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Dermatologic Manifestations of Chronic
Kidney Disease
Moderators : Dr. Basappa Dr. RaviPresented by : Dr. Chandan
Background and Classification
• 1. Dermatologic manifestations of diseases associated with the development of
ESRD
• 2. Dermatologic manifestations of uremia
• 3. Dermatologic disorders associated with renal transplantation.
• 1. Dermatologic manifestations of diseases
associated with the development of ESRD
• DM – Dermopathy, Necrobiosis, Acanthosis nigricans, Kyrle disease
• Connective tissue disorders • Fabrys disease : Angiokeratomas• Tuberous sclerosis : Adenoma sebaceum
Ash-leaf macule Periungual fibromas Shagreen patch
Background and Classification
• 1. Dermatologic manifestations of diseases associated with the development of
ESRD
•2. Dermatologic manifestations of uremia
• 3. Dermatologic disorders associated wit renal transplantation.
Cutaneous manifestations of Uremia• Xerosis • Pruritis• Pigmentary alteration• Nail Changes• Hair Changes• Acquired perforating disorder (Kyrle disease) • Bullous disease of dialysis • Calcinosis cutis (metastatic) • Calciphylaxis • Nephrogenic systemic fibrosis • Porphyria cutanea tarda
Xerosis
• Most common cutaneous abnormality
• Is predominantly seen over the extensor surfaces of the forearms, legs and thighs.
• The abdomen and chest may show fine scaling
Uremic Pruritis
• One of the most characteristic and annoying cutaneous symptoms of CRF
• Incidence : 50-90 %• Mechanisms :
Uremic Pruritis - Mechanisms :
– Xerosis – Decreased transepidermal elimination
of pruritogenic factors – Hyperparathyroidism – Hypercalcemia – Hyperphosphatemia – Elevated histamine levels – Increased dermal mast cell proliferation – Uremic sensory neuropathy – Middle molecule theory
Uremic Pruritus -Treatment :
– Emperical– Topical Steroids– UV phototherapy– Capsaicin– Erythropoietin– Naltrexone, Gabapentin– HD, Transplant– Primerose oil, Tacrolimus ?
Pigmentary changes
• Pallor – Anemia• Yellow hue – Carotenoids• Hyperpigmentation - increase in
poorly dialyzable beta-melanocyte stimulating hormone
Purpura / Echymosis / Easy bruising
• Defects in primary hemostasis like increased vascular fragility
• Abnormal platelet function • Use of heparin during dialysis are
the main causes of abnormal bleeding in these patients
Nail changes
• Lindsay's nails (half and half nails, prevalence 15-50 % )
• Others – Koilonychia – Subungual hyperkeratosis – Onycholysis – Splinter hemorrhages – Brown nail bed arcs
Half and Half Nails
Yellow nail syndrome (YNS) is triad of yellow nails, lymphedema, and respiratory tract involvement
Hair abnormalities
• Sparse body hair and diffuse alopecia with dry, lusterless hair
• Decreased secretion of sebum• Chronic telogen effluvium • Drugs – Heparin / Statins /
Antihypertensives
Calcific Uremic Arteriolopathy (Calciphylaxis)
• Characterized by calcification, intimal hypertrophy, and thrombosis of small vessels, which results in necrotizing, nonhealing ulcers.
• Infectious complications – non healing ulcers
• 1-year survival rate of 45% • Treatment : Wound Care
Intensified HD Discontinuation vitamin D analogs Urgent Parathyroidectomy Calcimimetic cinacalcet Hyperbaric O2
Acquired Perforating Dermatosis ( APD )
Acquired Perforating Dermatosis ( APD )
• Papulonodular hyperkeratosis with central crust
• Excessive scratching + diabetic vasculopathy - dermal necrosis- eliminated through the epidermis
• Kyrle’s disease• Elastosis Perforans serpiginosa• Perforating folliculitis• Reactive perforating collagenosis
Porphyria Cutanea Tarda
• Commonly presents as bullae on the dorsal surfaces of the hands and feet
• Sporadic form of PCT occurs in approximately 5% of patients on dialysis; this form is caused by increased uroporphyrin concentrations and can be triggered by ingestion of alcohol, estrogens or iron and by chronic infections such as hepatitis B, hepatitis C or HIV
• Treatment : Unsatisfactory
Bullous Disease of Dialysis
• Syndrome of cutaneous fragility and blistering • Sun-exposed skin, most often on the dorsal
hands• Resembles Porphyria• Plasma porphyrin levels are normal or only
minimally elevated • Mechanical fragility of skin subjected to
sunlight and incidental trauma • Rx : Protect from sunlight, Avoid Trauma• Drug induced pseudoporphyria - Nabumetone,
Furosemide, Tetracycline, Nalidixic acid
Nephrogenic fibrosing dermopathy (NFD)
Nephrogenic fibrosing dermopathy (NFD)
• Recentle described - 1997 • Resembles Scleromyxedema• Progressive development of painful,
erythematous, sclerotic dermal plaques, usually pruritic on the arms and legs, with sparing of the head and neck
• HPE - proliferation of fibroblasts in the dermis and subcutaneous septae accompanied by increased dermal and septal collagen and mucin
• No Effective Treatment
Nephrogenic systemic fibrosis in a 56-year-old patient.
(A)The typical red discoloration and orange-peel thickening
of the skin (peau d'orange) of the upper arm with a 'woody' texture.
(B) Secondary thrombosis of the arteriovenous fistula in the left arm (arrow) owing to progressive tightening of the skin.
(C) The patient's left hand is severely affected with limited
movement of the digital joints, which resulted in contractures.
Iatrogenic manifestations
• Arterial steal syndrome -pain and numbness. Prolonged ischemia may result in digital gangrene, peripheral neuropathy, or cutaneous atrophy
• 3. Dermatologic disorders associated with
renal transplantation.
InfectionsDrugs – Steroids, ImmunosuppresantsMalignancies
Skin changes in Acute Renal Failure
• 1. Edema• 2. Uremic Frost
Uremic Frost
Was a frequent In the pre-dialysis era
The frost consists of a white or yellowish coating of urea crystals on the beard area and other parts of the face, neck and on the trunk.
It is due to eccrine deposition of urea crystals on the skin surface of patients with severe uremia
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