RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE.

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DR. SUPHALA B POST GRADUATE STUDENT, NAME OF THE CANDIDATE DEPARTMENT OF SKIN AND STD 1. AND ADDRESS KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI- 580022.

KARNATAKA INSTITUTE OF MEDICAL 2. NAME OF THE INSTITUTION SCIENCES, HUBLI -580022.

M.D IN DERMATOLOGY ,VENEROLOGY COURSE OF THE STUDY AND 3. &LEPROSY SUBJECT DATE OF ADMISSION TO THE 17-5-2010 4. COURSE CUTANEOUS MANIFESTATIONS OF TITLE OF THE TOPIC CHRONIC RENAL FAILURE 5.

6. BREIF RESUME OF THE INTENDED WORK :

6.1 NEED FOR THE STUDY Chronic renal failure may be defined as a syndrome which result from progressive and irreversible destruction of nephrons,regardless of the cause.Some of the skin manifestations are due to chronic renal failure per se. These are pruritus, metastatic calcifaction, calciphylaxis, perforating collagenosis, Kyrle’s disease,half and half nail, uaemic frost (rare),diffuse hyperpigmentation, pallor, atrophy of skin, petechiae, bruising etc.

Over the past five decades, dialysis and transplantations have become effective in prolonging the lives of patients with renal insufficiency. These modes of management are associated with many adverse effects. Skin is one of the important target organ for the manifestation of these adverse effects.

Skin manifestations which are peculiar to dialysis are –local complications like extravasation, phlebitis, bacterial colonization of cannula, septicemia, allergic contact dermatitis to iodine solutions used as disinfectant and antiseptic, allergic contact dermatitis to tape or bandages used to secure dialysis cannula or tubing etc. Complications associated with haemodialysis are bullous dermatosis of haemodialysis, gynaecomastia.

6.2 REVIEW OF LITERATURE: Gurucharan singh, A K verma(1992), studied 30 cases of chronic renal failure(CRF).Generalised pruritus and numbness were the commonest symptoms observed in 14 and 11 cases respectively.Icthyotic skin changes of varying degree were observed in 27 cases and hyperpigmentations of sun exposed area of the skin in 11 cases. Half and half nails were seen in 4 cases only. Cutaneous changes like pruritus, pallor, scaling and hair loss correlated strongly with severity of renal failure.HPE revealed epidermal and dermal changes, latter were seen only in moderate to severe cases of renal failure.

P Udaykumar,S balasubramanian, (2006) from the Department of dermatology PSG hospital, Peelamedu,Coimbatore studied 100cases of CRF undergoing dialysis. 82%of patients complained of some skin problem. However, on examination, all patients had atleast one skin lesion attributable to CRF. The most prevalent finding was xerosis(79%),followed by pallor(60%),pruritus (53%), and cutaneous pigmentation (43%).Oher cutaneous manifestations included Kyrle’s disease(21%),fungal (30%),bacterial (13%) and viral (12%) infections, uremic frost (3%),purpura (9%),gynaecomastia (1%),and dermatitis (2%). The nail changes included half and half nail(21%),koilonychias(18%),onychomycosis(19%), subungual hyper keratosis (12%),onycholysis(10%),splinter haemorrhages (5%).Mee’s lines (7%),Muehrck’ sline (5%), and Beau’ s lines (2%).Hair changes included sparse body hair (30%),sparse scalp hair (11%),and brittle and lusterless hair (16%).Oral changes included macrogossia with teeth markings (35%),xerostomia (31%),ulcerative stomatitis (29%),angular cheilitis (12%) and uremic breath (8%).Some rare manifestations of CRF like uremic frost, gynaecomastia and pseudo- Kaposi’s sarcoma were also observed. Maha M sultan, Hayam H Mansour(2010), conducted study on 100 cases of CRF on regular haemodialysis. The most prevalent finding was pruritus (55%) followed by xerosis (54%) , hyperpigmentation(54%) and pallor (45%). Other cutaneous manifestations were wrinkles (40%), fungal infections (33%), ecchymosis (27%),dermatitis (23%), yellow face(22%),petichae (19%), delayed wound healing(11%),follicular hyperkeratosis(10%),bacterial infection (5%),viral infection (2%),uremic frost (1%).nail changes were koilonychias (39%),half and half nail(28%), splinter haemorrhages (16%), Muehrck’ sline(12%).other features were subungual hyperkeratosis (10%), Mee’s lines (8%),brown nail (6%), onycholysis(3%), Bea’s line .Hair changes were brittle and lusterless hair (47%), sparse scalp hair (46%), and sparse body hair (27%). Oral changes were macroglossia (42%), xerostomia (35%),coated tongue (27%), angular cheilitis (15%),ulcerative stomatitis.

Masmoudi A, Ben Hmida M(2006), conducted a prospective study of 363 haemodialysis patients.88% of patients had cutaneous manifestations. Pruritus was observed in 44.8%.Cutaneous xerosis was observed in 69%. Changes in pigmentation were observed in 17% cases,mainly in sun exposed area, follicular hyper keratosis was pbserved in 15%. Other cutaneous manifestations included petechiae,ecchymosis,follicular type infection, sub cutaneous calcificatuion, cutaneous pseudo- porphyria and eczema around gfistula (11.5%).

S Banerjee(2007), reported a series of six cases of renal failure with varied cutaneous manifestations ranging from infections to neoplasms due to prolonged immunosupression.first case had cutaneous cryptococcosis.the second case initially presented with florid warts and was treated successfully but later presented with an explosive reccurence of skin lesions due to malignant transformation.third cases had basal cell carcinoma. Fourth case had diabetic nephropathy that presented with septicemia and purpura fulminans.the last case had cutaneous manifestations of drug therapy because of heparin infusion.

6.3 OBJECTIVE: 1. To study various Cutaneous manifestations in chronic renal failure(CRF) 2. To study factors affecting cutaneous manifestations in CRF 3. To study various Cutaneous manifestations in dialysis patients 4. To correlate Cutaneous manifestations in CRF ,who are on dialysis and who are not on dialysis.

7. MATERIALS AND MEDTHODS

7.1 SOURCE OF DATA AND MATERIALS. Cases clinically diagnosed as chronic renal failure patients,attending nephrology unit,department of medicine, KIMS hospital Hubli from 15th November 2010 to 15th may 2012.

INCLUSION CRITERIA: All cases of chronic renal failure of all age groups and sexes attending nephrology unit,department of medicine, KIMS hospital Hubli.

EXCLUSION CRITERIA: 1. Patient with acute renal failure and those on peritoneal dialysis are excluded from the study 2. Patient with renal transplant are excluded from the study 3. Patient who don’t give consent for skin biopsy

7.2 METHOD OF COLLECTION OF DATA: A predesigned Proforma used for all cases including detailed history and clinical examination findings, necessary laboratory investigations are done including a punch biopsy for histopathological examinations, wherever necessary following a written consent.

SAMPLE SIZE: 100.This is calculated by taking average of yearly number of cases of CRF over last three years. As it’s a time bound study (18 months)all cases of CRF fulfilling the inclusion and exclusion criteria coming during the period of 15th November 2010 to 15th May 2012.

7.3 Does the study require any investigations or interventions to be conducted on patients, humans or animals? If so, please describe briefly. YES,

These investigations will be dione in all cases: 1. Routine blood and urine examination 2. Renal function tests and if required necessary radiological and other investigations

Skin biopsy for histopathological examination with H&E staining and special stains, if required in clinically undiagnosed or doubtful cases.

7.4 Has ethical clearance has been obtained from your institution in case of 7.4.

Yes, clearance has been obtained from the Ethical Committee of Karnataka Institute of Medical Sciences, Hubli.

7.5 Statistical analysis: Results will be analyzed by using appropriate statistical tests.

8. LIST OF REFERENCES:

1. Barry M Brenner, Michael Lazarus.Chronic renal failure. Harrisons principles of internal medicine, 15th edition: McGraw Hill Inc 2000

2. Gurucharan singh,A K Verma,Gurubir Singh,SJ Singh. Cutaneous changes in Chronic renal failure.Ind J dermatol Venereol and Leprol,1992;58:320-322

3. P Udaykumar,S Balasubramanian,KS Ramalingam,Chemboli Lakshmi,CR Srinivas.Cutaneous manifestations in patients with chronic renal failure on dialysis.Ind J Dermatol Venereol and Leprol,2006;72:119-125.

4. Maha M Sultan,hayam M Mansour, Iman M Wahby, Ali S Houdery. Cutaneous manifestations in Egyptian patients with with chronic renal failure on regular hemodialysis. J Egypt Women Dermatol Soc,2010;7:49-55.

5. Masmoudi A,Ben Hmida M,Mseddi M,Meziou TJ. Cutaneous manifestations of chronic haemodialysis-Prospective study of 363.Presse Med,2006;399-406.

6. S Banerjee, Cutaneous manifestations in renal failure patients:a case series, Ind J Dermatol Venereol and Leprol,2007;73:106-108.

7. Madiha Sanai, Shahbaz Aman,Muhammad Nadeem,Atif Hansnain Kazmi.Dermatological manifestations in patients of renal disease on hemodialysis.Journal of Pakistan Associations of dermatologists,2010;20:162-168.

SIGNATURE OF THE 9. CANDIDATE 10. REMARKS OF THE GUIDE

11. 11.1 NAME AND DR.RAVI M RATHOD, MD DESIGNATION PROFESSOR, DEPARTMENT OF OF THE GUIDE DERMATOLOGY VENEREOLOGY AND LEPROSY KIMS, HUBLI.

11.2 SIGNATURE

DR VENKATESH MOGER, MD, DNB PROFESSOR, DEPARTMENT OF MEDICINE 11.3 CO-GUIDE (IF ANY) KIMS, HUBLI

11.4 SIGNATURE

DR.RAGHAVENDRA TOPHAKHANE MD, PROFESSOR & HEAD , 11.5 HEAD OF THE DEPARTMENT OF DERMATOLOGY DEPARTMENT VENEREOLOGY AND LEPROSY KIMS, HUBLI.

11.6 SIGNATURE

12.1 REMARKS OF THE 12 CHAIRMAN AND THE PRINCIPAL

12.2 SIGNATURE.