Factors affecting dermatological manifestations in patients with End Stage Renal Disease

Objective: To determine skin changes in patients of End Stage Renal Disease (ESRD) on maintenance hemodialysis (MHD) and factors affecting these changes. Study Design: Cross-sectional observational study. Place and Duration of Study: Nephrology Department, Mayo Hospital, Lahore in collaboration with Dermatology Department, King Edward Medical University, Lahore, from October 2015 to January 2016. Methodology: Two hundred patients who were undergoing MHD for more than three months were included in the study. Patients' demographic data, laboratory reports and dialysis records were noted in a predesigned questionnaire. Skin examination was carried out by consultant dermatologist after patient's permission. Results: Among 200 patients included in study, 105 were males and rest of them were females. Major causes of ESRD were Diabetes Mellitus (n=83, 41.5%, followed by Hypertension (n=80, 40%), Nephrolithiasis (n=15, 7.5%) and Chronic glomerulonephritis (n=5, 2.5%). At least one cutaneous finding was present in every patient. Common skin findings observed were pigmentation (86%), xerosis (83%), pallor (79%), pruritus (69%), acquired ichthyosis (50.5%), and bacterial skin infections (18.5%). Among them, nail manifestations were half-and-half nails (52%), onychomycosis (30.5%), onycholysis (20.5%), subungual hyperkeratosis (23.5%), and Mee's lines (7.5). Among hair changes were sparse scalp hair (38.5%), brittle and lustreless hair (28%). The factors contributing to skin changes were patient's age, cause of ESRD, anti HCV positivity, high urea and creatinine levels, duration and frequency of hemodialysis, hemoglobin levels, calcium phosphate product and socioeconomic status. Some skin manifestations were interrelated with each other like xerosis with pruritus (p < 0.001), pruritus with bacterial infection (p < 0.022), acquired Ichthyosis (p=0.008) and hair changes (p=0.035). Conclusion: ESRD patients on hemodialysis develop various skin changes during the course of disease process, which contribute to increased morbidity. Different factors affecting skin changes were the cause of ESRD, adequacy and duration of dialysis, employment, financial status, anti HCV positivity, and metabolic factors.