CUTANEOUS AND NAIL CHANGES IN PATIENTS OF CHRONIC KIDNEY DISEASE: OBSERVATIONS IN A TERTIARY CARE UNIT FROM SOUTH INDIA

Authors: Dr.K.Sridevi, Dr.R.D.Nagaraj, Dr.P.SriramNaveen, Dr.V.Siva kumar.

Sir,
Chronic kidney disease (CKD) is associated with several skin and nail manifestations. They increase with increasing duration and severity of renal disease. Dialysis may in turn often perpetuate. Timely recognition and management vastly reduces morbidity and give comfort to these chronically ill patients. Sometimes the conditions such as xerosis and intractable pruritus may infact prompt for a search for underlying renal dysfunction.(1) The often discussed manifestations in various studies were xerosis, hyper pigmentation, pruritus and nail changes.(1,2)xerosis is a troublesome complication in patients of CKD. It is predominantly seen over extensor surfaces on the forearm, legs and thighs. It may also manifest as fine scaling on abdomen and chest. Reduction in size and function of eccrine sweat glands may be contributory. Alteration in vitamin A metabolism with increased skin content of vitamin A may also be a cause.(3,4)High dose diuretic therapy is also implicated.(5)Pruritus is another characteristic and annoying cutaneous symptom of chronic kidney disease. It is not present in patients of acute kidney Injury and it does not necessarily subside with dialysis. It has been attributed to several mechanisms: degree of renal insufficiency(urine output less than 500ml),Secondary hyperparathyroidism, increased serum level of Magnesium, Calcium, Phosphate, Aluminium, mast cell proliferation with increased level of histamine, hypervitaminosis A, Iron deficiency anemia, proliferation of nonspecific enolase positive sensory nerves in the skin and deposition of certain pruritogens and middle molecules and decreased skin water content(3,5).Hyper pigmentation is an another important accompaniment of CKD .It may be diffuse and prominent over the sun exposed areas. It may also present as macules on palms and soles.It is attributed to accumulation of Beta melanocyte stimulating hormone(-MSH) because of its reduced excretion through failing kidneys.(2,3,5)Though it was reported to decrease in severity as time in dialysis increases in some studies(6),in majority of studies hyper pigmentation is refractory to treatment and may get aggravate in dialysis patients and found to reverse on kidney transplantation.(2)Half and half nails are typical for chronic renal failure and dialysis patients. It is described as a unique systemic onychopathy characterised by red, pink or brownish discoloration of distal nail bed with proximal portion of nail

being dull white. The discoloured area does not fade with pressure. It is supposed to be due to increased melanin granules in the basal layers of nail bed epidermis and in the nail plate. Half and half nails is also known as Lindsays nails. The prevalence of nail changes increase with time in dialysis and seem, to disappear after kidney transplantation.(1,3,4,6)The other nail changes described were pale nails, koilonychia, Muehrckes lines, Mees lines, Beaus lines and onycholysis.(1,3,4,5,6) Keeping the above observations in view we conducted a cross sectional study with their consent on two hundred subjects of CKD from a tertiary care teaching institute in South India. Of them hundred patients were non dialysis group and the remaining were End Stage Renal disease on maintainence hemodialysis. All the patients were subjected to detailed cutaneous examination and manifestations were recorded. In the pre ESRD group the mean age was 56.7years, the male to female ratio was 74:23 and the mean duration of the disease was 22 months. In the ESRD group on dialysis the mean age was 51.7years and the male to female ratio was 75:25 and the mean duration of the disease was 35 months. The comparative analysis of the cutaneous manifestations (xerosis, pruritus, pigmentation, nail changes) were tabulated .Data was given as percentages. A comparison of categorical variables was done with Chi Square test. A P value of 0.05 or less was considered significant. Table 1: Showing the cutaneous manifestations in Pre-ESRD and ESRD groups variable Pre-ESRD group,(n=100)expressed in percentages(%) 61% 44% 36% 34% ESRD P value group,(n=100),expressed in percentages(%) 63% 0.44 41% 43% 45% 0.38 0.19 0.07

Xerosis Pruritus Pigmentation Nail changes

We did not find any statistical difference with regard to prevalence of xerosis, pruritus, pigmentation and nail changes between the groups. We further compared our data with studies from India an outside and the results were tabulated.

Table 2 (a): Showing the comparative analysis of cutaneous manifestations between different studies in Pre-ESRD group from our country. variable Xerosis Pigmentation Pruritus Nail changes Khanna et (7) (n=150) 69.3% 44.6% 28.6% 59% al Our study(n=100) 61% 36% 44% 34% P value 0.173 0.173 0.017 0.000

We observed higher prevalence of pruritus and lower prevalence of nail changes in comparison to a study from North India.(7) Table 2 (b): Showing the comparative analysis of cutaneous manifestations among different studies in ESRD group from our country. Variable Udayakumar et al(n=100)(from South India)(5) 79% 43% 53% 21% Khanna et al(n=50)(from North India)(7) 82% 68% 58% 28.5% Our study(n=100)(from South India) 63% 43% 41% 24% P value

Xerosis Pigmentation Pruritus Nail changes(half and half)

0.011 0.007 0.090 0.000

In the dialysis population we found low prevalence of xerosis in comparison to the studies from south India and North India. However with regard to pigmentary and nail changes we found a statistically significant reduction in comparison to study from North India only. Table 3: Showing the comparative analysis of cutaneous manifestations between two centers from abroad and India respectively variable Sultan et al Our study P value (3) ,Egypt(n=100) ,India(n=100) Xerosis 54% 63% 0.19 Pigmentation 54% 43% 0.12 Pruritus 55% 41% 0.048 Nail changes(half 28% 24% 0.5 and half)

In comparison with a study by Sultan et al from Egypt we found a significantly reduced prevalence of pruritus in our group while other changes were almost similar. To conclude, the skin and nail changes have been observed in a sizeable proportion of chronic kidney patients both of Pre-ESRD and ESRD groups .The often reported manifestations from India and abroad were xerosis, pruritus, hyperpigmentation and nail changes. Our study highlights the comparative analysis between studies from India and abroad. ACKNOWLEDGEMENT: We are thankful to Dr.Alok Sachin for his help in statistical analysis in this study. REFERENCES 1.Guptha AK, Guptha MA, Cardella CJ, Haberman HF. Cutaneous associations of chronic renal failure and dialysis. Int J Dermatol 1986;25:498-504. 2. Avermaete A, Altmeyer P, Bacharach Buhles M. Skin changes in dialysis patients: a review. Nephrol Dial Transplant 2001;16:2293-6. 3. Maha M.Sultan, M.D., Hayam H.Mansour, M.D., Iman M.Wahby, M.D., and Ali S.Houdery, M.D. J Egypt Women Dermatol Soc.2010;7:49-55. 4.Bencini PL, Montagnino G, Citterio A, Graziani G, Crosti C, Ponticelli C.Cutaneous abnormalities in uremic patients. Nephron 1985;45:316-21. 5.Udayakumar P, Balasubramanian S, Ramalingam KS, Lakshmi C, Srinivas CR, Mathew AC. Cutaneous manifestations in patients with chronic renal failure(CRF) on hemodialysis. Indian J Dermatol Venereol Leprol 2006;72:119-25. 6.Pico MR, Lugo Somolinos A. Cutaneous alterations in patients with chronic renal failure, Int J Dermatol 1992;31:860-3. 7.Deepshikha K, Archana S, Om prakash K. Comparision of Cutaneous manifestations in chronic kidney disease with or without dialysis.Postgrad Med J 2010;86:641-647.