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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 23-30

A clinical study of cutaneous manifestations in patients with chronic kidney disease on conservative management, hemodialysis, and renal transplant recipient


Department of Skin and VD, MGM Medical College, Aurangabad, Maharashtra, India

Date of Submission31-Dec-2018
Date of Decision27-Mar-2019
Date of Acceptance26-Apr-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Anirudha D Gulanikar
Department of Skin and VD, MGM Medical College, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_59_18

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  Abstract 


Background: The skin acts as an external reflection of renal diseases. The dermatologic disorders in chronic kidney disease (CKD) can be attributed to the etiology, the disease, or the treatment and can markedly affect a patient's quality of life. Aim: The aim is to study the pattern and proportion of cutaneous manifestations in CKD patients on dialysis, on conservative management and in posttransplant patients. Materials and Methods: A cross-sectional hospital-based study was conducted. Seventy-five patients with CKD on hemodialysis, 25 patients with CKD on conservative management, and 20 posttransplant patients were included in the study. All the patients were clinically examined after written consent. Results: At least, one dermatological manifestation was present in every patient included in the study. The most common underlying disease that leads to CKD was diabetes mellitus. The most common manifestation was xerosis seen in 60% patients followed by pruritus seen in 43%, pallor seen in 41% and pigmentary changes seen in 28% patients. Cutaneous infections were seen in 43%, nail changes in 82%, hair changes in 40%, and oral mucosa changes were seen in 38% of patients. Drug-induced cutaneous manifestations were seen in posttransplant patients like acneiform eruptions in 32% of patients followed by hirsutism in 8%, striae in 8%, and hypertrichosis in 4% of patients. Conclusion: The proportion of xerosis, pruritus, pigmentation, and pallor are more common in the dialytic group than nondialytic group. Early recognition and some prophylactic measures can prevent or decrease some of the adverse changes.

Keywords: Chronic kidney disease, cutaneous manifestations, dialysis, renal transplant, xerosis


How to cite this article:
Khare A, Gulanikar AD. A clinical study of cutaneous manifestations in patients with chronic kidney disease on conservative management, hemodialysis, and renal transplant recipient. Clin Dermatol Rev 2020;4:23-30

How to cite this URL:
Khare A, Gulanikar AD. A clinical study of cutaneous manifestations in patients with chronic kidney disease on conservative management, hemodialysis, and renal transplant recipient. Clin Dermatol Rev [serial online] 2020 [cited 2020 Feb 23];4:23-30. Available from: http://www.cdriadvlkn.org/text.asp?2020/4/1/23/275252




  Introduction Top


Chronic kidney disease (CKD) is a progressive loss of kidney function over a period of months or years through five stages leading to end-stage renal disease (ESRD). Individuals with either kidney damage with irreversible reduction in number of nephrons or a glomerular filtration rate of <60 ml/min/1.73 m 2 for 3 months are classified as having chronic renal failure corresponds to CKD Stages 3–5 and ESRD (CKD Stage-5).[1] Classification by severity is shown in [Table 1].
Table 1: Classification of chronic kidney disease by severity

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The skin acts as an external reflection of many renal diseases and serves as an important tool for the clinician.

Advances in nephrology have improved life expectancy in CKD, allowing later dermatological manifestations to emerge.

The dermatologic disorders in CKD can be attributed to the etiology, the disease, or the treatment and can markedly affect a patient's quality of life.

Cutaneous manifestations in patients with CKD on conservative management and hemodialysis were observed in different studies.

Cutaneous manifestation on body

  • Xerosis, pruritus, pigmentation, ecchymosis, and uremic frost
  • Perforating disorder (Kyrle's disease, reactive perforating collagenosis, perforating folliculitis)
  • Recurrent infection-bacterial, fungal, viral.


Manifestations in nails

Half-and-half nails, Koilonychia, onycholysis, subungual hyperkeratosis, onychomycosis.

Manifestations in hair

Sparse body hairs, brittle and lusterless hairs, diffuse alopecia.

Manifestations in mucosae

Xerostomia, angular cheilitis, ulcerative stomatitis, macroglossia.

Cutaneous manifestations in renal transplant patients

  • Purpura, pallor, seborrheic dermatitis, perioral dermatitis
  • Cutaneous malignancies.
  • Hair changes – Diffuse alopecia, brittle and lusterless hair.
  • Nail changes – Onychomycosis.
  • Oral mucosa changes – Gingival hyperplasia.


Various infections in renal transplant patients

Viral – Herpes zoster, herpes simplex, concomitant cytomegalovirus and herpes simplex infection, verruca vulgaris, molluscum contagiosum.

  • Bacterial – Folliculitis, furuncles.
  • Fungal – Dermatophyte, pityrasis versicolor, candidiasis.
  • Parasitic infections – Scabies.


Manifestations of immunosuppressive drugs in postkidney transplant patients

  • Acneiform eruptions, hypertrichosis, gingival hyperplasia, striae
  • Hirsutism, skin atrophy.


There are very few studies assessing cutaneous manifestations in post-kidney transplant (KT) patients in India. The present study was undertaken to evaluate the cutaneous manifestations among the CKD patients on hemodialysis, on conservative management (nonhemodialytic) and posttransplant patients.


  Materials and Methods Top


The ethical committee approved the study protocol, and informed consent was obtained. Detailed note regarding the onset, duration, progression, and associated symptoms of any cutaneous lesions were made. Various cutaneous lesions, their distribution, and morphology were recorded and photographed.

Inclusion criteria

The CKD patients, attending nephrology outpatient department (OPD)/admit in nephrology ward and patients referred to dermatology OPD were included. Furthermore, patients on dialysis at dialysis unit of nephrology department presenting with cutaneous lesions and symptoms too were included in the study. Even those patients who underwent renal transplantation were also selected for the study.

Exclusion criteria

Patients who are not willing to take part in study and patients of acute kidney disease were excluded from the study.

Study design

This study design involves cross-sectional hospital-based study.

Source of data

The CKD patients attended nephrology OPD/admitted in nephrology ward and patients referred to dermatology OPD of Mahatma Gandhi Medical College, Aurangabad.

A total of 120 patients of CKD were examined for cutaneous manifestations in a tertiary care hospital for 1 year from November 2017 to October 2018. We divided these 120 patients into three groups.

  • Group A-75 patients of CKD were undergoing dialysis
  • Group B-25 patients were on conservative treatment
  • Group C-20 patients had gone for renal transplant.


Specific examinations-skin biopsy, culture, and sensitivity for bacterial infections, Gram's stain, KOH mount and fungal culture were done.

Routine investigations complete blood count, kidney function test, blood sugar, and serum electrolyte were also done.

Data analysis

The collected data were compiled in MS excel sheet. The data represented in the form of frequency and percentage. The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., version 17.0 for Windows, Chicago, IL, USA). Continuous data were given as a mean ± standard deviation, range or as median with an interquartile range as appropriate. Normality of quantitative data was checked by measures of Kolmogorov–Smirnov tests of normality. For comparison of age and duration of disease one-way analysis of variance was applied for comparison of four groups. Discrete categorical data were presented as n (%): For categorical data, comparisons were made using Pearson Chi-square test or Fisher's exact test as appropriate. All statistical tests were two-sided and performed at a significance level of P = 0.05.


  Results Top


One-hundred and twenty patients (78 males and 42 females) were examined. The patients were ranged from 17 to 86 years with the most number of patients in 30–55 years age group. The duration of disease ranged from 1 month to 14 years. The most common underlying etiology causing CKD in this study was diabetes mellitus. All patients examined in the study showed at least one cutaneous manifestation.

Cutaneous manifestations

Xerosis

Most common cutaneous abnormality was xerosis. A total of 73 (60%) patients had xerosis. The maximum proportion was seen in Group A, 60 (80%) whereas the minimum was in Group C, 1 (5%) [Figure 1] and [Figure 2].
Figure 1: Xerosis in chronic kidney disease patient on hemodialysis

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Figure 2: Xerosis in chronic kidney disease patient on conservative treatment

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Pruritus

Pruritus was the second-most common manifestation observed in a total of 52 (43%) patients. The proportion of pruritus was slightly higher in Group A which has 38 patients (50%), compare to Group B having 12 patients (48%). Prurigo was observed in 10 patients of Group A because of chronic pruritus.

Pallor

Pallor was observed in a total of 50 (41.6%) patients. The proportion of pallor was much high in Group A patients 41 (54%), while it was observed in only 7 (28%) of Group B patients. Pallor was also observed in 2 (10%) patients of Group C.

Pigmentary changes

Hyperpigmentation is a common finding in CKD patients. Total 34 (28%) patients had pigmentary anomalies [Figure 3]. There were 28 (38%) Group A patients, 4 (16%) Group B patients, and 2 (10%) Group C patients.
Figure 3: Diffuse hyperpigmentation of face (sun-exposed area) in patients undergoing dialysis

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Acquired perforating disorder

We encountered a total of 8 patients of kyrle's disease. These eight patients were exclusively from Group A (10%) confirmed by histopathology findings [Figure 4] and [Figure 5].
Figure 4: Kyrle's disease (aquired perforating disorder) in chronic kidney disease patient on hemodialysis

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Figure 5: Kyrle's disease (aquired perforating disorder) in a chronic kidney disease patient on hemodialysis

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Cutaneous infections

Among the study population, a total of 52 (43%) patients had cutaneous infections. In Group A, a total of 36 (48%) patients had cutaneous infections, while in Group B, 8 (32%) and Group C 9 (40%) patients had cutaneous infections. The proportion of different cutaneous infections is shown in [Table 3] and [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10].
Table 3: Proportion of different cutaneous infections in our study

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Figure 6: Dermatophytic infection (Tinea corporis) in Group A patients (those who are on dialysis)

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Figure 7: Bacterial infection carbuncle in hemodialysis patients

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Figure 8: Warts (viral infection-molluscum contagiosum) in patients undergoing dialysis

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Figure 9: Multiple grouped vesicles (Herpes zoster) in patients treating with conservative management

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Figure 10: Half-and-half nails in patients undergoing hemodialysis

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Nail changes

A total of 99 (82%) patients showed nail involvement [Figure 10], [Figure 11], [Figure 12]. Maximum proportion was noted in Group A 70 (93%) patients followed by Group B 20 (80%) patients and Group C 9 (45%). The most common finding was absent lunula (31%). Proportion of different nail changes in all three groups is compiled in [Table 4].
Figure 11: Absent lunula on finger nails of both hands in patients undergoing hemodialysis

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Figure 12: Beau's lines on finger nails in hemodialysis patients

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Table 4: Proportion of different nail changes in our study

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Hair changes

Hair changes were observed in a total of 49 (40%) patients. Proportion observed in Group A 44%, in Group B 40%, and in posttransplant patients 20%. Total 24 patients had sparse body hair, 19 patients had dry, lusterless hair [Figure 13], and three patients had diffuse alopecia. Proportion of different hair changes in all three groups is compiled in [Table 5].
Figure 13: Hair loss on scalp in patients undergoing dialysis

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Table 5: Proportion of different hair changes in our study

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Oral mucosal changes

Oral mucosal changes have been observed in 46 (38%) patients [Figure 14] and [Figure 15]. The proportion of oral mucosal changes in Group A patient was 52%, while in Group B patient was 28%. We did not observe any mucosal changes in KT patients. Proportion of different oral mucosa changes in all three groups is compiled in [Table 6].
Figure 14: Macroglossia (uremic tongue) in patients undergoing dialysis

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Figure 15: Hyperpigmentation over tongue in patients treating with conservative management

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Table 6: Proportion of different oral mucosal changes in our study

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  Discussion Top


The most common cause of CKD in our study was diabetes mellitus (60%) followed by chronic glomerulonephritis (38%).

Xerosis was the most common cutaneous manifestation seen in the present study with 60% of patients were affected by it. Dialytic group (80%) had a higher proportion compared to nondialytic group (52%). This observation was consistent with Udaykumar et al.[2] and Khanna et al.,[3] who have observed xerosis as the most common cutaneous manifestations in 79% and 66.7%, respectively. Xerosis was predominantly seen over forearms, legs, and thighs. Reduced size and abnormal functioning of eccrine sweat glands, causing dehydration of epithelia may contribute to the development of xerosis.

Pruritus is the most troublesome symptom of CKD. Pruritus was recorded in 50% of dialytic group of patients and 48% of nondialytic group of patients. A similar proportion was observed by Udaykumar et al.[2] (53%) in CKD patients who underwent dialysis. Deshmukh et al.[4] reported 45% proportion in dialytic group of patients. In our study, we have observed pruritus even in two patients of renal transplant. A significant association was seen in pruritus and xerosis. Fifty patients of 73 patients who had xerosis also had pruritus. Etiology of pruritus could be increased level of magnesium, calcium and phosphate, increase serum levels of histamine. Exacerbation of xerosis and pruritus was observed after hemodialysis.

Pallor was the third-most common manifestation observed in our study. The proportion of pallor was 54% in dialytic group versus 28% in nondialytic group. We also observed pallor in 2 (10%) of posttransplant patients, which is less compared to studies of Udaykumar et al.[2] (60%), and Thomas et al.[5] (45.45%). Pallor was due to anemia as 56% of patients had iron level <7 g/dl. Proportion of xerosis, pruritus, pallor, and pigmentary changes among the study groups compiled in [Table 2].
Table 2: Proportion of xerosis, pruritus, pallor, and pigmentary changes among the study groups

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Pigmentary changes

Diffuse hyperpigmentation seen in sun-exposed area of CKD patients. The proportion is 38% in dialytic group and 16% in nondialytic group, which is less compared to Udaykumar et al. (43%)[2] and Khanna et al.[3] (50%) in patients of dialysis. Face and extremities were affected commonly. Etiology of hyperpigmentation can be due to increase level of beta melanocyte stimulating hormone (MSH) as the kidney fails to excrete β-MSH, the level of melanin increases in the basal layer.

Aquired perforating disorder

We observed eight cases (11%) of kyrle's disease. All the cases were observed in dialytic group of patients. Automated peritoneal dialysis (APD) has been reported to occur in 4.5%–17% of patients on hemodialysis. Udaykumar et al.[2] reported 21% proportion of APD in patients on hemodialysis. Thomas et al.[5] reported the proportion of 17.17%. Trauma to the skin in patients of CKD with pruritus could produce these types of lesion. Positive association of diabetes and APD have been observed in our study.

Cutaneous infections

About 43% of patients had cutaneous infection. We have observed the proportion of cutaneous infection in patients on hemodialysis was 48%, which is higher than the findings of Udaykumar et al.[2] (40%) and Deshmukh et al.[4] (34.2%) while patients on conservative patients had 32% and posttransplant patients had 40% proportion. Fungal infections were most common (50%) in all three groups. We have observed dermatophytic infections (65%) were most common among the fungal infections followed by Pityriasis versicolor infections (23%). While the bacterial infections were the second-most common finding in hemodialytic and nonhemodialytic group of patients, it was found that viral infections (herpes zoster and verruca vulgaris) were the second-most common in KT patients followed by bacterial infections. The proportion of infections was higher in KT patients due to prolonged use of immunosuppressive drugs.

Nail changes

The prevalence of nail changes in multiple studies varies from 10% as reported by Singh et al.[6] to 64% as reported by Khanna et al.[3] We have observed nail changes in 82% (99) of total patients. The proportion was much higher in the dialytic group of patients (93%) followed by 80% in nondialytic group of patients and 45% in posttransplant patients. The most common nail change was absent lunula, seen in 31% of patients. Half-and-half nails were seen in total 18 (18%) patients, 15 (15%) of which were from the hemodialytic group and 3 (3%) were from nonhemodialytic group. Previous studies have found a proportion of half-and-half nails between 16% and 50.6%. Udaykumar et al.[2] had observed the proportion of half-and-half nail in 21% of patients on hemodialysis. Other findings observed beau's lines (15%), subungual hyperkeratosis (13%), onycholysis (11%), and koilonychia in 11% of patients.

Hair changes

About 41% of patients had hair changes in our study. The most common finding was sparse body hair (47%) followed by brittle and lusterless hair in 38% of patients of all three groups. Diffuse alopecia was seen in 3 (6%) patients, two of which was from the hemodialytic group, while 1 is from KT group of patients. Decrease secretion of sebum could be a reason for dry and lusterless hairs.

Oral mucosal changes

Oral mucosal changes have been observed in 46 (38%) patients. Macroglossia with teeth markings (tongue sign of uremia) were seen in 12 (26%) patients. Thomas et al.[5] had macroglossia in 9.09%. Udaykumar et al.[2] in their study reported the proportion of macroglossia 35%. While xerostomia was seen in 10 (21%), can be due to mouth breathing and dehydration. Udaykuamr et al.[2] reported 31%. Other findings like coated tongue were seen in 11 (23%) patients, aphthous ulcer seen in 6 (13%), hyperpigmentation of tongue seen in 5 (11%) and angular cheilitis seen in 2 (4%) patients. We have not observed any changes in kidney recipients.

Iatrogenic manifestations

Two cases of zygomycosis were observed in patients undergoing hemodialysis. Zygomycosis is a rare infection caused by fungi zygomycetes, which causes infection in individuals with compromised immune system and even in immunocompetents. Both the cases were of CKD with diabetes mellitus. Histopathology confirmed zygomycosis and fungal culture showed an organism Rhizopus [Figure 16] and [Figure 17].
Figure 16: Atypical growth over peri-umbilical area (fungal culture-zygomycosis) in patients undergoing dialysis

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Figure 17: White growth over fingers (fungal culture - zygomycosis) in patients undergoing dialysis

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Cutaneous manifestations of immunosuppressive drugs in kidney transplant patients

All renal transplant patients were on one or two immunosuppressive drugs such as prednisolone, azathioprine, cyclosporine, and tacrolimus. Most common drug-induced cutaneous manifestations were acneiform eruptions in 32% [Figure 18] followed by hirsutism in 8%, striae in 8% [Figure 19], hypertrichosis in 1 (4%) patients. The proportion of these cutaneous manifestations is shown in [Table 7].
Figure 18: Acneform eruptions in a transplant recipient patient

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Figure 19: Striae on posttransplant patient

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Table 7: Proportion of different cutaneous changes in transplant recipients in our study

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  Conclusion Top


All 120 CKD patients showed at least one cutaneous change. It was observed in our study that, in CKD patients on hemodialysis and on conservative management xerosis, pruritus, pigmentation, nail changes, oral mucosa changes, and cutaneous infections were the predominant cutaneous manifestations, while transplant recipients acneiform eruptions, hirsutism, striae, and cutaneous infections were seen predominantly because of prolong use of immunosuppressive drugs. We have found dialysis often accentuates the cutaneous symptoms such as xerosis and pruritus.

Declaration of patient consent

The informed consent was obtained for participation in the study and publication of data and images for research and educational purposes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, et al. Definition and classification of chronic kidney disease: A position statement from kidney disease: Improving global outcomes (KDIGO). Kidney Int 2005;67:2089-100.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
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.  Back to cited text no. 3
    
4.
Deshmukh SP, Sharma YK, Dash K, Chaudhari NC, Deo KS. Clinicoepidemilogical study of skin manifestations in patients of chronic renal failure on hemodialysis. Indian Dermatol Online J 2013;4:18-21.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Thomas EA, Pawar B, Thomas A. A prospective study of cutaneous abnormalities in patients with chronic kidney disease. Indian J Nephrol 2012;22:116-20.  Back to cited text no. 5
  [Full text]  
6.
Singh G, Singh SJ, Chakrabarty N, Siddharaju KS, Prakash JC. Cutaneous manifestations of chronic renal failure. Indian J Dermatol Venereol Leprol 1989:55:167-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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