Skin Manifestations in Patient with Chronic Kidney Disease on

Hemodialysis

Rini Hastuti, Ratih Tri Kusuma Dewi,

Muhammad Eko Irawanto

Medical Faculty of Sebelas Maret University / Dr. Moewardi General Hospital Surakarta

Keywords: Chronic kidney disease, hemodialysis, skin manifestations

Abstract: Skin manifestations are common in patients with chronic kidney disease (CKD) and almost all patients have

at least one skin disorder. Early diagnosis and appropriate therapy should be given to improve the quality of

life of patients. This cross sectional study was conducted in 125 patients, male patients (52%) were more

common than female (48%), the highest number of patients in the age group of 56-65 years (29%), most

patients underwent hemodialysis for 0-5 years (91%) and most common aetiology is hypertension (48%).

Skin abnormalities were found in 106 patients (85%), xerotic skin was the most common, followed by

pruritus, hyperpigmentation, prurigo nodularis, cellulitis and purpura. Hair abnormality assessed was hair

loss were found in 43 patients (35%). Nail abnormalities were found in 60 patients (48%), where

onychodystrophy was the most common, followed by half and half of nail, white nail, discoloration, pitting

nail, longitudinal ridges and melanonychia. Mucosal abnormalities were found in 45 patients (36%) in

which xerostomia was the most common abnormalities, followed by gingivitis and stomatitis. There was a

significant association between xerotic with urea (p = 0.041) and creatinine (p = 0.040), skin disorders with

creatinine (p = 0.031), hair abnormalities with calcium (p = 0.001) and gender where women were

significantly more often affected (p = 0.020), and nail abnormalities with hemoglobin (p = 0.007). The

prevalence of all skin manifestations is 95%.

1 INTRODUCTION

Chronic kidney disease (CKD) is a condition in

which the kidneys are unable to fulfill their function

in disposing of metabolic waste and maintaining

fluid and electrolyte balance (Mourad et al., 2014).

Skin manifestations are common in patients with

CKD and almost all patients have at least one skin

disorder (Gursu et al., 2016). This study was

conducted to investigate skin manifestations

occuring in CKD patients undergoing hemodialysis

in Hemodialysis Installation of Dr. Moewardi

General Hospital Surakarta, so early diagnosis and

appropriate therapy can be given to improve the

quality of life of patients.

2 METHODS

The subjects of the study were CKD patients

undergone hemodialysis at Hemodialysis Installation

of Dr. Moewardi General Hospital Surakarta from

11 to 16 December 2017. This study was conducted

cross sectional by doing history taking, physical and

supporting examination. History taking was done to

determine the etiology of CKD, how long the

patients have undergone hemodialysis, and the

presence of skin complaints. Physical examination

was done to determine the existence of skin

abnormalities including hair abnormalities, skin,

nails and mucosa. The gram, tzank and potassium

hydroxide (KOH) examination was conducted when

a lesion was suspected. The data of laboratory

findings were taken from the medical record.

Statistical analysis was done with SPSS.

3 RESULTS

The number of CKD patients who underwent

hemodialysis at Hemodialysis Installation of Dr.

Moewardi General Hospital Surakarta from 11 to 16

December 2017 was 137 patients. Of these, 125

patients had complete laboratory examination. Based

on the data, male patients (52%) were more common

Hastuti, R., Dewi, R. and Irawanto, M.

Skin Manifestations in Patient with Chronic Kidney Disease on Hemodialysis.

DOI: 10.5220/0008151400880091

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 88-91

ISBN: 978-989-758-494-7

than female (48%), with the largest number of

patients in the age group of 56-65 years (29%), most

patients underwent hemodialysis for 0-5 years (91%)

and the most common aetiology is hypertension

(48%).of these patients, 119 patients had skin

disorders. Skin abnormalities were found in 106

patients (85%), in which xerotic skin (76%) was the

most common disorder, followed by pruritus (67%),

hyperpigmentation (40%), prurigo nodularis (1,6%),

cellulitis (0,8%) and purpura(0,8%). Hair

abnormality assessed was hair loss were found in 43

patients (35%). Nail abnormalities were found in 60

patients (48%), in which onychodystrophy (28%)

was the most common, followed by half and half

nails (23%), white nail (23%), discoloration (16%),

pitting nail (4%), longitudinal ridges (4%) and

melanonychia (2%) (Figure 1). Mucosal

abnormalities were found in 45 patients (36%) in

which xerostomia (73%) was the most common

abnormalities, followed by gingivitis (29%) and

stomatitis (18%).

Figure 1. A. Xerotic. B. Hyperpigmentation. C. Half and Half Nail. D. White Nail. E. Discoloration. F. Pitting Nail. G.

Longitudinal Ridges. H. Melanonychia

There was a significant relation between xerotic

and urea (p = 0.041) and creatinine (p = 0.040), skin

disorders with creatinine (p = 0.031), hair

abnormalities with calcium levels (p = 0.001) and

gender whereas female were significantly more

affected (p = 0.020) than male, while nail

abnormalities with hemoglobin levels (p = 0.007).

There was no significant relation between pruritus

and urea (p = 0,392) and creatinine (p = 0,396),

hemoglobin with xerotic (p = 0,258) and pruritus (p

= 0,286), pruritus with xerotic (p = 0,262), duration

hemodialysis with pruritus (p = 0.827) and xerotic (p

= 0.262). The relation between skin, hair, nails and

mucosa abnormalities with age, sex, duration of

hemodialysis and laboratory results can be seen in

Table 1.

Table 1. Relation between skin, hair, nail and mucosal abnormalities with age, sex, duration of hemodialysis and laboratory

examination results.

Skin Hair Nail Mucosa

Abnormalities Abnormalities Abnormalities Abnormalities

(p) (p) (p) (p)

Age 0.981 0.246 0.190 0.545

Gender 0.819 0.020* 0.271 1.000

Duration of Hemodialysis 0.204 0.185 0.521 0.445

Complete Blood Count

 Hemoglobin 0.757 0.920 0.007* 0.271

 White blood cell 0.740 0.126 0.223 0.998

 Platelet 0.107 0.614 0.801 0.769

Renal Function

 Urea 0.694 0.916 0.302 0.818

 Creatinin 0.031* 0.664 0.416 0.516

Electrolyte

 Natrium 0.459 0.136 0.205 0.385

Skin Manifestations in Patient with Chronic Kidney Disease on Hemodialysis

 Kalium 0.987 0.508 0.579 0.414

 Calsium 0.051 0.001* 0.106 0.701

*statistically significant.

4 DISCUSSION

One study suggested that 50-100% of hemodialysis

CKD patients had at least 1 skin manifestation

(Shrestha & Mathur, 2014). Study conducted by

Gunipudi et al showed that male patients (77%)

were more affected than female (23%), with the

highest number of patients in the age group of 60-69

years, most patients underwent hemodialysis for 1-5

years (55%) and the most common aetiology was

hypertension (39.3%) (Gunipudi et al., 2015).

In this

study showed that 119 patients (95%) had at least 1

skin manifestation, where male patients (52%) were

more common than female (48%), with the largest

number of patients in the age group of 56-65 years

(29%), most patients underwent hemodialysis for 0-

5 years (91%) and the most common aetiology is

hypertension (48%).

Data from various studies suggest that the

prevalence of xerotic varies from 46-90%. Various

causes have been identified as the cause of xerotic,

such as reduction in the size of eccrine sweat glands,

high dose diuretic regimen used to treat CKD,

elevated plasma vitamin A,

elevated retinol binding

protein,

dietary restrictions and protein malnutrition

(Al Haija et al., 2014). In this study, xerotic is the

most common skin disorder found in 81 patients

(76%). There was also significant correlation

between xerotic with urea (p = 0.041) and creatinine

level (p = 0.04), and there was no significant

correlation between xerotic and duration of

hemodialysis (p = 0.262)

Uremic pruritus is common in patients with

CKD, which is usually caused by combination of

several mechanisms, including increased histamine,

vitamin A and parathormone levels, mast cell

hyperplasia, peripheral polyneuropathy, and xerosis.

Several studies have suggested that uremic pruritus

may also occur as a result of inflammatory stages

associated with renal failure in which visible

increases in inflammatory cytokines, low serum

albumin levels and high ferritin levels in plasma

(Gerhardt et al., 2011). In this study, the prevalence

of pruritus was 67% with the most common affected

sites were on the back (55%), inferior limb (30%),

abdomen (7%), gluteal (3%), superior extremities

(3%) and facial (2%), and no significant association

between pruritus (p = 0.286), hemodialysis duration

(p = 0.827) and xerotic (p = 0.262).

One of the causes of hyperpigmentation in the

skin is due to elevated levels of β-melanocyte

stimulating hormone caused by inadequate excretion

by the kidneys. One study found that the prevalence

of hyperpigmentation in the skin reached 43%

(Dorchhom et al., 2014). Mourad et al reported that

56% of CKD patients had skin hyperpigmentation in

both sun-exposed and generalized areas (Mourad et

al., 2014). In this study, the prevalence of

hyperpigmentation in the skin reached 40%.

A study by Shaikh et al mentions that other skin

disorders reach 25% which includes acne vulgaris,

static dermatitis, psoriasis, contact dermatitis etc

(Shaikh & Chandravathi, 2016). In this study, other

skin disorders include prurigo nodularis (1.6%),

cellulitis (0.8%) and purpura (0.8%).

The same study by Shaikh et al also mentions

that hair abnormalities reach 18% which includes

rare head and body hair, dull hair, brittle hair,

discoloration of hair and dry hair that can be caused

by decreased sebum production (Shaikh &

Chandravathi, 2016). Other study performed by

Mookambika mentions hair abnormalities of 40%

(Mookambika et al., 2017). In this study, hair

abnormality accounted for 34% of hair loss, and

there was a significant relation between hair

abnormalities with levels of calcium (p = 0.001) and

gender where women were more frequently affected

(p = 0.020).

A study conducted by Ghunawat et al mentions

that nail abnormalities reach 43%, where half and

half nails are the most common nail abnormalities

(Ghunawat et al., 2015). The prevalence of half and

half nail as a distinctive mark varies from 16-50.6%

when compared to 1.44% in the normal population

(Deshmukh et al., 2013).

Half and half nails show a

white to normal proximal half and a reddish pink to

brown in distal half. The discoloration does not

dissapear with pressure and is not affected by nail

growth, suggesting an abnormality in the nail bed.

Another theory suggests that the cause of half and

half nail is an increase in levels of β-melanocyte

stimulating hormone that causes melanocyte

activation resulting in melanin pigment deposition

on the nail plate, then another theory also mentions

this may be due to the constriction of venous return

blood flow nail bed (Shafiee et al., 2015). Other nail

abnormalities that can be found include absent

lunula, vertical stripes, Terry`s nail, splinter

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

hemorrhage, Beau`s line, onychomycosis,

leukonychia, pitting nail, twenty nail dystrophy,

koilonychia and white nail (Ozturk et al., 2014;

Shrestha & Mathur, 2014). In this study , nail

abnormalities reached 48%, which included

onychodystrophy (28%), half and half nail (23%),

white nail (23%), discoloration (16%), pitting nail

(4%), longitudinal ridges (4%) and melanonikia

(2%), and there is a relation between nail

abnormalities with hemoglobin (p = 0.007).

A study conducted by Sanad et al mentions that

xerostomia is the most common mucosal disorder

with prevalence of 46%. This xerostomia can be

caused by various factors, such as fluid retention in

CKD patients and side effects of the use of anti-

hypertensive drugs. Other disorders that often occur

include macroglosia, thrush, cheilitis

and gingivitis

(Mourad et al., 2014;Sanad et al., 2014). In this

study, mucosal abnormalities reached 36%, which

included xerostomia (73%), gingivitis (29%) and

stomatitis (18%).

5 CONCLUSION

The prevalence of skin manifestations in CKD

patients is reach 95%, in which one person has at

least one skin disorder. Patients with CKD

undergoing hemodialysis should receive routine skin

examination so that early diagnosis and appropriate

therapy can be given to improve the quality of life of

the patients.

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Skin Manifestations in Patient with Chronic Kidney Disease on Hemodialysis