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 Table of Contents  
ONLINE ONLY ARTICLES - LETTER TO EDITOR
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 155

Cutaneous manifestations of chronic kidney disease - A cross sectional study


Department of Dermatology, Venereology, Leprology, Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India

Date of Submission30-Aug-2021
Date of Decision10-Feb-2022
Date of Acceptance23-Mar-2022
Date of Web Publication26-Aug-2022

Correspondence Address:
Ambresh S Badad
Dr Badad's Skin, Eye and Laser Care Centre, H NO 10-105, 16 A and B, Sharan Nagar, Tank Bund Road, Brahmpur, Kalalburagi - 585 103, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_65_21

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  Abstract 


Background: Systemic disorders often have cutaneous manifestations. Health of the skin usually reflects the overall health of a person. Therefore, early recognition of cutaneous signs and prompt initiation of treatment are essential in reducing morbidity and mortality. Cutaneous changes can be observed in all the stages of renal disease. They can be due to the cause, the disease, or the treatment. Aim: The aim is to study the pattern and proportion of cutaneous manifestation in chronic kidney disease (CKD) patients visiting a tertiary care center. Materials and Methods: This cross-sectional study was carried out at a tertiary care hospital. A total of 80 patients with CKD were included in this study. All patients were clinically examined after written consent. Results: Every patient included in this study had minimum one dermatological manifestation of CKD. The most common cutaneous manifestation was pallor in 80% of patients, followed by xerosis in 60%, pruritus in 50%, pigmentary changes in 40%, and hair changes in 35% of patients. Cutaneous infections were seen in 30%, oral mucosa changes in 20% of patients. Nail changes were observed in 10% of patients, the most common being onychomycosis. Kyrle's disease was seen in 5% of patients. Conclusion: There is a broad range of cutaneous manifestations of CKD. Although often benign, they may negatively impact the quality of life and can be life-threatening. Early detection and treatment are required to decrease the morbidity, mortality, and improve the quality of life of CKD patients.

Keywords: Chronic kidney disease, renal impairment, skin manifestations


How to cite this article:
Badad AS, Gadwal H, Hogade AS. Cutaneous manifestations of chronic kidney disease - A cross sectional study. Clin Dermatol Rev 2022;6:155

How to cite this URL:
Badad AS, Gadwal H, Hogade AS. Cutaneous manifestations of chronic kidney disease - A cross sectional study. Clin Dermatol Rev [serial online] 2022 [cited 2022 Dec 3];6:155. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/155/354758



Chronic kidney disease (CKD) patients often manifest with skin disorders.[1] The cutaneous manifestations can negatively affect the quality of life. The skin is the largest organ of the body, that shows remarkable functional and structural diversity.[2],[3],[4],[5] CKD is emerging to be an important chronic disease globally.[6] CKD is a progressive loss of kidney function over a period of time ranging from months to years. It affects between 8% and 16% of the population worldwide. CKD is defined by the presence of kidney damage with irreversible reduction in the number of nephrons or decreased glomerular filtration rate <60 ml/min/1.73 m2 for over 3 months, irrespective of the cause. Classification of CKD based on the severity is shown in [Table 1].[7] CKD is more prevalent in developing countries and contributes significantly to mortality and morbidity. Around 88% of CKD patients have at least one associated cutaneous change.[8] The prevalence of CKD is increasing, and it is, therefore, likely that the incidence and prevalence of associated skin diseases will also increase. Their early recognition and treatment to reduce morbidity and mortality are essential. This study was done to find out the prevalence and pattern of dermatological disorders in CKD patients. Furthermore, there is a paucity of studies assessing pigmentary anomalies in these patients.
Table 1: Classification of chronic kidney disease based on the severity

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This study was carried out at a tertiary care center after approval from the ethical committee. A total of 80 patients with CKD were included in this study. Information regarding demographic details was noted. Detailed history about the onset, duration, and progression of lesions was taken and recorded. Cutaneous lesions of each case were clinically examined after written consent. Appropriate and suitable pro forma were prepared and used for the study. The data were entered on pro forma, tabulated, and analyzed.

The CKD patients were attending the nephrology outpatient department (OPD) or referred to the Dermatology OPD, having at least one dermatological manifestation and willing to participate in the study.

Patients who are not willing to participate and patients with acute kidney disease or coexistent malignancy were excluded from the study.

This was a hospital based cross-sectional study.

The CKD patients were attending nephrology OPD or referred to the Dermatology OPD of a tertiary care center. Clinical examination for cutaneous lesions was done.


  Results Top


A total of 80 patients were examined and screened for cutaneous manifestations. The duration of CKD ranged from 5 to 15 years. The most common underlying etiology causing CKD was diabetes mellitus. [Table 2] illustrates the basic demographic characteristics of the study population. It shows that CKD was more common in males, of age group above 60 years, coming from rural areas. Furthermore, most of them were illiterates. [Table 3] shows that the most common cutaneous manifestation was pallor [Figure 1] in 80% of patients followed by xerosis in 60% of patients [Figure 2]. Most of the patients with xerosis had rough skin without scaling. Pruritus and prurigo nodularis were noticed among 50% of patients. Hyperpigmentation was seen in 40% of patients and hair changes in 35% of patients. Among various hair changes, telogen effluvium was the most common. Cutaneous infections were seen in 30% of patients of which tinea cruris was the most common. Nail changes were observed in 10% of patients, the most common being onychomycosis. Lindsay's nails were seen in one patient [Figure 3]. Oral mucosa changes were seen in 20% of patients [Figure 4]. Kyrle's disease was seen in 5% of patients. This study shows that the prevalence of skin manifestations was higher among male and that the incidence of cutaneous manifestation increased with an increase in age. In this study, yellowish hue of skin, purpura/ecchymosis, and gynecomastia were seen in 1.25% of patients.
Table 2: Distribution of participants according to demographic characteristics

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Table 3: Distribution of study population according to cutaneous manifestations of chronic kidney disease

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Figure 1: Pallor

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Figure 2: Xerosis

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Figure 3: Lindsay's nails

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Figure 4: Macroglossia

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Statistical analysis

The study data were entered in the SPSS 20 software SPSS; IBM; CHICAGO, USA and descriptive analysis was done.


  Discussion Top


The present study shows that pallor (80%) was the most common skin manifestation in CKS patients similar results were seen in studies done by Leena et al.[8] and Udayakumar et al.[9] This is a common early finding and adds significantly to mortality. Xerosis (60%) was the second-most common presentation in our study, whereas, in studies done by Udayakumar et al. and Thomas et al., xerosis was the most common cutaneous abnormality seen in 79% and 66.6% of patients, respectively. In our study, 50% of patients complained of pruritus, a finding similar to that in a study by Udayakumar et al.[9] and Thomas et al.[1] where they found the prevalence of pruritus to be 53% and 46.6%. In the study done by Udayakumar et al.,[9] pigmentary changes were observed in 43% of patients, whereas in our study, it was 40%. Another finding similar to study done by Leena et al.[8] was that, the skin infections were distributed among 30% of patients. In our study, purpura was seen in 1.25% of cases, whereas in the study done by Leena et al., it was 29%. Similar to the study by Leena et al., in our study gynaecomastia was seen in around 1.25% of patients. The study by Leena et al. indicates 3% prevalence of kyrle's disease among CKD patients, whereas, in our study, the prevalence was 5%. Similar to the study by Hasan et al.,[10] this study shows that the highest number of cases were noted among male (65%) and as age increases the incidence of CKD increases and so does the cutaneous manifestations of CKD. There was no correlation between the severity of CKD and the skin lesions in our study.

It was noticed that some cutaneous manifestations were completely overlooked by the doctors treating CKD. These manifestations required simple treatment and could have given great relief to the patient if a dermatological consultation was sought. Early recognition and treatment reduce morbidity and improve the quality of life. Increasing clinical awareness and implementing preventive strategies combined with early detection and treatment are all required to decrease the morbidity and mortality of dermatological disorders in CKD patients resulting in better quality of life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Limitations

Limitations of this study are the small sample size and no follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
  [Full text]  
2.
Ackerman B, Chongchitnant SJ, Gou Y, Bennin B, Reichel M, Randall MB. Histologic Diagnosis of Inflammatory Skin Diseases. 2nd ed. Baltimore: Williams & Wilkins; 1997. p. 12-34.  Back to cited text no. 2
    
3.
Weedon D, Strutton G. Skin Pathology. New York: Churchill Livingstone; 1997. p. 135-43.  Back to cited text no. 3
    
4.
Garg A, Levin NA, Bernhard JD. Structures of skin lesions and fundamentals of clinical diagnosis. In: Gilchrest BA, Paller AS, Wolff K, Leffell DJ, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York: Mc Graw- Hill; 2008. p. 25-6.  Back to cited text no. 4
    
5.
Goldsmith LA. Physiology, Biochemistry, and Molecular Biology of the Skin. Oxford University Press: New York; 1991. p. 67-8.  Back to cited text no. 5
    
6.
Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SR, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India – Results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2013;14:114.  Back to cited text no. 6
    
7.
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. 7
    
8.
Leena J, Islam M, Ahmed A, Ahmed D, Rahman M. Cutaneous manifestations of chronic kidney disease – An observational study in 100 cases. Faridpur Med Coll J 2012;7:33-6.  Back to cited text no. 8
    
9.
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. 9
[PUBMED]  [Full text]  
10.
Hasan M, Sutradhar I, Gupta RD, Sarker M. Prevalence of chronic kidney disease in South Asia: A systematic review. BMC Nephrol 2018;19:291.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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