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A Prospective Study of Cutaneous Abnormalities in Patients with Chronic Kidney Disease

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A Prospective Study of Cutaneous Abnormalities in Patients with Chronic Kidney Disease Original Article A prospective study of cutaneous abnormalities in patients with chronic kidney disease E. A. Thomas, B. Pawar1, A. Thomas Departments of Dermatology, and 1Nephrology, Christian Medical College and Hospital, Ludhiana, Punjab, India ABSTRACT There are diverse ways in which the skin is affected by chronic kidney disease (CKD). Various specific and nonspecific skin abnormalities are observed in patients with CKD. The aim of the study was to document the prevalence of skin diseases that commonly occur in patients with CKD on medical treatment and dialysis. A total of 99 patients with CKD were examined for evidence of skin diseases. Ninety-six had at least one cutaneous abnormality attributable to CKD. The most prevalent finding was xerosis (66.7%), followed by pallor (45.45%), pruritus (43.4%), and cutaneous pigmentation (32.3%). Other cutaneous manifestations included dermatitis (27.27%); Kyrle’s disease (17.17%); fungal (8.08%), bacterial (11.1%), and viral (5.05%) infections; purpura (10.1%); gynecomastia (4.04%); and yellow skin (5.05%). The common nail changes were half and half nails (36.36%) and onycholysis (13.13%). CKD is associated with various cutaneous abnormalities caused either by the disease or by treatment, the most common being xerosis and pruritus. The dermatologic complications can significantly impair the quality of life in certain individuals; therefore, earlier diagnosis and treatment is important to improve their quality of life. Key words: Chronic kidney disease, dialysis, uremic pruritus Introduction Materials and Methods Dermatologic abnormalities are common in chronic Patients with CKD, on medical treatment or dialysis kidney disease (CKD) and range from the nearly were included in this prospective, observational study. universal xerosis and pruritus to uncommon conditions The history of duration of CKD and dialysis as well as such as hyperpigmentation of exposed areas, purpuric the onset of skin disease with regard to diagnosis of skin changes, acquired perforating dermatosis, and nail CKD were taken. A complete clinical and dermatological abnormalities.[1] In a study by Pico et al.,[2] all patients examination was carried out. The creatinine clearance of with CKD had one or more skin manifestations, while these patients was calculated using the Crockroft–Gault Bencini et al.[3] noticed skin changes in 79% of the formula.[4] patients. This study was conducted to determine the prevalence of cutaneous abnormalities in stable and Staging of CKD was done according to the Kidney Disease dialysis‑dependent CKD patients. Outcomes Quality Initiative (K/DOQI) clinical practice guidelines.[5] Address for correspondence: Dr. Emy Abi Thomas, Department of Dermatology, Christian In all patients, a complete blood count; renal function Medical College and Hospital, Ludhiana, Punjab - 141 008, India. tests such as blood urea, serum creatinine and electrolytes, E-mail: [email protected] serum calcium, inorganic phosphorus, and alkaline phosphatase; urine analysis and renal ultrasound were Access this article online performed. Specific investigations such as skin biopsies, Quick Response Code: Website: culture and sensitivity for bacterial infections, Gram’s www.indianjnephrol.org stain, potassium hydroxide mount, and fungal culture were done wherever clinically indicated. DOI: 10.4103/0971-4065.97127 The severity of xerosis was assessed using a modified version of grading used by Morton:[6] Grade‑ 0 (smooth skin), 116 March 2012 / Vol 22 / Issue 2 Indian Journal of Nephrology Thomas, et al.: Skin disorders in chronic kidney disease grade‑ 1 (rough skin), and grade‑ 2 (rough skin with scaling). Table 1: Cutaneous manifestations in different stages of chronic kidney disease Patients with CKD stage V were further classified as either Skin III IV V V V Total Percentage manifestations stable CAPD HD stable CKD, hemodialysis‑dependent CKD (HD‑CKD), and Xerosis on continuous ambulatory peritoneal dialysis (CAPD). Mild (grade‑I) 3 6 3 3 36 51 66.7 Renal transplant recipients were excluded from this Severe (grade II) 2 2 1 1 9 15 43.4 prospective observational study. Pruritus Mild 3 4 1 1 17 26 45.45 Severe 2 2 0 1 12 17 32.3 Results Pallor ‑ 2 4 1 38 45 5.05 Pigmentation ‑ 1 1 1 29 32 10.1 Of the 99 patients, 78 were males. By staging the Yellow skin ‑ ‑ 1 ‑ 4 5 17.7 Purpura ‑ 1 2 ‑ 7 10 4.04 severity of CKD according to the K/DOQI clinical practice Kyrle’s disease 1 ‑ 1 3 12 17 11.1 guidelines,[5] 1 patient was found to be in stage II, 8 in Gynecomastia ‑ ‑ ‑ ‑ 4 4 5.05 stage III, 10 in stage IV, and 80 in stage V. Stage V patients Infections were further divided into stable (6), HD‑CKD (70), and Bacterial 2 2 ‑ 2 5 11 8.08 Viral ‑ ‑ ‑ 1 4 5 1.01 CAPD (4). There were no patients with stage I CKD. Most Fungal 3 2 ‑ 1 2 8 1.01 of the patients were in the age group of 40‑60 years, Parasitic ‑ ‑ ‑ ‑ 1 1 27.27 with a mean age of 50.5 years. The youngest patient was Mycobacterium Lupus vulgaris ‑ ‑ ‑ ‑ 1 1 11 years old and the eldest, 86 years old. The etiology Dermatitis 4 4 6 ‑ 13 27 of CKD in this study showed that diabetic nephropathy CAPD = Continuous ambulatory peritoneal dialysis, HD = Hemodialysis was the cause of CKD in 42 patients followed by chronic interstitial nephritis (18), chronic glomerulonephritis Table 2: Nail changes in different stages of chronic (14), hypertension (5), autosomal dominant polycystic kidney disease kidney disease (6), obstruction (6), amyloidosis (2), and Nail changes III IV V V V Total Percentage undetermined etiology in 6 patients. stable CAPD HD Half and half nail 5 3 2 1 25 36 36.36 A total of 10 patients (9 male and 1 female) were Onycholysis 2 ‑ ‑ 2 9 13 13.13 Onychomycosis 2 2 ‑ 1 2 7 7.07 Hepatitis C Virus (HCV) antibody‑positive and 2 (2 male) Pitting 1 1 ‑ 1 4 7 7.07 were Hepatitis B Surface Antigen (HBsAg) positive. Mee’s line 1 ‑ ‑ 1 6 8 8.08 Anemia was a common problem when these patients Beau’s line ‑ 2 ‑ ‑ 3 5 5.05 were first seen, 7 had hemoglobin levels of less than Koilonychia ‑ ‑ ‑ ‑ 5 5 5.05 Subungual ‑ ‑ 1 ‑ 5 6 6.06 5 g/dl, 54 patients had hemoglobin levels in the range hyperkeratosis of 5‑8 g/dl and 38 had greater than 8 g/dl. In this study, Clubbing 2 ‑ ‑ ‑ 2 4 4.04 96 patients had at least one cutaneous abnormality; Muehrcke’s line ‑ ‑ ‑ ‑ 3 3 3.03 Brown nail bed arc ‑ ‑ ‑ ‑ 4 4 4.04 42 had multiple skin lesions, whereas 3 patients did Splinter ‑ ‑ 1 ‑ ‑ 1 1.01 not have any symptoms and signs of skin disease. Skin hemorrhage abnormalities in relation to staging of CKD are shown CAPD = Continuous ambulatory peritoneal dialysis, HD = Hemodialysis in Table 1. line (3.03%), brown nail bed arc (4.04%), and Splinter One patient on hemodialysis developed bullous hemorrhage (1.01%). dermatosis of hemodialysis. Other skin lesions seen in patients with CKD were diabetic bullae (1), diabetic Oral mucosa changes seen in this study were macroglossia dermopathy (1), psoriasis (2), vitiligo (1), acanthosis with teeth markings (tongue sign of uremia) in 9 (9.09%) nigricans (2), Darier’s disease (1), neurofibromatosis (1), of the patients; of this 22.22% were in stage IV and and Schamberg’s disease (1). 77.79% in stage V. Other mucosal changes were angular cheilitis (5.05%), ulcerative stomatitis (2.02%), and Nail changes in CKD are shown in Table 2. Among xerostomia (5.05%). the nail changes observed, Lindsay’s nails (half and half nails) were the most common and were seen in Discussion 36 patients (36.36%). Other nail changes included onycholysis (13.13%), onychomycosis (7.07%), and Xerosis was the most common cutaneous abnormality Mee’s lines (8.08%). Beau’s lines (5.05%), koilonychia (66.7%), which is comparable with other studies.[7‑10] This (5.05%), subungual hyperkeratosis (6.06%), Muehrcke’s abnormality was observed mainly in patients who were on Indian Journal of Nephrology March 2012 / Vol 22 / Issue 2 117 Thomas, et al.: Skin disorders in chronic kidney disease maintenance hemodialysis (45.45%); this being similar reported that pigmentary alterations occurred in 25‑70% to Anderson et al.,[11] who reported a high frequency of of dialysis patients and increases over the duration of renal xerosis (50‑70%) in dialysis patients [Figure 1]. None of disease. The pigmentation on sun‑exposed areas has been the patients had xerosis from childhood, but one patient attributed to an increase in melanin in the basal layer had hypothyroidism prior to the diagnosis of CKD. of the epidermis due to an increase in poorly dialyzable Features of atopy, associated with dry skin and keratosis beta‑melanocyte–stimulating hormone.[19] The intensity pilaris‑like lesions were seen in eight patients. A reduction of melanin pigmentation increases with respect to the in the size and functional abnormality of eccrine sweat duration of end‑stage renal disease. A yellowish tinge of the glands, suggesting compromised eccrine secretion skin was reported in 40% of patients by Pico et al.,[2] but leading to epithelial dehydration[12] may contribute to we encountered yellowish discoloration in only 5 (5.05%) the development of xerosis. patients, probably because of the dark complexion of Indians, which masks this finding. The yellowish skin color Pruritus is one of the most characteristic and annoying has been attributed to retained lipid soluble pigments such symptoms of CKD. In this study, 43.4% of patients as lipochromes and carotenoids, which are deposited in complained of pruritus, a finding similar to that in a study the dermis and subcutaneous tissue.[20] by Udayakumar et al., where they found the prevalence of [9] pruritus to be 53%.
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