Association between Xerosis and Severity of Pruritus in Patients with

Chronic Renal Failure Undergoing Hemodialysis

at Dr. Mohammad Hoesin (RSMH) General Hospital Palembang,

Indonesia

Fifa Argentina

, Ramdani

, M. Zulkarnain

, Debby Handayati Harahap

, Citra Tresna Murti

Dermatology and Venereology Department, Faculty of Medicine, Sriwijaya University/

Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Jl. Jendral Sudirman KM 3.5, Palembang, South Sumatera, Indonesia

Medical Education Program Study, Faculty of Medicine, Sriwijaya University/

Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Jl. Dr. Moh. Ali, Sekip Jaya, Kemuning, Palembang, South Sumatera, Indonesia

Public Health Sciences, Faculty of Medicine, Sriwijaya University, Indonesia

Medical Research Unit, Faculty of Medicine, Sriwijaya University, Indonesia

Keywords: chronic renal failure, pruritus, xerosis.

Abstract: Chronic renal failure (CRF) is a disease that affected many people and had become a global epidemic. Xerosis

and pruritus are the most common cutaneus manifestation in patients with CRF undergoing hemodialysis.

Xerosis allegedly play a role in the pathogenesis of pruritus. The aim of this research was to analyze the

association between xerosis and severity of pruritus. This research was an observational analytic study with

cross-sectional design conducted in Hemodialysis Installation (HI) of RSMH Palembang. The research

subjects were 81 patients with CRF undergoing hemodialysis period September-November 2016. The

assessment consists of: evaluation of pruritus by using interviews, severity of pruritus was measured by using

visual analog scale (VAS), xerosis was assessed by physical examination, severity of xerosis was measured

by body surface area (BSA) affected. The data were processed using application of computer for which p

<0,05 were accepted as significant. From 81 subjects research, xerosis were observed in 69,1%, pruritus in

61,7%. There was association between xerosis and pruritus (PR= 4,86; p = 0,003) and severity of xerosis and

pruritus (PR= 8,09; p = 0,005). There was no association between xerosis and severity of pruritus (PR = 3,600;

p= 0,144). There was significant association between xerosis and pruritus but not with the severity of pruritus;

and significant association between the severity of xerosis and pruritus. Patient with xerosis had five times

higher possibility suffer from pruritus. Patient with moderate until severe xerosis had eight times higher

possibility suffer from pruritus.

1 INTRODUCTION

Chronic renal failure (CRF) is a syndrome

characterized by progressive and irreversible kidney

function loss with a diverse etiology. This disease is

one of the most common chronic diseases and has

become a global epidemic and the incidence rate is

increasing worldwide developed countries and

developing countries. (Peres , 2014)It is estimated

that more than 50 million people worldwide

experience CRF and 1 million of them require renal

replacement therapy. Data show that cases of chronic

renal failure are mostly diagnosed in the late stages

with a high rate of morbidity and mortality. This is

largely due to poor screening and treatment programs

of disease causes. CRF is caused by a diverse etiology

and in Indonesia glomerulonephritis disease is still a

major cause of chronic renal failure in the past few

decades even in the United States it is reported that

diabetes mellitus is ranked first. (Suwitra,

2014)Chronic renal failure affects and manifests to

many systems such as the nervous system,

gastrointestinal, cardiovascular, hematologic,

endocrine and skin. (OnelmisSener, 2012)

Argentina, F., Ramdani, ., Zulkarnain, M., Harahap, D. and Murti, C.

Association between Xerosis and Severity of Pruritus in Patients with Chronic Renal Failure Undergoing Hemodialysis at Dr. Mohammad Hoesin (RSMH) General Hospital Palembang,

Indonesia.

DOI: 10.5220/0008154602310235

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 231-235

ISBN: 978-989-758-494-7

231

In relation to the skin system, in end-stage CRF

patients 50-100% have at least one cutaneous

manifestation. This manifestation is very diverse and

can be obtained both before and after initiating

dialysis. This manifestation may be divided into

specific cutaneous manifestations such as calcifilaxis,

bullous dermatosis, acquaired perforating dermatosis

and manifestationsnon-specific cutaneous ones such

as pruritus, xerosis and pigmentation. (Masmoudi,

2014)Pruritus and xerosis are the most common

manifestations in patients with CRF and are more

common in patients undergoing hemodialysis than

peritoneal dialysis. (Manetil, 2009) These two

manifestations can be obtained in varying degrees of

chronic renal failure. In several case series studies it

was reported that the prevalence of xerosis in patients

with CRF undergoing hemodialysis between 23-79%

and for pruritus between 36-57%. This prevalence

may increase with increasing degrees of CRF.

(Khanna ,2010)Although this is not life-threatening

but may affect the quality of life and tends to make

the patient anxious and depressed as each symptom

increases. (Szepietowski, 2011)

In some studies conducted by Khanna et al.

Thomas et al., that was a significant relationship

between xerosis and pruritus. (Khanna,2010)

(Thomas, 2012). Onelmis et al. (2012) also suggested

a significant association between the severity of

xerosis, especially severe xerosis with pruritus

events. This suggests that xerosis plays a role in the

pathogenesis of pruritus.

In the Peres et al (2014)

study also stated that xerosis plays a role in the

occurrence of pruritus in patients with chronic renal

failure. The symptoms of pruritus in patients with

CRF are generally found to vary from mild to severe,

which can interfere with sleep and even daily

activities. Pruritus is also often found to provide

secondary manifestations of the skin due to strong

and repeated scratching such as excoriation, chronic

lichen simplex, prurigo nodularis, acquaired

perforating dermatosis.

Research on the relationship

between xerosis and severity of pruritus is still low

and in RSMH Palembang has never been done.

Therefore, researchers want to do researchis to

determine the relationship between xerosis and

severity of pruritus in patients with chronic renal

failure who underwent hemodialysis at RSMH

Palembang.

2 METHODS

Observational analytic research with cross sectional

approach was undertaken in October to November

2016 at Hemodialysis Installation of RSMH

Palembang. There were 81 patients with chronic renal

failure who undergoing hemodialysis who fullfilled

the inclusion and exclusion criteria. The inclusion

criteria in this study included CRF patients

undergoing hemodialysis from September to

November 2016 and who signed informed consent.

Exclusion criteria included patients with

accompanying hepatitis, HIV, and cancer, patients

with other skin diseases, patients who had taken oral

antihistamine drugs 2 days before the examination

and who had been using emollient moisturizing

therapy 3 weeks prior to the examination. The

protocol has been approved of Ethic Committe,

Faculty of Medicine Sriwijaya University.

Pruritus events are known by interviewing

patients, the severity of pruritus is measured by using

Visual Analoge Scale (VAS). The incidence of

xerosis is obtained by performing a physical

examination and the severity of xerosis is measured

by looking at the affected Body Surface Area (BSA).

The analysis was performed by statistical test

Comparative analysis using Chi-square test or

Fisher's exact test on computer program to know the

relationship between xerosis andpruritus, xerosis and

severity of pruritus, severity of xerosis and pruritus.

3 RESULTS

Table 1 shows that of the 81 respondents (22.2%) are

the age group of 44-51 years and the least (4.9%) in

the 20-27 age group. Male respondents (54.3%) more

than female respondents (45.7%) and the majority of

respondents (51.9%) did not work. Respondents who

work as laborers/farmers and ABRI/PNS have the

same proportion of 12.3%, while the rest (23.5%)

work as self /private employees.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

232

Table 1. Distribution of Respondents Based on Sociodemographic Characteristics.

Characteristics Total Percenta

(

)

Age (years)

 20-27

 28-35

 36-43

 44-51

 52-59

 60-67

 68-75

4.9

7.4

16.1

22.2

21.0

19.8

8.6

Sex

 Male

 Female

54.3

45.7

Occupation

 Laborers/Farmers

 ABRI/PNS

 Self/Private Employees

 Not Work

12.3

23.5

51.9

(Primary Data, 2016)

In this study an analysis was conducted to

determine the relationship between xerosis and

pruritus by using Chi-Square test. The results showed

that there was a statistically significant relationship

between xerosis and pruritus (PR = 4.86; p = 0.003).

This means that respondents with xerosis are 5 times

more likely to have pruritus.

Table 2. Relationship Between Xerosis and Pruritus (n=81).

Characteristic

Pruritus Total

PR*

(

CI 95%

)

p value*

Yes No

Xerosis

 Yes

 No

4.859

(1.773-13.319)

0.003

Total 50 31 81

(Chi-Square Test, pvalue = 0.05)

Table 3. Relationship Between Xerosis and Severity of Pruritus (n=50).

Characteristic Pruritus Severity

Total

PR*

(CI 95%)

p value*

Moderate-

Severe

Mild

Xerosis

 Yes

 No

3.600

(0.676-19.163)

0.144

Total 42 8 50

(Fisher Exact Test, p value = 0.05)

Association between Xerosis and Severity of Pruritus in Patients with Chronic Renal Failure Undergoing Hemodialysis at Dr. Mohammad

Hoesin (RSMH) General Hospital Palembang, Indonesia

233

In addition, by statistical analysis using Fisher's

exact test test results obtained no significant

relationship between xerosis and severity of pruritus

(PR = 3.600; p = 0.144).

Fisher's exact test was performed to determine the

relationship between the severity of xerosis and

pruritus, and there was a significant correlation

between the severity of xerosis and pruritus (PR =

8.094 ; p = 0.005) which means that respondents who

had moderate and severe xerosis were 8 times more

likely to have pruritus.

Table 4. Relationship Between Severity of Xerosis and Pruritus (n=56).

Characteristic Pruritus

Tota

PR*

(CI

95%)

p value*

Yes No

Xerosis Severity

 Moderate -Severe

 Mild

8.094

(1.905-

34.393)

0.005

Total 41 15 56

(Fisher Exact Test, p value = 0.05)

4 DISCUSSION

In this research note that respondents who

experienced pruritus at most respondents had xerosis.

The number of respondents who experienced pruritus

with xerosis were 41 respondents (73.2%). In

previous studies, the proportion of pruritus was

greater in the respondents with xerosis.8 This is

consistent with the theory that xerosis plays a role in

the occurrence of pruritus in patients with chronic

renal failure. (Peres, 2014)

Several studies have reported that elevated

serum phosphorus levels and calcium levels

contribute to the pathogenesis of pruritus. It was

considered because it has been an increase in the

concentration of divalent ions in the skin which then

causes mikropresipitasi calcium or magnesium

phosphate which can be a cause of

pruritus.Hyperparathyroidism, iron deficiency

anemia, xerosis also reported to contribute to the

cause pruritus.

(

OnelmisSener, 2012) Many factors

are involved in the pathogenesis of pruritus such as

secondary hyperparathyroidism, xerosis, increased

levels of calcium, magnesium, phosphorus, serum

histamine, hipervitaminosis A. pruritus in patients

with chronic renal failure caused by the accumulation

of slow metabolic processes or hormonal imbalances

in the body. (Thomas, 2012)

The results showed a very significant

relationship between xerosis and pruritus (PR =

4.859; p = 0.003). Patients with chronic renal failure

with xerosis have 5 times higher probability to

experience pruritus compared with patients without

xerosis. Xerosis contributes to the pathogenesis of

pruritus. Impaired skin barrier function in the form of

decreasing water content in the stratum corneum

facilitates incoming irritants that can trigger or trigger

the occurrence of pruritus and can initiate an

inflammatory response.

(

Yosipovitch, 2004).Xerosis

in patients with chronic renal failure may reduce the

threshold of pruritus, thus facilitating other factors to

trigger the itch.

(

Zucker, 2003)

that, in response to the low humidity

environment there will be increased and

degranulation of mast cells and histamine levels in the

epidermis. Pruritus in patients with xerosis has been

associated with abnormal function of nerve fibers in

the epidermis and papilla dermis. (Peres, 2014)

The results showed that there was a very

significant relationship between the severity of

xerosis and pruritus (PR = 8.094; p = 0.005). Patients

with chronic renal failure with moderate to severe

xerosis are 8 times more likely to have pruritus than

patients with mild xerosis. This is in accordance with

the results of previous studies conducted by Khanna

et al. (2012) and Onelmis et al. (2012) indicating that

the severity of xerosis was significantly significant as

a pruritus risk factor. (OnelmisSener,2012)

(Khanna,2010)

5 CONCLUSIONS

From this research can be concluded there is a very

meaningful relationship between xerosis and pruritus

and the severity of xerosis and pruritus. However,

there is no association between xerosis and the

severity of pruritus. Patients with chronic renal failure

who undergo hemodialysis and having xerosis are 5

times more likely to have pruritus and those with

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

234

moderate to severe xerosis may be 8 times higher for

pruritus.

ACKNOWLEDGEMENTS

The authors would like to thank the Faculty of

Medicine of Sriwijaya University and all those who

assist in the effort of this research.

REFERENCES

Khanna, D., Singal, A., & Kalra, O. P., 2010. Comparison

of cutaneous manifestations in chronic kidney disease

with or without dialysis. Postgraduate medical

journal, 86(1021), pp. 641-647.

ManetiL, Tansida P, & Vaglio A., 2009. Uraemic pruritus

clinical characteristics, pathophysiology and treatment.

Drugs. 69(3), pp. 251-263.

Masmoudi, A., Darouiche, M. H., Salah, H. B., Hmida, M.

B., & Turki, H., 2014. Cutaneous abnormalities in

patients with end stage renal failure on chronic

hemodialysis. A study of 458 patients. Journal of

dermatological case reports, 8(4), pp. 86.

Onelmis, H., Sener, S., Sasmaz, S., & Ozer, A., 2012.

Cutaneous changes in patients with chronic renal failure

on hemodialysis. Cutaneous and ocular

toxicology, 31(4), pp. 286-291.

Peres, L.A., Passarini, S.R., Branco, M.F., Kruger, L.A.,

2014. Skin lesions in chronic renal dialysis. J Bras

Nefrol, 36(1), pp. 42-47.

Suwitra, K., 2014. Chronic renal failure. in: Sudoyo AW,

Setiyohadi B, Alwi I, Simadibrata KM, Setiati S,

editors. Science Book of Internal Medicine. Vol 2. 6

ed. Jakarta: Interna Publishing.

Szepietowski, J.C., Balaskas, E., Taube, K.M., Taberly, A.,

Dupuy, P., 2011. Uraemic xerosis working group.

Quality of life in patients with uraemic xerosis and

pruritus. Acta Dermatology and Venereology, 91(3),

pp. 313-317.

Thomas, E. A., Pawar, B., & Thomas, A., 2012. A

prospective study of cutaneous abnormalities in

patients with chronic kidney disease. Indian journal of

nephrology, 22(2), 116-120.

Yosipovitch, G., 2004. Dry skin and impairment of barrier

function associated with itch–new

insights. International journal of cosmetic

science, 26(1), pp. 1-7.

Zucker, I., Yosipovitch, G., David, M., Gafter, U., & Boner,

G., 2003. Prevalence and characterization of uremic

pruritus in patients undergoing hemodialysis: uremic

pruritus is still a major problem for patients with end-

stage renal disease. Journal of the American Academy

of Dermatology, 49(5), pp. 842-846.

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