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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 2-6

Nail Changes in the Chronic Kidney Failure – A Cross-Sectional Study


1 Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
2 Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission03-Mar-2022
Date of Decision11-Mar-2022
Date of Acceptance28-Mar-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Ruchita Kabra
Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_90_22

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  Abstract 


Background: Nail manifestations observed in chronic renal failure (CRF) patients are multifarious and heterogeneous in nature. The prime objective of the study is to evaluate the prevalence and features of various kinds of nail manifestations in the patients of CRF. CRF causes heterogeneous pathology of nail which may be or may not be associated with renal condition itself, complications related to it and its therapy. Objective: To study nail changes in the patients of CRF whether managing conservatively or on maintenance hemodialysis (HD). Patients and Methods: The study consists of 100 patients suffering from CRF. Nails of these 100 patients suffering from CRF were examined and different kinds of nails were appreciated and frequencies of the same type of nails in different patients were noted. Results: Nail changes found in chronic kidney disease are longitudinal ridges, half and half nails, leukonychia, pitting nails, onychomycosis, absence of lunula, splinter hemorrhage, and onycholysis as decreasing trend they observed. Conclusions: Nail changes that are seen on examination of patients with CRF managing on HD are very frequent and nail changes if found earlier can be an indicator for early diagnosis of systemic diseases.

Keywords: Half and half nails, leukonychia, onychomycosis, onycholysis


How to cite this article:
Kabra R, Acharya S, Shukla S, Kumar S. Nail Changes in the Chronic Kidney Failure – A Cross-Sectional Study. J Datta Meghe Inst Med Sci Univ 2022;17:2-6

How to cite this URL:
Kabra R, Acharya S, Shukla S, Kumar S. Nail Changes in the Chronic Kidney Failure – A Cross-Sectional Study. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:2-6. Available from: http://www.journaldmims.com/text.asp?2022/17/1/2/352252




  Introduction Top


By definition, chronic kidney disease (CKD) is a structural damage of kidneys or estimated glomerular filtration rate <60 ml/min/1.73 m2, continual for 3 or more months, irrespective of the cause of it.[1] It is a condition of progressive functional loss of the kidney. The leading cause of CKD remains hypertension and diabetes mellitus which progressively lead to dialysis.

CRF is one of those conditions which affect all body systems, causing neurological disorders, gastrointestinal disorders, cardiovascular disorders, pulmonary disorders, hematological disorders, endocrine and metabolic disorders and dermatological disorders,[2] they may be caused by function of renals itself and the complications caused due to its treatment which further leads to dry skin called xerosis, itching, pruritus, black pigmentation, calcified skin, bullous diseases besides the involvement of the nails.[3],[4],[5]

There is a diffusion of dermatological diseases which are very frequently seen in CKD patients and renal transplants patients rather than other population. The importance of skin manifestations in renal disease for doctors and patients for early diagnosis and to decrease the mortality and morbidity for these patients.

Some report says that nail disorders occur in uremic patients and the most common findings include longitudinal ridging, white nails/total leukonychia, koilonychias, and Lindsay's nail are commonly known as half and half nails, pitting nails, onychomycosis, onycholysis, absence of lunula, and splinter hemorrhage.

The main objective of our study is to evaluate and analyze the different types of nails and prevalence of its occurrence in the patients with chronic renal failure (CRF) whether managing conservatively or on maintenance hemodialysis (HD).


  Patients and Methods Top


This study has been done on 100 patients affected by CRF whether managing conservatively or on maintenance HD in the Department of Medicine at JN Medical College, DMIMS, Sawangi (Meghe), Wardha, Maharashtra, India.

Subjects selected are free from other systemic congenital or primary skin disorders which can contribute to nail changes. They are free from injuries or infection of the fingernails or any ornamental dyes like henna application.

Nails are examined under daylight or bright light and prevalence of its occurrence and features of various kinds of nail manifestations are noted and their frequency of occurrence is observed and noted.


  Results Top


Nail changes found in chronic kidney disease are longitudinal ridges, half and half nails, leukonychia, pitting nails, onychomycosis, absence of lunula, splinter hemorrhage, and onycholysis as decreasing trend they observed.


  Discussion Top


Chronic kidney disease is a disease which over a period of time progresses and leads to functional loss of kidneys over a period of a long time which may be in years which goes through 5 stages of progression.[5],[6]

The effects of CKD are very complex because it involves multiorgan systems.

The most accessible and visible organ of the body functions, i.e., skin is an important tool of diagnosis for various diseases affecting all systems of the body including renal system. Similarly, nail changes are seen in the patients with chronic kidney disease or uremic patients.

CRF affects entire systems of the body, causing gastrointestinal disorders, cardiovascular disorders, hematological disorders, endocrine and metabolic disorders and skin disorders,[2] they may be caused by function of renals itself and the complications caused due to its treatment which further leads to dry skin called xerosis, itching, pruritus, black pigmentation, calcified skin, bullous diseases besides the involvement of the nails.[3],[4],[5]

Some report says that nail disorders occur in uremic patients and the most common findings include longitudinal ridging, white nails/total leukonychia, koilonychias, half and half nails/Lindsay's nails, onychomycosis, onycholysis, splinter hemorrhage, absence of lunula, and pitting nails.

We examined 100 patients. The duration of the disease taken in the study ranges from 6 months to 10 years. Nails of the subjects are examined under bright light. Prevalence and features of various kinds of nail manifestations are noted and their frequency of occurrence is observed and noted.

A total of 60/100 (60%) patients had nail manifestations seen in fingernails which include longitudinal ridges (20%), leukonychia (6%), half and half nails (12%), absence of lunula (4%), onycholysis (3%), onychomycosis (5%), splinter hemorrhage (4%), pitting nail (6%), and no any change (40%).

The prevalence rate of abnormalities of nail seen in CRF patients is shown in [Table 1]. These results do not have any significant relation between the nail abnormalities and severity of renal failure.
Table 1: Nail changes seen in study

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There are various skin changes seen in end-stage renal disease patients, which further include black pigmentation, pallor, yellow skin hue, and slate gray discoloration.

Pallor is paleness of the skin which is associated with anemia, while the slate-gray discoloration occurs due to deposition of hemosiderin.[7] Yellowing of the skin is seen because of deposition of urochromes and carotenoids in the skin. Hyperpigmentation is very commonly seen in areas which are sun exposed and is related to increased melanin deposition in the skin which occurs due to more hormone stimulating beta-melanocytes.[8]

As a hormone-stimulating beta-melanocyte, carotenoids and urochromes are not dialyzed during dialysis, hyperpigmentation and yellow hue appear continuously despite treatment of CRF that is dialysis.[9] An increase in hormone-stimulating beta-melanocyte can be a mechanism for half-and-half nails or Lindsay's nails. This involves the fingernails more often than the toes and appears to be red to brown with a distal color of 20%–60% of the nails and a close white color change.[10] This solves with kidney transplants [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].
Figure 1: Longitudinal ridges

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Figure 2: White nails

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Figure 3: Half-and-half nails

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Figure 4: Absence of lunula

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Figure 5: Onycholysis

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Figure 6: Onychomycosis

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Figure 7: Splinter hemorrhage

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Figure 8: Pitting nails

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Figure 9: Half and half nails

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Half-and-half nails also known as Lindsay's nails are found in about 12% of patients on dialysis[8] in this study. They are observed as a change in the color of the nails with an intimate white part and a reddish-brown part.[8] The color change does not change with the growth of the nails. The color does not disappear due to the pressure. The mechanism for half and half nails is not well understood, but capillary number increases and wall of capillary stiffened in nail bed.[11] It does not improve with the treatment of CRF or dialysis. They only way which can improve it is renal transplantation.[12],[13]

The absence of lunula is manifested by the nonvisual representation of the visible part of the nail matrix.

Leukonychia is white discoloration of nails. Different types of leukonychia like total, subtotal and transverse leukonycia. In total, leukonychia entire nails are as white as porcelain; which occurs in chronic liver disease. In subtotal leukonychia, the two-thirds part of proximal nail is white which is because of delay in keratin maturation. Transverse leukonychia is seen in patients undergoing chemotherapy or poisoning which affects function of matrix. Other causes of leukonychia are low albumin states.

Onycholysis is a separation of distal part plate of nail from bed of nail. The area of separation is white or yellowish due to air under the nail. The correlation of onycholysis with the diseases of other body systems is over-rated. It is associated with anemia, lung cancer, thyroid disorders, cutaneous T-cell leukemia, bronchiectasis, and diabetes mellitus.[14],[15]

Splinter hemorrhages in nails are characterized as hemorrhage from vessels running longitudinally across nail bed seen in patients of cardiac conditions such as infective endocarditis, valvular replacement, rheumatic heart disease, systemic lupus erythematosus, antiphospholipid antibodies syndrome, intravenous drug abusers, and congenital cyanotic heart diseases. It may be seen in other systemic conditions too.[16],[17],[18]

Our study found that there are diffuse types of nail changes seen in the patients with CRF and these nail changes varied from the most frequent (longitudinal ridges) to the rare one like onycholysis. Cause of these nail changes remains unknown which cannot be traced to any typical abnormality occurring in the renal condition, its treatment. It needs further investigations to find the actual mechanism of their occurrence.


  Conclusion Top


Chronic kidney disease affects almost all systems in the body. Similarly, it affects the dermatological system of which nails are affected the most. Nail changes that are seen on examination of patients of CRF managing on HD are very frequent; however, the cause of it remains unknown which cannot be traced to any typical abnormality occurring in the renal condition, its treatment. Nail changes are so frequent that if they found earlier can be tool for early diagnosis of systemic diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luke RG. Insuficiencia renal cronica. In: Ausiello D, Cecil GL, editors. Tratado de Medicina Interna. 20th ed. Rio de Janeiro: Guanabara Koogan; 2001. p. 632-40.  Back to cited text no. 1
    
2.
Robinson-Bostom L, DiGiovanna JJ. Cutaneous manifestations of end-stage renal disease. J Am Acad Dermatol 2000;43:975-86.  Back to cited text no. 2
    
3.
Clayton BD, Jorizzo JL, Sherertz EF. Alteracoes cutaneas nos disturbios renais. In: Fitzpatrick – Tratado de Dermatologia. 5th ed. Rio de Janeiro: Livraria e Editora Revinter; 2005. p. 1930-3.  Back to cited text no. 3
    
4.
Welter EQ, Bonfa R, Petry V, Moreira LL, Weber MB. Relacao entre grau de prurido e qualidade de vida de pacientes em hemodialise. An Bras Dermatol 2008;83:137-40.  Back to cited text no. 4
    
5.
Goddard J, Turner AN, Cumming AD, Stewart LH. Kidney and urinary tract disease. In: Boon NA, Colledge NR, Walker BR, Hunter JA, editors. Davidson's Principles and Practice of Medicine. 20th ed. Edinburgh: Churchill Livingstone, Elsevier; 2006. p. 455-518.  Back to cited text no. 5
    
6.
Watnick S, Morrison G. Kidney. In: Tierney LM, McPhee SJ, Papadakis MA, editors. Current Medical Diagnosis and Treatment. 43rd ed. New York: McGraw Hill; 2004. p. 863.  Back to cited text no. 6
    
7.
Lupi O, Rezende L, Zangrando M, Sessim M, Silveira CB, Sepulcri MA, et al. Cutaneous manifestations in end-stage renal disease. An Bras Dermatol 2011;86:319-26.  Back to cited text no. 7
    
8.
Udayakumar P, Balasubramanian S, Ramalingam KS, Lakshmi C, Srinivas CR, Mathew AC. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. Indian J Dermatol Venereol Leprol 2006;72:119-25.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Abdelbaqi-Salhab M, Shalhub S, Morgan MB. A current review of the cutaneous manifestations of renal disease. J Cutan Pathol 2003;30:527-38.  Back to cited text no. 9
    
10.
Lindsay PG. The half-and-half nail. Arch Intern Med 1967;119:583-7.  Back to cited text no. 10
    
11.
Kurban MS, Boueiz A, Kibbi AG. Cutaneous manifestations of chronic kidney disease. Clin Dermatol 2008;26:255-64.  Back to cited text no. 11
    
12.
Neild GH, Alston H, Burns A. Half and half nails. NDT Plus 2011;4:361.  Back to cited text no. 12
    
13.
Markova A, Lester J, Wang J, Robinson-Bostom L. Diagnosis of common dermopathies in dialysis patients: A review and update. Semin Dial 2012;25:408-18.  Back to cited text no. 13
    
14.
Zaic MN, Daniel CR. Nails in systemic disease. Dermatol Ther 2002;15:99-106.  Back to cited text no. 14
    
15.
Daniel CR 3rd. Onycholysis: An overview. Semin Dermatol 1991;10:34-40.  Back to cited text no. 15
    
16.
Lawry M, Daniel CR 3rd. Nails in systemic disease. In: Scher RK, Daniel CR, editors. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Science Limited; 2005. p. 147-69.  Back to cited text no. 16
    
17.
Singh G. Nails in systemic disease. Indian J Dermatol Venereol Leprol 2011;77:646-51.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Monk BE. The prevalence of splinter haemorrhages. Br J Dermatol 1980;103:183-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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