cheilitis###3###0###4.136###0.042

Ulcerative stomatitis###12###10###1.514###0.218

Half and half nails###19###36###2.170###0.141

Koilonychia###3###2###0.647###0.421

Table 3 Comparison of manifestations in both genders (n=160).

###Sex###Chi-square###P value

###Male###Female###value

Pruritus###50###41###5.697###0.223

Pallor###65###54###0.500###0.479

Xerosis###52###44###4.164###0.244

Hyperpigmentation###67###48###0.672###0.412

Ecchymosis/petechiae###7###21###13.468###0.000

Fissured tongue###14###4###3.819###0.051

Angular cheilitis###1###2###0.652###0.419

Ulcerative stomatitis###7###15###6.187###0.013

Half-and-half nails###30###25###0.099###0.753

Koilonychias###2###3###0.554###0.457

Table 4 Comparison of manifestations according to duration of chronic kidney disease duration (n=160).

###Duration of disease###Chi-square###P value

###3years###0.05); however, ecchymosis/petechiae, angular stomatitis and ulcerative stomatitis were more frequent in female patients (P<0.05).

Table 4 shows the correlation between cutaneous manifestations and duration of CKD.

It was noted that only hyperpigmentation and half-and-half nails were more frequent in patients with CKD of [greater than or equal to]3 year duration (P<0.05).

Discussion

In chronic kidney failure, there is an irreversible deterioration in renal function. The resulting impairment of the excretory, metabolic and endocrine functions of the kidney leads to the development of the clinical syndrome of uremia.

The purpose of all renal replacement techniques including hemodialysis is to mimic the excretory functions of the normal kidney. These include excretion of nitrogenous wastes, maintenance of normal electrolyte concentrations and extracellular volume in the body.12,13

There is higher prevalence of cutaneous changes reported in patients undergoing hemodialysis. In our study at least one cutaneous manifestation was present in 100% of patients. A prospective study conducted on 'dermatological manifestations in chronic renal failure patients on hemodialysis in Civil hospital, Karachi by Mirza et al.9 showed cutaneous changes in 96% of patients.

In present study, pallor (74.4%) was found to be the most common skin manifestation among CKD patients. In a study carried out by Udayakumar et al.14 pallor was observed in 60% of Indian patients, while only 45% of Egyptian patients in a study by Sultan et al.8 were pale. Pallor in CKD is due to anemia. Anemia is primarily the result of inadequate erythropoietin production by the failing kidneys. Other contributory factors of anemia in CKF patients include iron, folic acid or vitamin B12 deficiencies and decreased erythrocyte survival. The difference in frequency of pallor in our study may be due to different patient factors. Loss of appetite due to CKD may potentiate nutritional deficiencies. Socioeconomic conditions can be responsible for availability of erythropoietin, blood transfusions and a healthy diet in our region.

In our study, hyperpigmentation was seen in 71.9% of CKD patients. Mirza et al.9 and Sultan et al.8 reported hyperpigmentation in 54% of patients in each study. Other studies reported a prevalence of hyperpigmentation 20-22%.15,16 In the present study, result of hyperpigmentation was higher than similar studies. Diffuse hyperpigmentation seen on sun-exposed areas is attributed to an increase in melanin in the basal layer and superficial dermis due to failure of the kidneys to excrete beta melanocyte stimulating hormone ([beta]-MSH). Sun exposure induced pigmentation is modified to some extent by socioeconomic, cultural, educational and living conditions. Exposure to hakeem medication may be a contributing factor.

Xerosis, in our study was observed in 60% of CKD patients while it was the most common cutaneous abnormality (79%) in study done by Udayakumar et al.14 Prevalence of xerosis observed in previous reports (46-90%)16,17,18 is comparable with our findings. While study by Mirza et al.9 demonstrated prevalence of xerosis in 96%, being the most common finding in that study. The factors that contribute to xerosis included a reduction in size and functional abnormalities of eccrine sweat glands, high doses of diuretics and alteration of vitamin A metabolism. The variation in finding can possibly be explained by different geographic, as well as, environmental conditions such as humidity and temperature.

In present study, pruritus was observed in 56.9% of patients. Pruritus was the most common cutaneous abnormality (55%) in Egyptian CKD patients on hemodialysis seen by Sultan et al.8 In Udayakumar et al.14 study, 53% of patients complained of pruritus. Our results are comparable with previous reports of pruritus. It is one of the most characteristic and annoying cutaneous symptoms of CRF. The etiology is multifactorial. It is not present in acute renal failure and does not necessarily subside with dialysis but improves to variable extent with kidney transplantation.

Prevalence of ecchymosis was 17.5% in this study while Sultan et al.8 reported higher rate of ecchymosis (27%). Purpuric lesions were seen in 13.6% of patients by Mirza et al.9 The causes may be due to defects in primary hemostasis like increased vascular fragility, abnormal platelet function and the use of heparin during dialysis.

Mucosal changes like ulcerative stomatitis was seen in 13.8% of our patients which was higher than the percentage (9%) seen in Egyptian patients by Sultan et al.8 Udayakumar et al.14 described 29% of patients with ulcerative stomatitis. Bad oral hygiene may contribute to mucosal changes in patients.

Fissured tongue was seen in 11.3% patients of our study, a feature not seen by Sultan et al.8 and Mirza et al.9 Angular chelitis was seen in only 1.9% of our patients while higher percentages were seen in Udayakumar et al.14 and Sultan et al.8 as 12% and 15%, respectively.

In current study half-and-half nails were present in 34.4% of patients which is consistent with the finding in the study of Mirza et al.9 demonstrated half-and-half nail in 36.7% patients. 28% patients showed Lindsay nails in Egyptian patients in Sultan et al.8 study. The white appearance of proximal nail bed is due to nail bed edema associated with dilated capillaries.

Koilonychia was seen only in 3.1% of our patients. While 39% of patients had spoon shaped nails in study by Sultan et al.8

Other less common, specific manifestations of CKD patients on hemodialysis like acquired perforating disorders (1.3 % by Mirza et al.9), calciphylaxis (2% by Mirza et al.9), porphyria cutanea tarda and few others that were described in literature, only reactive perforating collagenosis was seen in our study in 2.7% frequency, 3.7% patients had onychomycosis. Further stratification has shown that RPC are more often seen in males and with relatively longer duration of CKD.

Conclusion

Chronic kidney disease is associated with a complex array of cutaneous manifestations caused either by the disease or by treatment. Pallor, hyperpigmentation and xerosis were the most common among patients with CKD, so early recognition of cutaneous signs could relieve suffering and decrease morbidity.

References

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11. Wesseling C, Crowe J, Hogstedt C, Jakobsson K, Lucas R, Wegman DH. The epidemic of chronic kidney disease of unknown etiology in Mesoamerica: a call for interdisciplinary research and action. Am J Public Health. 2013;103:1927-30.

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Publication:Journal of Pakistan Association of Dermatologists
Article Type:Report
Date:Sep 30, 2017
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