| Abstract|| |
To evaluate the fingernail changes in patients with end-stage renal failure (ESRF) on regular hemodialysis (HD), we reviewed 69 patients (male 25, female 44; age 40 ± 14.8 years) who have been on HD at Samtah General Hospital, Gizan, Kingdom of Saudi Arabia for a mean of 4.3 ± 3.06 years. They were free from congenital, systemic or primary skin disorders contributing to nail changes. The patients were also free from ornamental dyes like henna, traumatic injuries or infections in the fingernails. They were also clinically free from features suggestive of the carpal tunnel syndrome or vascular steal syndrome secondary to arteriovenous fistula (AVF) created for vascular access. Their nails were examined under bright day light by the authors independently. The findings consistent among all three observers were taken for analysis. Hemoglobin and serum albumin levels were also estimated. We compared these changes according to age, sex, and duration on chronic hemodialysis, AVF, and the levels of serum albumin and hemoglobin. One or more nail changes were observed in 44/69 (64%) patients. The commonest abnormality was the so-called "Half-and-half nail changes", which was observed in the finger nails of 18/69 (26%) of the study patients (males to female ratio was 2:1). Typically, the half-and-half nails are nails where the distal portion of the nail bed is red, pink or brown, occupies 20-60% of the total nail length and is always sharply demarcated with the proximal portion. The latter has a dull whitish ground glass appearance and when pressure is applied, the distal discoloration does not fade completely. Non-specific nail changes were observed 26/69 (38%) patients. The hemoglobin and serum albumin levels were not significantly different of those with 'half-and-half' nail, non-specific nail changes or no nail changes. We conclude that various fingernail changes are observed in ESRF patients on HD. These nail changes are independent of the age of the patient, duration on HD, AVF or hemoglobin or albumin levels. However, a gender dependent trend was noticed and the half-and-half nail seems to be characteristic of uremia.
Keywords: Nail changes, Half-and-half nail, End-stage renal failure, Hemodialysis, Arteriovenous fistula, Hemoglobin, Serum albumin.
|How to cite this article:|
Jamal A, Subramanian P T, Hussain K S. Nail Changes in End-Stage Renal Failure Patients on Hemodialysis. Saudi J Kidney Dis Transpl 2000;11:44-7
|How to cite this URL:|
Jamal A, Subramanian P T, Hussain K S. Nail Changes in End-Stage Renal Failure Patients on Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2019 Nov 15];11:44-7. Available from: http://www.sjkdt.org/text.asp?2000/11/1/44/36692
| Introduction|| |
Skin changes are known to occur in chronic renal failure patients and in those with endstage renal failure (ESRF) on hemodialysis.  Various nail changes have been reported in uremic patients from time to time. Among them, half-and-half nail is typical of uremia. 
We present our observations on nail changes in ESRF patients on chronic maintenance hemodialysis (HD). The objectives of the study were to find out the finger nail changes in these patients and to correlate them with age, sex, duration of chronic HD, arteriovenous fistula (AVF), and to the levels of hemoglobin and serum albumin.
| Materials and Methods|| |
We evaluated 69 patients on chronic maintenance HD at Samtah General Hospital, Gizan, Kingdom of Saudi Arabia. They were free from congenital, systemic or primary skin disorders contributing to nail changes. The patients were also free from ornamental dyes like henna application, injuries or infection in the fingernails. They were also clinically free from features suggestive of the carpal tunnel syndrome or vascular steal syndrome secondary to arteriovenous fistula (AVF). Their nails were examined under bright day light by authors independently. The findings consistent among all three were taken for analysis.
Hemoglobin and serum albumin levels were also estimated. We compared these changes according to age, sex, and duration of chronic hemodialysis, AVF, and the levels of serum albumin and hemoglobin.
| Statistical Analysis|| |
Chi square test and Student's 't' test were used to compare frequencies and means of values. The statistical significance was set as P<0.01.
| Results|| |
The mean age of the patients included in the study was 40.3 ± 14.8 years (ranged from 13 to 80 years). These patients were on HD over a period ranging from 6 months to 11 years with a mean of 4.3 ± 3.06 years. All the patients had functioning AVFs in the upper limbs.
One or more nail changes were observed in 44/69 (64%) patients [Table - 1]. However, subgroup analysis revealed interesting observations. Half-and-half nail was diagnosed when the distal portion of the nail bed was found to be distinctly red, pink or brown in color, occupying 20-60% of the total nail length and sharply demarcated from the proximal portion. The latter had dull whitish ground glass appearance and when pressure was applied, the distal discoloration did not fade completely. Such changes were detected in the fingernails of 26% (18/69) of the study patients, and was noticed more in males (12/25) than in females (6/44), with ratio 2:1, (p<0.01).
Various non-specific nail changes were noticed in 26 patients; Muehrcke's lines in eight, koilonychia in six, Beau's line and friable nail in five each, peeling of nails in three, pitting in two and onychodystrophy in one [Table - 1]. Some of the patients had more than one non-specific change in their nails. Overall, these nail changes were independent of the age of the patient, duration on chronic maintenance HD or AVF.
The mean hemoglobin level was 8.43 ± 1.98 grams/L and the mean serum albumin level was 38.4 ± 4.2 grams/L. None of these parameters differed in those with "half-andhalf-nail" in comparison to those with nonspecific nail changes or no nail changes.
| Discussion|| |
In this study, nail changes in dialysis patients were classified as specific and nonspecific. Half-and-half-nail was considered characteristic of uremia. The remaining changes were put under the non-specific group, as they are seen in other conditions too.
The half-and-half nail change has already been described by Lindsay who discussed the importance of half-and-half nail in chronic renal failure.  This change can affect single nail or all the nails of the fingers and/or toes. It was also called later as Lindsay nail. It received considerable attention in the past  and is of value even today in differentiating chronic from acute renal failure at the bedside. Interestingly this change disappears after successful renal transplantation. 
Histological studies of the half-and-half nail revealed melanin pigment in the nail plate. , However, Kint et al  found no melanin but noted increase in the capillary density under the nail plate. The increase in the capillary density of the nail bed with remarkable thickening of the capillary walls might account for the band of discoloration. ,
The half-and-half nail often develops before the need for chronic dialysis. It occurs in 15 to 50% of patients on regular dialysis.  In our study, the distal portion was pink to brown and occupied about 20 to 30% of the nail length. This change was observed in 26% of the patients studied. Daniel et al  observed this in 10 to 35% of their series. In other study reported from India,  it was seen in 20% of hemodialysis patients. Gilchrest et al 10 observed halfand-half nail in 30% of their cases.
Also, among our study population, the changes were noticed more in males than females (p<0.01) for which we are unable to provide any definite explanation.
The non-specific nail changes were observed significantly more in females and possibly attributed to household activities resulting in frequent contact with water and chemicals including detergents.
Muehrcke's lines  are paired parallel white lines and are associated with hypoalbuminemia. However, in our study, it was observed in eight cases, all of them were normoalbuminemic.
Beau's lines  are horizontal grooves that appear on all nails after severe illness. In our series it was seen in 5 of 69 patients (7%) only.
Koilonychia is a term applied for spoon shaped depression of the nail plate; sometimes brittle. It is often encountered in iron deficiency anemia or results from overuse of solvents such as nail varnish remover or detergents, or may be consequent to mechanical stress.  In our study koilonychia was seen in only two males and four females in whom detergent use was a possible cause. However, their mean hemoglobin level was 5.7 ± 1.39 and it was significantly (p<0.001) lower than their counterparts.
Friable nails, manifesting with peeling and pitting of nails, were only seen in women. These changes may be related to their household activities.
In chronic renal failure the nails are sometimes described as opaque.  White nails were also associated with hypoalbuminemia.  None of the patients taken for this study had opaque or white nails.
In onychodystrophy, the nail plate is thick, dull and opaque with a yellowish white or grey color. It may be noticed in older individuals. In our study, it was seen in the thumb nail of a 60 years old female on the AVF contralateral side.
Among our study patients, shedding of finger nails (onycholysis) was not seen. Onycholysis was reported in some hemodialysis patients who received large doses of cephaloridine or cloxacillin.
Onychorrhexis was observed in the finger nails and toenails by Gilchrest et al,  but it was not seen in any of our patients. Splinter hemorrhages though not seen in the present series, have been previously observed in patients treated with hemodialysis or peritoneal dialysis by different authors.,
We conclude that various fingernail changes are observed in ESRF patients on HD. These nail changes are independent of the age of the patient, duration on HD, AVF or hemoglobin or albumin levels. However, a gender dependent trend are noticed and the half-and-half nail is characteristic of uremia.
| References|| |
|1.||Ponticelli C, Bencini PL. Dermatological disorders. In: Davison AM, Cameron JS, Grunfeld J, et al (eds). Oxford textbook of Clinical Nephrology, Oxford University Press, Second edition 1998;3:1995-2001. |
|2.||Lindsay PG. The half-and-half nail. Arch Intern Med 1967;119:583-7. [PUBMED] [FULLTEXT]|
|3.||Depner TA, Gulyassy PF. Chronic renal failure. In: Earley LE, Gottschalk CW, (eds). Strauss and Welt's diseases of the kidney, Boston, Little Brown and Company, USA, 3 rd edition 1979; vol I, section II, chapter six, p 248. |
|4.||Fienstein EI. The skin. In: Daugirdas JT, Ing TS (eds). Handbook of Dialysis. Boston, Little Brown and Company, USA. Second edition 1994;36:588. |
|5.||Leyden JJ, Wood MG. The half-and-half nail: a uremic onychopathy. Arch Dermatol 1972;105:591-2. [PUBMED] |
|6.||Stewart WK, Raffle EJ. Brown nail-bed arcs and chronic renal failure. Br Med J 1972;1:784-6. [PUBMED] [FULLTEXT]|
|7.||Kint A, Bussels L, Fernandes M, Ringoir S. Skin and nail disorders in relation to chronic renal failure. Acta Derma Venereol 1974;54:137-40. |
|8.||Daniel CR 3d, Bower JD, Daniel CR Jr. The 'half-and-half fingernail': the most significant onychopathological indicator of chronic renal failure. J Miss State Med Assoc 1975;16:367-70. |
|9.||Rao KR, Ismail M. Nail changes in chronic renal failure. J Assoc Phy India 1999;47:76. |
|10.||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;2:1271-75. [PUBMED] |
|11.||Ryan TJ. Diseases of the skin: diseases of nails, hairs and sweat glands. In: Weatherall DJ, Ledingham JGG, Warrell DA (eds). Oxford text book of medicine, Oxford, Oxford University Press, 3 rd edition 1996; 3760-1. |
|12.||Swash M (eds). The kidney and urine. In: Hutchison's clinical methods. London, ELBS with Baillere Tindall, 19 th edition 1989;154. |
|13.||Dramstadt GL, Al-Lane. Disorders of nails. In: Nelson EN, Behrman RE, Kliegman RM, Arvin AM. Nelson text book of pediatrics, Philadelphia, WB Saunders company, USA, 15 TH edition 1996;1886-88. |
|14.||Eastwood JB, Curtis JR, Smith EK, DeWardener HE. Shedding of nails apparently induced by the administration of large amounts of cephaloridine and cloxa-cillin in two anephric patients. Br J Dermatol 1969;81:750-2. |
|15.||Blum M, Aviram A. Splinter hemorrhages in patients receiving regular hemodialysis. JAMA 1978;239:47. [PUBMED] |
Department of Nephrology, Samtah General Hospital, Samtah, Gizan
[Table - 1]