|Year : 2017 | Volume
| Issue : 1 | Page : 8-14
Dermatological manifestations in chronic renal failure patients with and without hemodialysis: A study at a tertiary care centre
Geetha M Chanda, Sudha R Chintagunta, Geetakiran Arakkal
Department of DVL, Gandhi Medical College and Hospital, Hyderabad, Telangana, India
|Date of Web Publication||20-Mar-2017|
Sudha R Chintagunta
Associate Professor, Govt. Medical College and Hospital, Nizamabad, Telangana
Source of Support: None, Conflict of Interest: None
Background: Skin is an important diagnostic window to many diseases of internal organs including the renal system. Subtle changes in the skin may act as a clue to the underlying renal pathology. The cutaneous manifestations may be caused either by the disease or drugs used in the treatment of chronic kidney disease (CKD).
Aim: The aim of this study is to investigate and compare cutaneous manifestations in patients with CKD on hemodialysiswith patients not on dialysis. Materials and Methods: One hundred patients with CKD were recruited, 50 each in maintenance hemodialysis (MHD) and nondialysis group. Detailed cutaneous examination and necessary investigations were done, and cutaneous manifestations were compared among the two groups.
Results: Of the 100 patients, 72 were males and 28 were females. Mean duration of disease was 32.4 months in the dialytic group and 11.2 in the nondialytic group. The most common underlying disease that lead to CKD was diabetes mellitus. Specific cutaneous manifestations observed were Kyrles disease 4%, calcinosis cutis 1%, and uremic frost in 1%. The common nonspecific manifestations observed were xerosis in 59% (dialytic 61.03%, nondialytic 38.98%), pallor in 57% (dialytic 49.1%, nondialytic 50.9%), pruritus in 38%, (dialytic 63.16%, nondialytic 36.84%), pigmentation in 32% (dialytic, 65.63%, nondialytic 34.37%), purpura in 8% of dialytics, and none of the nondialytic patients had purpura. Cutaneous infections were found in 28%, of which fungal were 20%, bacterial 7%, and viral infections 2%. Nail changes were observed in 46% (dialytic 62%, nondialytic 30%), hair changes in 16%, and mucosal manifestations in 11% of the patients. Puncture marks were found in 74% of the dialytic patients. Xerosis, pruritus, and pigmentation had significantly higher prevalence in diabetic uremics compared to nondiabetic uremics.
Conclusions: There was a significant association with the mean duration of disease, which is higher in dialytic patients compared to the nondialytic group. Xerosis, pruritus, and hyperpigmentation were common in dialytic patients.
Keywords: Chronic renal failure, cutaneous manifestations, dialysis group, nondialytic group
|How to cite this article:|
Chanda GM, Chintagunta SR, Arakkal G. Dermatological manifestations in chronic renal failure patients with and without hemodialysis: A study at a tertiary care centre. J NTR Univ Health Sci 2017;6:8-14
|How to cite this URL:|
Chanda GM, Chintagunta SR, Arakkal G. Dermatological manifestations in chronic renal failure patients with and without hemodialysis: A study at a tertiary care centre. J NTR Univ Health Sci [serial online] 2017 [cited 2018 Jan 20];6:8-14. Available from: http://www.jdrntruhs.org/text.asp?2017/6/1/8/202583
| Introduction|| |
Skin is the mirror of internal disease, and the ability to diagnose systemic disease by cutaneous manifestations has always fascinated clinicians. Skin problems are common and diverse in patients with chronic kidney disease (CKD), especially among those on hemodialysis. They could predate onset of dialysis or could be precipitated by it. Though various inherited and acquired disorders affect both sites, the skin is affected by uremia regardless of the cause and drugs used in renal patients.
| Materials and Methods|| |
A total of 100 chronic renal failure patients of both sexes, aged between 20 and 80 years attending the nephrology ward, Gandhi hospital during a 1-year period (March 2011 to February 2012) were recruited in the study. After obtaining informed written consent, patients were grouped as the dialytic group and nondialytic group to compare dermatological manifestations in CKD patients. The dialytic group included 50 consecutive CKD patients on maintenance hemodialysis who were selected for hemodialysis according to the predialysis criteria of serum creatinine – >4 mg/dl, blood urea > 70 mg/dl, serum potassium > 6.5. If symptomatic, irrespective of the abovementioned criteria, patients were considered for dialysis. The nondialytic group included 50 CKD patients attending the nephrology and DVL outpatient department who were selected randomly. Patients with acute renal failure and renal failure for less than 3 months, patients undergoing peritoneal dialysis, and patients with known systemic or psychological dysfunctions were excluded. Detailed history and thorough physical examination was done in both the groups for the presence of mucocutaenous manifestations and recorded on a predesigned proforma. This included detailed assessment of skin, nails, hair, and mucous membrane for specific and nonspecific cutaneous manifestations of CKD. Patients on maintenance hemodialysis (MHD) were examined for any puncture marks, extravasation, and arteriovenous shunt dermatitis. The various investigations done were CUE, CBP, RBS, RFT, serum calcium and phosphorous, chest X-ray, and ultrasonography. Investigations such as Gram stain, Tzanck smear, KOH mount, and skin biopsies were done wherever indicated.
Chi-square/Fisher exact test was used to find the significance of various dermatological manifestations between the two groups of patients.
The statistical software graph pad prism 6 version 6.01 was used for the data analysis, and Microsoft word and excel were used to generate graphs, tables, etc.
| Results|| |
Of the 100 study participants, 72 were males and 28 were females. The patients' age ranged between 20 and 80 years, with majority belonging to 41–50 years in the dialytic group and 31–40 years in the nondialytic group. The mean duration of the disease in dialytic patients was 32.9 months and that in the nondialytic patients was 11.2 months. The most common underlying etiology causing CKD in our study was diabetes mellitus [Figure 1].
Specific dermatological manifestations such as Kyrles disease was observed in 4 uremic patients, of which 3 (6%) patients were dialytic and 1 (2%) patient was nondialytic. Calcinosis cutis and uremic frost were observed in 1 dialytic patient each. Nephrogenic fibrosing dermopathy was not encountered in our study [Figure 2].
The mean prevalence of specific skin changes was compared using Chi-square test, resulted in Chi-square value of 5.250 and P value of 0.0724 (>0.05). There was no statistically significant difference in the prevalence of specific skin manifestations in the dialytic group compared to the nondialytic group. Nonspecific dermatological manifestations observed were xerosis in 59%, pallor in 57%, pruritus in 38%, pigmentation in 32%, and purpura in four [Table 1].
|TABLE 1: DERMATOLOGICAL MANIFESTATIONS IN CKD PATIENTS WITH AND WITHOUT HAEMODIALYSIS|
Click here to view
Xerosis was the most common nonspecific manifestation observed in 59 (59%) patients, generalized in 30 (50.8%), and localized in 29 (49.2%). The extremities were the most commonly involved site. Twenty-eight (47.4%) patients had grade 1 xerosis whereas grade 2 and 3 xerosis was seen in 7 (11.8%) and 24 (40.8%) patients, respectively. Prevalence of xerosis was more in the dialytic group 36 (61.02%) compared to the nondialytic group 23 (38.98%), with statistically significant higher prevalence in the dialytic group with P value 0.014 (<0.05) [Table 1].
Pallor was the second most common finding constituting 57% of the patients; dialytic 28 (49.1%) and nondialytic 29 (50.9%) patients, which was statistically not significant (P > 0.05). There was a significant association between pallor and absent lunula with a P value of 0.0013 [Table 1].
Pruritus was found in 38 patients, generalized in 26 (68.4%) and localized in 7 (31.6%). There was significant association (P = 0.0194) between pruritus and xerosis. Out of the 38 pruritic patients, 25 (65.7%) had xerosis. There was statistically significant higher prevalence of pruritus in the dialytic group 24 (63.16%) compared to the nondialytic group 14 (36.84%), with a P value 0.039 (<0.05) [Table 1].
Pigmentation was found in 32 patients. There were 21 dialytic patients and 11 nondialytic patients. Generalized pigmentation was seen in 21 (65.6%) and localized in 11 (34.37%) patients. Face and extremities were commonly affected. There was statistically significant higher prevalence of pigmentation in the dialytic group (65.63%) compared to the nondialytic group (34.37%), with a P value of 0.032 (<0.05). There was significant association between HCV positive patients and prevalence of pigmentation in dialytic patients, with a P value 0.009 (<0.01) [Table 1].
Purpura was observed in 4 (8%) patients in the dialytic group, and none of the nondialytic group patients had purpura; this was statistically significant with a P value of 0.041 (<0.05) [Table 1].
Cutaneous infections were observed in 28 patients, fungal in 20 (dialytic 12, nondialytic 8), bacterial in 6 (dialytic 4, nondialytic 2), viral in 2 (dialytic 2, nondialytic 0) [Table 1]. There was no statically significant difference in the prevalence of cutaneous infections in the dialytic group compared to the nondialytic group. Among fungal infections, pityriasis versicolor was noted in 40%, tinea corporis 25%, tinea cruris in 20%, and candidial intertrigo 15%. Among bacterial infections, 57% patients had furunculosis, 28.6% had diabetic foot ulcer, 14.3% had carbuncles. Out of the two cases of viral infections, one had herpes zoster and another had herpes labialis.
Out of the 100 patients, 46% had nail changes. Dialytic group patients had higher prevalence of nail changes, i.e., 31 patients (62%) compared to the nondialytic group, i.e., 15 patients (30%) [Table 2]. The mean prevalence of nail changes were calculated in both the groups and compared using Chi-square test, resulting in Chi-square value of 13.70 (P = 0.03). There was statistically significant higher prevalence of nail changes in dialytic group compared to nondialytic group [Table 2].
Hair changes were noted in 16 patients in dialytic group 10 (62.5%), whereas in nondialytics, it was 6 patients (37.5%); the difference was not statistically significant. Most of them complained of diffuse alopecia as well as dull and brittle hair.
Mucosal changes were noticed in 11 patients, of which the dialytic group consisted of 8 (16%) patients and nondialytic group 3 (4%). Xerostomia, chelitis, aphthous stomatitis, and uremic fetor was observed in 5, 3, 2, and 1 patients, respectively.
Among 100 patients, 45 patients were diabetics (dialytic group 23, nondialytic 22). There was no significant difference in the prevalence of diabetes between dialytic and nondialytic groups. Diabetic uremics had significantly higher prevalence of xerosis and pruritis compared to nondiabetic uremics, with a P value < 0.05 [Table 3].
|TABLE 3: DERMATOLOGICAL MANIFESTATIONS AMONG DIABETICS VERSUS NON DIABETIC PATIENTS|
Click here to view
Statistically significant higher prevalence of HCV positivity (8 patients) was encountered in dialytic patients compared to nondialytic patients. HCV positive patients had significantly higher prevalence of pigmentation and melanonychia compared to HCV negative patients.
| Discussion|| |
In the present study, out of 100 patients, 95% had at least one skin manifestation and nail, hair, and mucosal manifestations in 46%, 16%, and 10% respectively. Pico et al. also found skin involvement in all patients undergoing dialysis. Nunley reported that 50–100% of patients with ESRD had at least one cutaneous lesion.
Among 100 CKD patients, 72 were males and 28 were females. The most common affected age group affected was 41–50 years (30%) followed by 51–60 years (28%) in the dialytic group and nondialytic group 31–40 years (36%) followed by 41–50 years (30%).
The most common underlying etiology causing CKD in our study was diabetes mellitus (45%) followed by chronic glomerulonephritis (23%). In studies by Ghunawat et al. and Khanna et al., common cause was chronic glomerulonephritis followed by diabetes mellitus in 48%, 28% and 45%, 22% patients, respectively. In other Indian studies, the frequency of skin involvement ranged 96–100%.,
Out of 100 patients, 45 were diabetics and 55 were nondiabetics. In a study by Udayakumar et al., nearly all cutaneous manifestations were common among diabetic patients. In dialytic group, 8 were HCV positive and 2 were HIV positive. None of the nondialytic patients were positive for HCV or HIV.
Specific skin manifestations included acquired perforating dermatosis (APD), metastatic calcification (MC), uremic frost (UF), nephrogenic fibrosing dermopathy, (NFD), and bullous dermatosis of dialysis (BDD). APD is reported to occur in 4.5–17% of the patients on hemodialysis. In this study, Kyrles disease was noted in 4 patients (dialytic 3 and nondialytic 1), MC in 1 dialytic patient, and UF in 1 nondialytic patient. Other specific manifestations such as BDD and NFD were not observed. There was no statistically significant higher prevalence of specific cutaneous manifestations in dialytics compared to the nondialytic group.
Xerosis was the most common nonspecific manifestations noted, with an overall prevalence of 59%. Dialytic group (61.02%) had statistically significant higher prevalence (P = 0.014) compared to nondialytic patients (38.98%). Prevalence of xerosis in CKD patients was reported to be variable (59–93%)., Gilchrest et al. observed xerosis in 69% of nondialytic uremics and 70% of patients on hemodialysis. These figures were reported to be 62% and 91% by Yopisowitch et al. The higher prevalence of xerosis in our study could be to inadequate use of emollients due to poor economic status. Other factors such as caloric intake and protein malnutrition are more prevalent in the Indian scenario, and the tropical climate with greater sun exposure and resultant chronic dehydration maybe contributory.
Pallor was the second most common manifestation observed in 57% (dialytic 56% and nondialytic 58%). There was no significant difference between dialytic and nondialytic groups. Udayakumar et al. reported pallor in 60% of uremic patients. Malnutrition and iron deficiency anemia superimposed on the anemia of chronic disease, may result in a higher prevalence of skin pallor.
Pruritis was found in 38% patients, dialytic group (63.16%) has higher prevalence compared to the nondialytic group (36.84%). The reported prevalence of pruritis in the predialytic period ranges from 22% to as high as 85%., Recent reports show that 20–50% are affected.,, Udayakumar et al. reported pruritis in 53% of the patients. Xerosis is thought to contribute in the pathogenesis of pruritis, and the two may coexist in several skin conditions. There was statistically significant association (P = 0.00194) between xerosis and pruritis in our study, 65.7% of pruritic patients are xerotics.
Pigmentation was found in 32 patients, dialytic group (65.63%) had higher prevalence compared to nondialytic group (36.84%). Udayakumar et al. observed pigmentary changes in 53% of the patients. Smith et al. reported pigmentation and increased b-MSH values in both undialysed and dialysed patients, however, Gilchrest et al. reported hyperpigmentation in none of the 14 undialysed uremic patients. Higher number in our study could be due to large variation in sample size, patient profile, and racial differences. Comprehensive studies stating the exact prevalence of different types of pigmentary alterations in the undialysed patients are lacking.
Purpura was found in 8% of dialytic patients, and none of the nondialytics had purpura. Comparison is statistically significant with a P value of 0.041 (<0.05). Heparin use in dialysis may be the cause for purpura in dialytic patients. Udayakumar et al. observed purpura in 9% patients on hemodialysis.
A total of 28 patients had cutaneous infections fungal (20), bacterial (6), viral (2), and parasitic (0). Statistically significant difference was not found between the two groups. Udayakumar et al. reported fungal infections in 30%, bacterial in 13%, and viral in 12% patients. The high prevalence of skin infection is an expected finding in these patients due to lymphopenia, decreased B cell activity, and alteration of the T cell subsets and activities.
Nail changes constituted 46%, dialytic group had statistically significant higher prevalence compared to the nondialytic group. Absent lunula (26%) was significantly associated with pallor. Mean hemoglobin in patients with absent lunula was significantly lower compared to those without it. Melanonychia (13%) was found only in dialytic patients and was significantly associated with HCV positive patients. Attia et al. reported absent lunula in 33.7% of the patients and half and half nails in 21% of the patients. Udayakumar et al. reported beau's lines in 2% of the patients. Melanonychia and its association with HCV positive patients was not reported in any other study.
Hair changes were observed in 16 patients (dialytic 10 and nondialytic 6), difference was not statistically significant. Diffuse alopecia seen in this study has also been reported by kint et al., resulting from telogen effluvium due to heparin in hemodialysed patients.
Mucosal changes were observed in 11 patients (dialytic 8 and nondialytic 3). There was no statistically significant difference in mucosal changes between dialytic and nondialytic groups. Xerostomia, cheilitis, angular stomatitis. and uremic breath were reported in 5%, 3%, 2%, and 1% of the patients, respectively. Udayakumar et al. reported the abovementioned manifestations in 31%, 12%, and 1%, patients, respectively.
Local complications of dialysis were seen in 74% of the dialytic patients. Out of the 50 dialytic patients, 37 had puncture marks. Multiple cannulations for obtaining intravenous access for dialysis and administration of numerous drugs result in a large number of puncture marks.
Xerosis, pruritis, and pigmentation had significantly higher prevalence in diabetic uremics compared to nondiabetic uremics. Similar observation was reported in study by Attia et al.
HCV positive patients had significantly higher prevalence of pigmentation and melanonychia compared to HCV negative patients. Higher prevalence of hyperpigmentation in HCV positive patients was observed in the study by Attia et al.
The increasing prevalence of cutaneous manifestations such as xerosis, pigmentation, and pruritis with increasing severity of kidney disease was also reported by Gilchrest et al. However, their study included very few patients (n = 25), which is not statistically significant. In our study, all cutaneous findings were higher in patients on dialysis than the nondialytic group. This could be because of higher mean duration of disease in dialytic patients compared to nondialytic group. Second, most of our dialytic patients belonged to stage 5 CKD whereas nondialytic patients comprised stages 3 and 4 CKD.
| Conclusions|| |
In our study cutaneous manifestations in CKD was significantly associated with mean duration of disease, which is higher in dialytic patients compared to nondialytic group. Specific manifestations such as Kyrles disease and calcinosis were predominantly noted in dialytic group. There was statistically significant higher prevalence of nonspecific manifestations such as xerosis, pruritus, hyperpigmentation, purpura, and nail changes in dialytic patients. Any such cutaneous marker in the absence of a primary dermatological problem warrants a thorough search, including hematological, urine, and radiological investigations to rule out kidney disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pico MR, Lugo-somolinos A, Sanchez JL, Burgos-Calderón R. Cutaneous alterations in patients with chronic renal failure. Int J Dermatol 1992;31;860-3.
Nunley JR. Dermatologic manifestations of renal disease. eMed J 2002: topic 550 (online review) [Last accessed on 2004 Jan 31].
Ghunawat S, Barman KD, Sarkar R, Garg VK, Alhawat RS. Spectrum of dermatological manifestations in patients with Chronic Kidney Failure. MAMC J Med Sci 2015;1:96-100. [Full text]
Khanna D, Singal A, Kalra OP. Comparison of cutaneous manifestations in chronic kidney disease with or without dialysis. Postgrad Med J 2010;86:641-7.
Udayakumar P, Balasubramanian S, Ramalingam KS, Lakshmi C, Srinivas CR, Mathew AC. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. Indian J Dermatol Venereol Leprol 2006;72:119-25.
] [Full text]
Bencini PL, Montagnino G, Citterio A, Graziani G, Crosti C, Ponticelli C. Cutaneous abnormalities in uremic patients. Nephron 1985;40:316e21.
Stahle-Backdhal M, Hagermark O, Lins LE. Pruritus in patients on maintenance haemodialysis. Acta Med Scand 1988;224:55-60.
Gilchrest BA, Rowe JW, Mihm MC Jr. Clinical and histological skin changes in chronic renal failure: Evidence for a dialysis resistant, transplant responsive microangiopathy. Lancet 1980;2:1271-5.
Yosipovitch G, Reis J, Tur E, Sprecher E, Yarnitsky D, Boner G. Sweat secretion, stratum corneum hydration, small nerve function and pruritus in patients with advanced chronic renal failure. Br J Dermatol 1995;133:561-4.
Young AW Jr, Sweeney EW, David DS, Cheigh J, Hochgelerenl EL, Sakai S, et al
. Dermatologic evaluation of pruritus in patients on hemodialysis. N Y State J Med 1973;73;2670-4.
Gilchrest BA, Stern RS, Steinman TI, Arndt KA, Anderson WW. Clinical features of pruritus among patients undergoing maintenance haemodialysis. Arch Dermatol 1982;118:154-6.
Patel TS, Freedman BI, Yosipovitch G. An update on pruritus associated with CKD. Am J Kidney Dis 2007;50:11-20.
Mettang M, Weisshaar E. Pruritus: Control of itch in patients undergoing dialysis. Skin Ther Lett 2010;15:1-5.
Feramisco JD, Berger TG, Steinhoff M. Innovative management of pruritus. Dermatol Clin 2010;28:467-78.
Smith AG, Shuster S, Comaish JS, Plummer NA, Thody AJ, Alvarez-Ude F, et al
. Plasma immunoreactive beta melanocyte stimulating hormone and skin pigmentation in chronic renal failure. Br Med J 1975;1:658.
Avermaete A, Altmeyer P, Bacharach-Buhles M. Skin changes in dialysis patients: A review. Nephrol Dial Transplant 2001;16:2293-5.
Attia EA, Hassan SI, Youssef NM. Cutaneous disorders in uremic patients on hemodialysis: An Egyptian case control study. J Egypt women Dermatol Soc 2010;7:49-55.
Kint A, Bussels L, Fernandes M, Ringoir S. Skin and nail disorders in relation to chronic renal failure. Acta Derm Venereol 1974;54:137-40.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]