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Dr. D M J S Dissanayake
Registrar im medicine
Introduction
• Dermatologic manifestations of renal disease are common findings in
patients with end-stage renal disease (ESRD).
• Xerosis
• Pruritus
• Pigmentary alteration
• Half-and-half nails
• Alopecia
• Uremic frost
• Porphyria cutanea tarda
• Arterial steal syndrome
Xerosis
• Pruritus frequently affects the patient's sleep pattern and psychologic well-being.
• Cutaneous manifestations of pruritus include excoriations, prurigo nodularis, and
lichen simplex chronicus.
Mechanisms - poorly understood and are believed to result from metabolic
disequilibrium. Some causes of uremic pruritus include the following:
• Xerosis
• Decreased transepidermal elimination of pruritogenic factors
• Hyperparathyroidism
• Hypercalcemia
• Hyperphosphatemia
• Elevated histamine levels
• Increased dermal mast cell proliferation
• Uremic sensory neuropathy
• Middle molecule theory
Therapeutic options,
• Koilonychia
• Subungual hyperkeratosis
• Onycholysis
• Splinter haemorrhages
• Brown nail bed arcs
Hair abnormalities / Alopecia
• Alopeca is more common in end-stage renal disease (ESRD) than in
the general population.
• Uremic frost is rarely seen in the present day because of early dialytic
intervention.
• When the blood urea nitrogen (BUN) level is adequately high (usually
> 250-300 mg/dL), the concentration of urea in sweat is increased
greatly.
• Evaporation results in the deposition of urea crystals on the skin.
• Uremic frost is commonly found in the beard or on other parts of the
face, neck, and trunk as fine white-to-yellow crystals that dissolve
readily when challenged by a drop of water.
Bullous Disease of Dialysis
• Syndrome of cutaneous fragility and blistering
• Sun-exposed skin mostly –dorsum of hands
• Resembles porphyria
• Plasma porphyrin level normal or minimally elevated
• Mechanical fragility of skin subjected to sunlight and incidental
trauma.
• Treatment –protect from sunlight, avoid trauma
Purpura /Ecchymosis / Easy bruising
Calaiphylaxis / Calcific Uremic Arteriolopathy
Acquired Perforating Dermatosis
Arterial steal syndrome
• The arterial steal syndrome is an uncommon but highly morbid complication of the
vascular access necessary for hemodialysis. Vascular access typically is placed in
the nondominant upper extremity.
• The arterial steal syndrome may develop if the inevitable proximal shunting of
blood is significant enough to cause hand ischemia.
• Proximal shunting is attributed to the reversal of blood flow through distal arteries,
induced by the low-pressure system produced by the arteriovenous connection.
• Symptoms of arterial steal syndrome include pain and numbness.
• Prolonged ischemia may result in digital gangrene, peripheral neuropathy, or
cutaneous atrophy.
• Individuals at heightened risk for this complication include those with peripheral
vascular disease, especially diabetes mellitus.
Dermatologic Disorders Associated With
Renal Transplantation
• The best therapeutic option for many patients with end-stage renal
disease (ESRD) is renal allograft transplantation. Successful
transplantation results in regression of many of the metabolic and
cutaneous changes of uremia.
• A broad range of skin diseases occurs in patients with ESRD, from the
benign and asymptomatic to the physically disabling and life-
threatening. Many of them negatively impact on quality of life. Their
early recognition and treatment are essential in reducing morbidity
and mortality.
• The cutaneous manifestations can be divided into two main
categories: nonspecific and specific. The nonspecific manifestations
are commonly seen and include skin color changes, xerosis, half-and-
half nails, and pruritus. The specific disorders include acquired
perforating dermatosis, bullous dermatoses, metastatic calcification,
and nephrogenic systemic fibrosis
• THANK YOU!