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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 268-272
Skin changes in patients with chronic renal failure


Department of Medicine, University College Hospital, Ibadan, Nigeria

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Date of Web Publication18-Mar-2011
 

   Abstract 

Management of patients with renal failure remains a major problem in poor­resource nations. Cutaneous manifestations in this group of patients are varied and remain helpful in differentiating acute from chronic renal failure (CRF). We studied the prevalence and pattern of skin disorders in patients with CRF at The University College Hospital, Ibadan, Nigeria, during the period between May 2006 and February 2007. Relevant information was collected with the aid of a questionnaire. The patients were then examined for skin disorders. One hundred and twenty patients who met the inclusion criteria were recruited into the study. The mean age of the CRF patients was 43.12 ± 15.38 years, while that of the control subjects was 43.13 ± 15.38 years. Seventy-six of the 120 patients (63.3%) were on chronic hemodialysis while 44 (36.5%) were on conservative management. A total of 107 patients (89.1%) had at least one skin problem. The skin disorders seen include xerosis in 72 (60%), pruritus in 32 (26.7%), hyper-pigmentation, icthyosis and pityriasis versicolor in nine patients each (7.5%), either singly or in combination. Pallor of the skin was seen in three of the patients (2.5%), while uremic frost was seen in one (0.8%). Nail changes were seen in 48 patients (40%). We conclude that xerosis, pruritus, pigmentary and nail changes were the most common skin disorders in patients with CRF in our environment.

How to cite this article:
Falodun O, Ogunbiyi A, Salako B, George AK. Skin changes in patients with chronic renal failure. Saudi J Kidney Dis Transpl 2011;22:268-72

How to cite this URL:
Falodun O, Ogunbiyi A, Salako B, George AK. Skin changes in patients with chronic renal failure. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2014 Apr 19];22:268-72. Available from: http://www.sjkdt.org/text.asp?2011/22/2/268/77602

   Introduction Top


Chronic renal failure (CRF) is common a­mong patients attending hospitals in Nigeria, as in other parts of the world. [1],[2],[3] Skin problems are common and diverse in patients with CRF, especially in those on hemodialysis (HD). [4],[5],[6] They could predate the onset of dialysis or could be precipitated by it. Some of these cu­taneous disorders disappear following kidney transplantation, confirming that the metabolic milieu resulting from the malfunctioning kid­ney is responsible for some of these changes. Other lesions may be related to the cause of CRF. It is known that dialysis prolongs the life of the patients thus allowing them to develop further complications, including cutaneous dis­orders. Many of the skin problems are benign and do not affect the course of CRF; however, some of them may suggest the presence of a serious systemic disorder in the patient. As more patients in our environment are able to afford dialysis, it is likely that skin manifes­tations associated with CRF will be seen more frequently as the patients live longer.

Presently, there is paucity of information on the skin manifestations of CRF among Nige­rians in particular, and Africans in general. This study was undertaken to highlight the prevalence and clinical features of skin disor­ders seen in patients with CRF in a black po­pulation, emphasizing the peculiarities in the features seen compared with those documen­ted in studies carried out in other parts of the world.


   Materials and Methods Top


The cross-sectional study was carried out between May 2006 and February 2007 using subjects recruited from the clinics and wards at the University College Hospital Ibadan.

The diagnosis of CRF was made based on history, physical examination and laboratory in­vestigation results. The study subjects were 18­years and above and had their glomerular fil­tration rate calculated using the Cockcroft-Gault formula to ensure that they met the cri­teria for diagnosis of CRF. A total of 120 pa­tients with CRF were recruited into the study with an equal number of age- and sex matched controls with normal creatinine clearance. A questionnaire was distributed by the investiga­tors. This was to assess the relevant demogra­phic data as well as the presence, pattern and severity of cutaneous symptoms in the patients. The subjects then had a careful physical exa­mination of their skin and appendages. Skin biopsy was performed where necessary to confirm the clinical diagnosis.


   Results Top


The mean age of the CRF patients was 43.12 + 15.38 years, while that of the control group was 43.13 + 15.38 years. Seventy-six study patients (63.3%) were managed on HD, while 44 (36.7%) were managed conservatively. A total of 107 patients (89.1%) had at least one cutaneous disorder. The most prevalent skin manifestation was xerosis, which was seen in 72 patients (60%). Other skin manifestations included half and half nails seen in 48 patients (40%), pruritus seen in 32 (26.7%) and hyper-pigmentation and ichthyosis in nine patients each (7.5%) [Table 1]. Skin pallor was seen in three of the patients (2.5%). In those with pru­ritus, generalized pruritus was the most com­mon presentation, and was seen in 75% of the patients. Pityriasis versicolor and acneiform e­ruptions occurred less frequently in patients with CRF compared with controls [Table 1]. [Table 2] shows the skin disorders seen in pa­tients with CRF on HD and conservative ma­nagement.
Table 1: Frequency distribution of skin manifestations in patients with chronic renal failure and control subjects.

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Table 2: Skin disorders seen in patients on dialysis and on conservative management.

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The mean duration of treatment among pa­tients with CRF in this study was 13.92 ± 2.62 weeks. There was no significant association between the mean duration of treatment, mean duration of symptoms, creatinine clearance and presence of skin manifestations.


   Discussion Top


Skin disorders are common in patients with CRF; while most of them are benign, some may increase the discomfort of the patient. The overall prevalence of skin disorders in our study patients was 89.1%. Other authors have reported prevalence rates between 79 and 100%. [4],[5],[6]

Xerosis/Icthyosis

Xerosis was the most common cutaneous ab­normality seen in 60% of the patients, while acquired icthyosis was seen in 7.5%, in this study. Previous studies have documented pre­valence rates of 40-90% for xerosis in their patients with CRF. [5],[6] Possible etiological fac­tors for xerosis include atrophy of the pilose­baceous follicles and eccrine sweat glands. [7],[8] It has also been suggested that there is less hy­dration of the stratum corneum, especially in patients on HD, which is believed to contri­bute to its presence. [9] We noticed that more patients on dialysis had xerosis compared with those on conservative management, although it was not statistically significant.

Pruritus

Pruritus was seen in 26.7% of our patients, and was mostly generalized. The prevalence rates previously reported varied between 12 and 90% in patients with CRF. [10],[11] The lowest rate of 12% was reported in patients with CRF in Senegal, where a significant number of pa­tients were unable to afford dialysis. [10] That may also account for our low prevalence com­pared with other studies where most of the patients were on dialysis and were receiving treatment for longer periods of time. The du­ration of treatment of our study patients was 13 ± 2.62 weeks, which is relatively short compared with previous reports. Although not statistically significant, patients receiving dia­lysis had a higher prevalence of pruritus than those on conservative treatment, confirming that dialysis may actually precipitate pruritus in this group of patients. Xerosis is believed to be a significant cause of pruritus. Other pos­sible factors include secondary hyperparathy­roidism, mast cell proliferation and degranu­lation, pruritogenic cytokines, deranges in di­valent ion metabolism and abnormal pattern of cutaneous innervations. [12]

Pruritus was mainly generalized in our pa­tients. This appears to be the most common form of presentation in patients with CRF. [12],[13] Pruritus in our patients was said to be mild to moderate, and none of the patients had com­plained to their physicians. Pruritus may lead to excoriations that may get infected and re­quire treatment.

Nail changes

Nail changes were seen more frequently in patients who were not on dialysis. They inclu­ded half and half nails (Lindsay nails), leuko­nychia and bluish discoloration of the nails. Lindsay nails was seen in 40% of our patients. Other studies have reported rates between 16 and 50%. [4] Half and half nails are characterized by pinkish or brownish discoloration of the distal 20-30% of the nail. We noticed that the discoloration reduced or disappeared on pres­sure, suggesting that it may originate both from the nail bed and possibly from the nail plate. Although we did not perform any biop­sies in our patients, previous reports had reported melanin pigment in the nail plate. [14],[15] Another study had reported an increase in the capillary density in the nail bed, with remar­kable thickening of the capillary walls as being the possible cause for the band of discolora­tion. [16],[17] The pathogenesis of this distal band of pigmentation remains unclear. It is absent in patients with acute renal failure. It is also com­monly seen in individuals who use topical hy­droquinone to lighten the skin. [18] Leukonychia was seen in patients with hypoalbuminemia resulting from the nephrotic syndrome. Bluish discoloration of the nails previously reported in patients with HIV infection was seen in two patients who had HIV and CRF. [19]

Pigmentation disorders

Generalized hyper-pigmentation has been re­ported in patients with CRF. In our series, only 7.5% of the patients had obvious hyper-pig­mentation. Similar studies carried out among Caucasians and Asians, however, have repor­ted higher prevalence rates. [4],[5],[6] Diffuse hyper­pigmentation in the black skin may be masked unless it is extensive. This may have resulted in the few numbers of patients we had. We had earlier noticed that pigmented macules deve­lop on the soles in blacks with ageing, and increases in situations where there is increased melanin production, as seen in patients with CRF and chronic liver disease (unpublished observation). Increased pigmentation in CRF patients is due to an increase in melanin in the basal layer and superficial dermis due to a fai­lure of the kidneys to execrete B-melanocyte­stimulating hormone (B-MSH). [20] Pigmented macules occurred slightly more frequently (not statistically significant) in individuals with CRF compared with the normal population. We feel that the palms and soles may be the areas of the skin to look for increase in pigmentation in middle-aged and elderly blacks. Pallor in the pigmented skin is difficult to appreciate, and only 2.5% of our patients with CRF had pallor of the skin; however, all of them had pallor of the mucosal surfaces.

It was of note that the control population had more individuals with pityriasis versicolor and acneiform eruptions, even though the pa­tients and controls were age and sex matched. We believe that the reduced sebum production due to reduction in the function of the pilose­baceous and eccrine sweat glands in patients with CRF could have been responsible for this finding as sebum is one of the factors in the development of these conditions. This finding has not been previously reported. We also no­ted that the lesions of pityriasis versicolor were mainly on the extremeties in patients with CRF rather than in classical sebum-producing areas of the face, chest and upper back, as seen in the controls.

Other infrequent skin changes seen in our pa­tients were uremic frost, alopecia, seborrheic keratosis and chronic eczema. Oral thrush, va­ricella, herpes zoster and warts occurred more frequently in patients with CRF, although this was not statistically significant. This may be as a result of the associated immune suppres­sion in this group of patients.

Clinical conditions like calciphylaxis, perfo­rating disorders and nephrogenic fibrosing der­mopathy were not observed in this study. A plausible explanation may be the shorter du­ration of treatment of our study group and the high mortality rate among individuals with CRF in the developing world. Many patients in this environment do not live for more than six months after diagnosis. 21

In conclusion, skin manifestations are com­mon among our patients with CRF. The pre­sence of xerosis, half and half nails, pruritus and hyper-pigmentation in a patient with renal derangement should heighten the suspicion of possible CRF among other causes, and should prompt the clinician to investigate for under­lying kidney disease even in the absence of symptoms of uremia.

 
   References Top

1.S Sani MU, Mohammed AZ, Bapp A, Borodo MM. A 3year review of mortality patterns in medical wards. Niger Postgrad Med J 2007;14: 347-51.  Back to cited text no. 1
    
2.Salako BL. Management of chronic renal fai-lure. Africa Health 1997;19:26-7.  Back to cited text no. 2
    
3.Arogundade FA, Bashorun RS. Chronic kid-ney disease prevention in sub Saharan Africa a call for governmental and non-governmental and commu­nity support. Am J Kidney Dis 2008;51(3):515-23.  Back to cited text no. 3
    
4.Pico MR, Lugo Somolinos A, Sanchez JL. Cu­taneous alterations in patients with chronic renal failure. Int J Dermatol 1992;31(12):860-3.  Back to cited text no. 4
    
5.Udayakumar P, Balasubramanian S, Ramalingam KS, Lakshmi C, Srinivas CR, Mathew AC. Cutaneous manifestations in patients with chronic renal failure on haemodialysis. Indian J Dermatol Venereol Leprol 2006;72:119-25.  Back to cited text no. 5
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6.Silverberg NB, Singh A, Laude TA. Cutaneous manifestations of chronic renal failure in children of colour. Paediatr Dermatol 2001;18: 199-204.  Back to cited text no. 6
    
7.Landing B, Wells T, Williamson M. Anatomy of Eccrine sweat glands in children with chronic renal insufficiency and other fatal chronic diseases. Am J Pathol 1970;54:15-21.  Back to cited text no. 7
    
8.Sathle-Backdahl M. Pruritus in hemodialysis pa­tients. Skin Pharmacol 1992;5:14-20.  Back to cited text no. 8
    
9.Morton CA, Lafferty M, Hau C, et al. Pruritus and skin hydration during dialysis. Nephrol Dial Trans­plant 1996;11:2031-6.  Back to cited text no. 9
    
10.Diouf B, Niang A, Ka EH, Badiane M, Mo-reira Diop T. Chronic renal failure in one Dakar Hospital department. Dakar Med 2003; 48(3):185-8.  Back to cited text no. 10
    
11.Sathle-Backdahl M. Uraemic pruritus. Semin Dermatol 1995;14:297-301.  Back to cited text no. 11
    
12.Szepietowski JC, Schwartz RA. Uremic pruritus: Review. Int J Dermatol 1998;37:247-53.  Back to cited text no. 12
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13.Szepietowski JC. Selected elements of the patho­genesis of pruritus in hemodialysis patients; my own study. Acta Med Scan 1988;244;55-60.  Back to cited text no. 13
    
14.Leyden JJ, Wood MG. The half and half nail: A uraemic onychopathy. Arch Dermatol 1972; 105:5 91-2.  Back to cited text no. 14
    
15.Stewart WK, Raffke EJ. Brown nail-bed arcs and chronic renal failure. Br Med J 1972;1: 784-6.  Back to cited text no. 15
    
16.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;119: 583-7.  Back to cited text no. 16
    
17.Kint A, Bussels L, Fernandes M, Ringoir S. Skin and nail disorders in relation to chronic renal failure. Acta Dermatol Venereol 1974; 54:137-70.  Back to cited text no. 17
    
18.Morrand JJ, Ly F, Lightburn E, Mahe A. Compli­cations of cosmetic skin bleaching in Africa. Med Trop (Mars) 2007;6:627-34.  Back to cited text no. 18
    
19.Glaser DA, Remlinger K. Blue nails and Acquired immuno deficiency syndrome not always associated with azidothymidine use. Cutis 1996;57(4):243-4. Smith AG, Shuster S, Thody AJ, Alvarez-Ude F, Kerr DN. Role of kidney in regulating plasma immunoreactive beta-melanocyte stimulating hormone. Br Med J 1976;1:874-6.  Back to cited text no. 19
    
20.Adelakun TA, Akinsola A. Hypertension induced chronic renal failure: clinical features, management and prognosis. West Afr J Med 1998;17(2):104-8.  Back to cited text no. 20
    

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Correspondence Address:
Adebola Ogunbiyi
Department of Medicine, University College Hospital, Ibadan
Nigeria
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    Tables

  [Table 1], [Table 2]

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