Skin in ckd Dr.chandan

1. Dermatologic Manifestations of
Chronic Kidney Disease
Moderators : Dr. Basappa
Dr. Ravi
Presented by : Dr. Chandan

2. 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.

3. •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

4. 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.

5. 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

6. 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

7. Xeroderma

8. Uremic Pruritis
•One of the most characteristic and annoying cutaneous
symptoms of CRF
•Incidence : 50-90 %
•Mechanisms :

9. 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

10. Uremic Pruritus -Treatment :
–Emperical
–Topical Steroids
–UV phototherapy
–Capsaicin
–Erythropoietin
–Naltrexone, Gabapentin
–HD, Transplant
–Primerose oil, Tacrolimus ?

11. Pigmentary changes
•Pallor – Anemia
•Yellow hue – Carotenoids
•Hyperpigmentation - increase in poorly
dialyzable beta-melanocyte stimulating hormone

12. 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

13. Nail changes
•Lindsay's nails (half and half nails, prevalence 15-50 % )
•Others
–Koilonychia
–Subungual hyperkeratosis
–Onycholysis
–Splinter hemorrhages
–Brown nail bed arcs

14. Half and Half Nails

16. Yellow nail syndrome (YNS) is triad of yellow nails,
lymphedema, and respiratory tract involvement

17. Hair abnormalities
•Sparse body hair and diffuse alopecia with dry,
lusterless hair
•Decreased secretion of sebum
•Chronic telogen effluvium
•Drugs – Heparin / Statins / Antihypertensives

18. 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

20. Acquired Perforating Dermatosis ( APD )

21. 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

22. 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

23. 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

25. Nephrogenic fibrosing dermopathy (NFD)

26. 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

27. 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.

28. Iatrogenic manifestations
•Arterial steal syndrome -pain and numbness.
Prolonged ischemia may result in digital
gangrene, peripheral neuropathy, or cutaneous
atrophy

29. •3. Dermatologic disorders associated with
renal transplantation.
Infections
Drugs – Steroids, Immunosuppresants
Malignancies

30. Skin changes in Acute Renal Failure
•1. Edema
•2. Uremic Frost

31. 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

34. THANK YOU