Chronic Kidney Disease marked by the deteriorating condition of the kidney and the renal function, is an all encompassing disease. It does not thrive in isolation; it rather creeps into every corner of the body and manifests itself in different shapes and forms. One such manifestation that is apparent and extremely common is on the skin. The skin’s condition is highly affected as a result of the impaired kidney function along with the medicines that are consumed and the therapy that is done on the patient. These cutaneous appearances are not just bothersome, unpleasant and painful to look at but also deadly in certain cases. Early diagnosis and treatment of the skin disease might help the patient drive far away from toxicity and keep the skin wrapped in the blanket of health and wellness.

Chronic Kidney Disease and Skin problems: The inevitable link

According to Julia R. Nunley (2020), the majority of (50% – 100%) patients with end-stage renal disease are believed to be suffering from at least one dermatological condition. Her study analyses the relation between skin problems and CKD, to establish 3 categories:

1. Dermatological manifestations of diseases associated with the development of ESRD
2. Dermatological manifestations of uremia
3. Dermatological disorders associated with renal transplantation

Some skin issues that the CKD patient experiences are:

1. Renal pruritus:Itchiness is a common symptom faced by people suffering from CKD. The intensity of the itching might range from a simple irritation to full blown destruction of one’s everyday activities. Renal pruritus in extreme cases might become an “independent risk factor for increased mortality and a poor prognosis” (Mendez et al., 2015). The itchiness might spread to other parts of the body and cause psychological distress, health anxiety, sleeping issues and eating disorders etc. Itchiness is experienced differently by different patients. Some feel itchy all the time, while others experience it in breaks. Some patient’s itchiness is only confined to one area while others’ condition spreads through different parts of the body.

Renal Pruritus is a condition that occurs due to a couple of causes (Mendez et al., 2015): such as high levels of uremic nitrogen, calcium, phosphorus, magnesium, aluminium, Vitamin A, histamine and mast cells. Itching might also be caused due to an allergy to the dialysis treatment and to counteract this allergy, creams and medicines are given for relief.

As per the research conducted by Mendez et al., this condition is often a lingering problem that is worsened due to heat, sweating or dryness. It sometimes gives way to extreme scratching that might result in skin lesions such as excoriations, lichen simplex, nodular prurigo and keratotic papules.

Since the association of Pruritus with increased mortality and low quality of life gets intense gradually, measures must be taken to check and prevent the same. Diet prescribed to balance the high levels of phosphorus, magnesium, VitaminA, aluminium etc in the body might be the most effective treatment option.

Along with this, treatment to boost skin hydration, increased patient education about scratching and how to control it along with the most definitive treatment i.e. kidney transplantation supported with improving the quality of haemodialysis. Creams and gels such as Capsaicin and pramoxine or treatment with gabapentin are believed to be the most effective, however consulting a professional should be the right route to take, who will diagnose your condition and give you the best possible treatment.

1. Xerosis: Desai et al. (2013) in their study of CKD and skin manifestations of it understand Xerosis or dry skin as one of the most common symptoms associated with kidney disease. Since this condition aggravates pruritus (Combs et al., 2015), and leads to other infections, it becomes integral to make sense of dry skin and discern that it is not the most favourable condition for a person suffering from kidney disease.

As understood by Mendez et al. (2015), it is caused by, “decreased hydration of the stratum corneum; decreased sweat gland and sebaceous gland size along with abnormal function related to hypervitaminosis A in dialysis patients and the use of diuretics.” 

According to Desai et al. (2013), these changes and circumstances cause dryness especially over the extensor surfaces of the forearms, legs and thighs and must be treated with the help of topicals and certain behavioural changes. To treat scaly, rough and tight skin, avoiding long hot showers, using a good and moisturizing soap instead of a harsh one, water based gels, creams and lotions along with other moisturising products for sensitive skin are advised. Avoiding products that are alcohol based and only using products that wet and soothe the skin are integral to ease out any dryness, scaling, redness and itching on the skin.

1. Nephrogenic systemic fibrosis (NSF): This rare disorder consists of “visible fibrosis of the skin, consisting of hardened, thickened, tethered, hyper pigmented and/or shiny changes.” (Desai et al., 2013). As a fibrosing disorder, it does not just impact the health of the skin, but also the health of the body and its different organs such as heart, lungs, liver diaphragm. According to research and analysis done by Perazella, 2007, it might be one of the contributors of physical disability and death of the patient along with other diseases. Perazella backs her understanding of NSF by looking at stats and figures, and ultimately establishes that although the cause of NSF is unclear but every patient suffering from it, also suffers from kidney disease. While some are on haemodialysis, others have Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD). Therefore, the link between kidney problems and NSF is well established and this very link then becomes the key to unlocking the solutions to this problem.

Although the cause of NSF is a little vague, but vast research done by Yerram et al. (2007), suggests the role of recent vascular surgeries, high dosage of iron and epoetin therapy along with the exposure to gadodiamide (gadolinium based MRI contrast agent) to the development of this exceptional disease.

NSF’s development on the skin is visible as a woody appearance, indurated, erythematous hyperchromic plaques with an orange peel. Yellowing plaques or nodules and bullae may be present on the hands and/or feet. No visible signs are seen on the face and the condition is occasionally observed on the trunk and buttocks. A burning sensation and stinging pain along with itching might irritate the patient. (Mendez et al. 2015).

Treatment options include kidney transplant, UV-A 1 phototherapy, plasmapheresis, physical therapy, and haemodialysis along with certain medications such as Imatinib etc. However, consulting a doctor might be the best first step towards healthy living.

1. Acquired perforating dermatosis (APD): Found especially in people with diabetes or undergoing haemodialysis and are at the end stage of CKD, APD and its link to kidney diseases is often discussed about. As researched by Pratt. And C. Lynde in 2009, APD occurs in about 10% of patients receiving dialysis.

APD of haemodialysis is characterised by “hyperkeratotic papular lesions” (Desai et al. 2013). Although the birth of APD is obscure and ambiguous in nature, researches like Mendez et al. (2015) make sense of it as a “transepidermal elimination of dermal components (collagen, elastin and cell detritus) or the result of “dermal connective tissue dysplasia and decay.” (Desai et al., 2013).

Clinical manifestations in the form of intensely itchy papules or nodules that pop up commonly in lower limbs are frequent. These dome shaped papules with a scaling centre develop less on the scalp, trunk and buttocks but more generally on the extensor surfaces of the arms and legs.

Often investigated via skin biopsy, the treatment of APD is directed at relieving the pruritus, oral or topical retinoids, phototherapy, use of antibiotics, laser therapy and/cryotherapy. Steroids and other oral drugs are prescribed to reduce the collagen damage and itching along with decreasing inflammation and resolving skin lesions. Treatment could get exhausting and infuriating since the lesions might become stubborn and persist for a long time, leading to the development of scars.

1. Calcific Uremic Arteriolopathy (CUA): Also known as calciphylaxis, this skin condition is discovered mostly in patients with end stage renal disease who are on dialysis with a mortality rate of 40% to 60%. Understanding the complications that CUA carries along with it, Udomkarnjananun et al., 2019, seek to understand its pathophysiology. They define it as a, “systematic process of vascular calcification, particularly in small dermal and subcutaneous arteries and arterioles, leading to microthrombi and tissue ischemia.”

It is mostly found in patients suffering from kidney disease, undergoing long term dialysis or kidney transplantation. Other factors that may contribute to this condition are: obesity, diabetes, uremia (build-up of toxic substances in the body and not being flushed out via the urine), some medications, imbalance of calcium, phosphorus and aluminium in the body and overproduction of parathyroid hormone (PTH).

CUA is experienced in the form of pain, sensitivity and/or discolouration of the skin. Skin lesions then progress onto becoming worse, in the form of plaques or nodules. Distributed bilaterally and symmetrically, they mostly develop on the lower extremities, the abdomen or the buttocks i.e. mostly in the areas where the fat content is high. They may progress onto developing as painful, irregularly shaped, non-healing ulcers. Not just the skin, it may also affect the body and its functioning, which could lead to the development of muscle weakness, bowel infarction, cardiac valve etc. (Galperin et al. 2014). Internal organs such as the brain, liver and intestines may face a strong and harsh blow and lead to a level of suffering that may even cause death.

Early diagnosis and treatment are paramount to slow down the progression of CUA and make sure that the patient’s suffering and pain shoots low along with skin lesion resolution. Treatment and management options include balancing the serum calcium and phosphate levels, oral treatment with sodium thiosulfate along with other drugs and dialysis treatment, which can give relief to the patient. The Wound is often treated by either surgically removing it or healing through wet dressing.

1. Nail disorders: Changes in the nails and its appearance are pretty common for patients with chronic kidney disease. The changes are visible in the form of thickness, colour, texture and shape. Some changes observed on patients with kidney disease or renal failure are: Mees lines, Lindsay nails (half and half), muehrcke’s lines. Further in-depth research by Aqil et al., 2019 elaborates on the nail disorders. Their research focuses on 70 patients with renal failure,outofwhich80%showednailabnormalities. These Included:

• Absence Of Lunula(51.7%):
• Half And Half Nails(33.9%)
• Splinter haemorrhages (58.9%)
• Melanonychia(14.2%)
• Onycholysis(71.4%)
• Beau’s Lines(35.7%)
• Koilonychias (7.1%)
• Muehrcke Lines(7.1%)
• Signs Of Onychomycosis(48.2%)
• Pincer Nail Deformity(10.7%)
• Brittle Nails(10.7%)
• Onychogryphosis(10.7%)
• Leukonychia(25%)
• Longitudinal Ridging(64.2%)
• Subungual Hyperkeratosis(55.3%)
• Paronychia(5.4%)
• Nail Clubbing(1.8%)

Many are unable to place a finger on the exact cause of these nail disorders but some of the explanations are that they arise as a result of the kidney damage, the complications of this damage or the medications and therapies to aid the kidney disease. Anaemia, deficiencies in important proteins, minerals, vitamins along with uremia may cause these changes in the appearance of the nails. Furthermore, latest studies such as the one done by Ebrahim et al., 2019, are also suggestive of protein, mineral and vitamin imbalance as the root cause of nail disorders in kidney patients. Anaemia and hypoalbuminemia might also be an underlying cause for nail changes. According to this respective study, some of the common nail abnormalities observed in patients with kidney disease are:

1) Half-and-half nail:a discoloration of the nails that is characterised by a proximal white portion and a distal reddish-pink to brown portion marked by an increase in the number of capillaries and capillary wall thickness in the nail bed. It is known to get eradicated completely only after renal transplantation.

2) Absence of lunula: as one of the most common nail changes in haemodialysis patients, it can be caused by anemia and/or malnutrition.

3) Onycholysis: shedding of finger nails is often observed among patients who are known to consume large doses of cephaloridine or cloxacillin. The detachment of nails from the nail bed is a characteristic of the nail abnormalities faced by patients with kidney disease.

The internal health of the body is often reflected on the external surface, which is visible to the naked eye. A blanket disease such as Chronic Kidney Disease, that wraps other organs under its authority, is one that should be carefully observed, examined and treated. Kidney disease frequently marks its existence and presence on the skin of the person. It indicates its existence in the form of dry and itchy skin, an unusual colour change of the skin such as becoming pale, an unpleasant swelling on legs, ankles, feet etc, development of blisters, boils, ulcers, skin that becomes too tight or presence of rashes on the skin along with nail and hair changes. These changes are not just unappealing to look at, but often hurtful. They might be a result of the kidney treatment going on or because of any underlying condition that clubs itself with the kidney disease or even just the fact that your kidney has stopped filtering waste and toxins from your body.

Some general tips for skin care:

• Avoid hot baths
• Wear clothes that are airy and light on the skin. Preferable material is cotton.
• Avoid the use of harsh soaps, lotions or other products that are alcohol based or made from ingredients that might be too strong, since they are capable of making things worse, if not better.
• Scratching is your biggest enemy, no matter how tempting it gets. Try to control your natural desire to scratch yourself and save yourself from the trauma of dry, flaky skin and rashes.
• Steer clear of heat, such as firewood, stove or being in the sun for a long time.
• Moisturise yourself or use the lotions recommended by your dermatologist.

These tips are generalised. For specific medications, you must visit a dermatologist.