Cutaneous manifestations of chronic renal failure and renal transplantation

INTRODUCTION: The kidney and the skin are the two large networks of the body with their abundant blood supply, far in excess of their nutritional demands, the former for the constancy of the milieu interior and the latter maintaining mainly homeostasis. No wonder therefore, that they share many diseases and reflect mutually one another’s pathology which should be made use of by the clinician. Scientific and technologic improvements during the second-half of the 20th century have provided renal replacement therapy as a life sustaining option for many individuals who otherwise might have died. In each and every year of the last decade, the number of individuals with ESRD (end stage renal disease) has grown approximately from 20 to 30,000 per year. Cutaneous examination of patients with ESRD has shown that 50 – 100% of patients have at least one dermatologic condition. In addition to ESRD, uraemia and conditions associated with renal replacement therapy are fraught with numerous and often, relatively unique cutaneous manifestations. AIMS OF THE STUDY: 1. To study the various cutaneous manifestations and their incidence in patients with chronic renal failure. 2. To study the agewise and sexwise incidence of the individual cutaneous manifestation. 3. To study the incidence of cutaneous manifestations in renal transplant recipients. 4. To study the incidence of cutaneous manifestations of associated systemic disorder that may contribute to chronic renal failure. MATERIALS AND METHODS: This study was done for 2 years from October 2009 to October 2011 at Nephrology OPD, ward and medicine ward, Tirunelveli Medical College Hospital, Tirunelveli. Approval was obtained from the institutional ethical committee prior to the conduct of this study. During this period, 100 patients who had the presence of skin manifestations were selected and studied. 80 patients were known cases of chronic renal failure, diagnosed at Nephrology department or medical department and 20 patients were renal transplant recipients who were referral cases. Patient selection: Inclusion criteria: 1. Age : All ages, 2. Sex : Both males and females, 3. Patients with chronic renal failure, 4. Renal transplant patients. Exclusion criteria : 1. Patients with HIV infection, 2. Patients with previous malignancies, 3. Drug related cutaneous manifestations, 4. Patients on dialysis. SUMMARY: This clinical study of cutaneous manifestations of chronic renal failure and renal transplant recipients done during the period from October 2009 to October 2011, revealed the following: 1. Most of the specific cutaneous manifestations of chronic renal failure and renal transplantation were noted in this study. Pruritus (58.8%) and xerosis (57.5%) were the most common among the specific cutaneous manifestations of chronic renal failure, which is similar to another study[104]. Pigmentary changes (55%) and nail abnormalities (56.2%) were the next. Mucosal and hair abnormalities were noted in good percentage of cases. Nearly 4 % had perforating dermatosis. Interesting findings noted in this study were digital gangrene, poor wound healing and restless leg syndrome. The onset of cutaneous manifestations after CRF ranges between 6 months to 3 years in this study. 2. Skin changes due to renal transplantation were mostly due to infections (excluding medication related disorders), with fungal infections (40%) being the most commonly noted. The next to follow was viral infections (35%) with verruca vulgaris being the commonest manifestation. The high incidence of cutaneous infections in these patients could be due to impaired immunity resulting in increased susceptibility to infections. Premalignant and malignant lesions were not noted in this study. After renal transplantation, there is improvement in pruritus in 9 (45%) patients and xerosis in 6 (30%) patients. 3. Skin changes specific to associated systemic diseases helped in finding various etiologies of chronic renal failure such as diabetes mellitus, systemic lupus erythematosus, scleroderma, vasculitis and ITP. 4. Other associated skin conditions were not related to etiology and were found to be just coincidental. CONCLUSION: Pruritus and xerosis were the most common among the specific cutaneous manifestations of chronic renal failure, followed by nail abnormalities and pigmentary changes. Calciphylaxis and uremic frost were not noted in any patient. The incidence of hair and nail abnormalities were more among females than males in this study. Cutaneous manifestations of renal transplantation were mostly due to infections, of which fungal infections were commonly observed followed by viral infections