Cutaneous Manifestations in Egyptian Patients with Chronic Renal Failure on Regular Hemodialysis

8/7/2019 Cutaneous Manifestations in Egyptian Patients with Chronic Renal Failure on Regular Hemodialysis

http://slidepdf.com/reader/full/cutaneous-manifestations-in-egyptian-patients-with-chronic-renal-failure-on 1/7

49

Original Article

Cutaneous Manifestations in Egyptian Patients with ChronicRenal Failure on Regular Hemodialysis

Maha M. Sultan, M.D.*, Hayam H. Mansour, M.D.†, Iman M. Wahby, M.D.‡ and

Ali S. Houdery, M.D.§

*Department of Dermatology and Venereology, †Department of Internal Medicine (Nephrology Unit),

‡Department of Community Medicine, Faculty of Medicine for Girls and §Department of Pathology,

Faculty of Medicine, Al-Azhar University, Egypt.

Background. Hemodialysis patients experience frequent and various cutaneous manifestations of often hypothetical

pathogenesis. Chronic renal failure (CRF) presents with an array of cutaneous manifestations. Objective. To evaluate

the prevalence and nature of cutaneous lesions, associated with CRF patients on hemodialysis in Egyptian patients.

Patients and methods. One hundred patients with CRF on regular hemodialysis from nephrology units were examined

for cutaneous changes. Specic investigations like skin biopsy, culture and sensitivity for bacterial infections, potassiumhydroxide mount and fungal culture were done when indicated. Results. All patients included in this study had at

least one cutaneous manifestation attributable to CRF. The most prevalent ndings was pruritus (55%), followed by

xerosis (54%), hyperpigmentation (54%) and pallor (45%). Other cutaneous manifestations were wrinkles (40%),

fungal infections (33%), ecchymosis (27%), dermatitis (23%), yellow face (22%), Petichae (19%), delayed wound

healing (11%), follicular hyperkeratosis (10%), bacterial infections (5%), viral infections (2%) and uremic frost (1%).

Nail changes were koilonychia (39%), half and half nail (28%), splinter hemorrhages (16%), Muehrcke’s lines (12%),

subungual hyperkeratosis (10%), Mees’ lines (8%), brown nail (6%), onycholysis (3%) and Beau’s lines (2%). Hair

changes were brittle and lusterless hair (47%), sparse scalp hair (46%) and sparse body hair (27%). Oral changes

were macroglossia (42%), xerostomia (35%), coated tongue (27%), angular cheilitis (15%), ulcerative stomatitis (9%),

acquired perforating dermatosis (3%). Some rare manifestations of CRF like calciphylaxis (2%) were seen. There

was no association between any particular etiology of CRF and certain mucocutaneous, nail or hair abnormalities.

Conclusion. At least one cutaneous manifestation is found in all CRF patients. The most prevalent ndings were

pruritus followed by xerosis and hyper-pigmentation then pallor. With the advent of hemodialysis, the life expectancy of

these patients has increased giving time for more and newer cutaneous changes to manifest. The aetiology of CRF does

not affect the development of cutaneous, nail or hair abnormalities. ( J Egypt Women Dermatol Soc 2010; 7: 49 - 55)

Keywords. Chronic renal failure, hemodialysis, cutaneous manifestations, calciphylaxis

Corresponding Author. Maha M. Sultan, M.D., Lecturer of

Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar

University, Cairo, Egypt. E-mail. [email protected]

Conict of interest. None declared.

Copyright © 2009 Egyptian Women Dermatologic Society. All rights

reserved.

The skin is a mirror for many systemicdiseases including renal diseases1. Chronicrenal failure (CRF) often produces specic

skin changes, which can develop long before failuremanifests clinically2. These symptoms tend to alter and

are aggravated relatively quickly when chronic renalinsufciency leads to compulsory dialysis treatment3.There are many reports of cutaneous changes in CRFfrom different parts of the world4. The aim of thisstudy was to elucidate the prevalence and nature of cutaneous manifestations in Egyptian patients withCRF on regular hemodialysis.

PATIENTS AND METHODS

One hundred patients of CRF on regular hemodialysis were selected from Nephrology Units

in Al-Zahraa University Hospital, Al-Aziz Bellahand Al-Ber wa El-Takwa Hospitals in Cairo. All

patients were subjected to full history and clinicalexamination. Complete dermatological examinationincluding skin, hair, nails and oral mucosa was done.

Complete blood picture, kidney function tests, liver function tests and fasting and postprandial bloodglucose levels were done. Patients with elevatedliver enzymes were excluded. Specic investigationslike skin biopsy, culture and sensitivity for bacterialinfections, Gram’s stain, potassium hydroxide mountand fungal culture were done when indicated, after taking patients’ informed consent.

Statistical Analysis.Data was analyzed by Statistical Package for

Social Science (SPSS) version 12. Parametric data



Cutaneous Manifestations in Egyptian Patients with Chronic

Renal Failure on Regular Hemodialysis

50

J Egypt Women Dermatol Soc. Vol. 7, No. 1, 2010

was expressed as mean ± SD and non parametricdata was expressed as number and percentage of thetotal.

RESULTS

They were 66 males and 34 females. Their ageranged from 15 - 73 years with mean age of 49.53+ 18.54 years. The total duration of hemodialysisranged from 0.08 - 20 years with a mean of 4.95 +4.03 years (Table 1). The various causes leading torenal failure are shown in table (2).

Table 1. Data of patients.

Variables

Sex

- Male 66 (66%)

- Female 34 (34%)

Age- Range 15 - 73 years- Mean ± SD 49.53 ± 18.54 years

Duration of hemodialysis

- Range 0.08 - 20 years- Mean ± SD 4.95 ± 4.03 years

Hemoglobin level

- Range 5.3 - 14 gm %

- Mean ± SD 10.45 ± 1.64 gm %

Blood urea before hemodialysis

- Range 160 - 350 mg/dL

- Mean ± SD 253.74 ± 58.38 mg/dL

Blood urea during hemodialysis- Range 60 - 160 mg/dL

- Mean ± SD 109.75 ± 28.88 mg/dL

Serum creatinine before hemodialysis

- Range 6 - 22 mg/dL

- Mean ± SD 13.20 ± 5.41 mg/dL

Serum creatinine during hemodialysis

- Range 6 - 11 mg/dL

- Mean ± SD 18.6 ± 1.63 mg/dL

Table 2. Etiology of chronic renal failure.

Causes n %

HTN 60 (60%)

DM 14 (14%)

Obstruction 7 (7%)

Analgesic 5 (5%)

Unknown 4 (4%)

SLE 3 (3%)

Polycystic kidney 2 (2%)

RUTI 2 (2%)

Reux 1 (1%)

FMF 1 (1%)

Wegener 1 (1%)

HTN: hypertension, DM: diabetes mellitus, FMF: familialmediterranean fever, RUTI: recurrent urinary tract infection, SLE:systemic lupus erythematosus.

All patients examined in the study showed at leastone cutaneous manifestation. The most prevalentnding was pruritus (55%) (Figure 1), followed byxerosis (54%), hyper-pigmentation (54%) (Figure2) and pallor (45%). Other cutaneous manifestationswere wrinkles (40%) (Figure 3), fungal infections(33%), ecchymosis (27%), dermatitis (23%), yellowface (22%), petichae (19%), delayed wound healing(11%), follicular hyperkeratosis (10%), bacterial

infections (5%), viral infections (2%) and uremicfrost (1%). Nail changes were koilonychia (39%) (Figure

4), half and half nail (28%) (Figure 5), splinter hemorrhages (16%), Muehrcke’s lines (narrowwhite transverse bands occurring in pairs) (12%),Mees’ lines (white transverse bands, single or multiple) (8%) (Figure 6), subungual hyperkeratosis(10%), brown nail (6%), onycholysis (3%) andBeau’s lines (transverse furrows that begin in the

Table 3. Percentage of cutaneous manifestations in relation to etiology.

Skin HTN DM Obstructive Analgesic FMF Polycystic R UTI Reux SLE Wegener

Yellow face 16.67 14.29 14.29 40.00 - 100.00 100.00 100.00 33.33 -Pallor 38.33 28.57 57.14 20.00 - 100.00 50.00 - 33.33 100.00

Hyperpigmentation 61.67 64.29 42.86 40.00 100.00 - 50.00 - 33.33 -Pruritus 51.67 42.86 28.57 60.00 - - 100.00 - 33.33 -Xerosis 58.33 71.43 42.86 60.00 100.00 - 50.00 - - 100.00Dermatitis 25.00 21.43 28.57 - - - - - - -Wound healing 8.33 7.14 14.29 20.00 100.00 - 50.00 - - -Uremic frost 1.67 7.14 - - - - - - - -Follicular hyperkeratosis 10.00 14.29 14.29 40.00 - - - - - -Echymosis 33.33 50.00 57.14 40.00 - - - - - -Petichae 18.33 28.57 28.57 40.00 - - - - - 100.00Jaundice 23.33 28.57 14.29 20.00 - - - - - -Wrinkles 33.33 35.71 57.14 60.00 100.00 - 50.00 - - -

Bacterial infection 5.00 14.29 - - - - - - - -TC 6.67 7.14 - - - - - - - -TP 11.67 7.14 28.57 - - - 50.00 - - 100.00TV 16.67 21.43 14.29 20.00 - - - - 33.33 100.00HZ - - 14.29 - - - - - - -Wart 1.67 - - - - - - - - -

Sparse body hair 21.67 35.71 14.29 20.00 - 50.00 - - - -Sparse scalp hair 40.00 64.29 14.29 80.00 100.00 50.00 50.00 - 33.33 100.00Brittle and lusterless hair 43.33 57.14 14.29 80.00 100.00 50.00 50.00 - 33.33 100.00

HTN: hypertension, DM: diabetes mellitus, FMF: familial mediterranean fever, RUTI: recurrent urinary tract infection, SLE: systemic lupus

erythematosus, TC: tinea circinata, TP: tinea pedis, TV: tinea versicolor, HZ: herpes zoster.



Maha M. Sultan et al.51


matrix and progress distally as the nail grows)(2%). Hair changes included brittle and

lusterless hair (47%), sparse scalp hair (46%)and sparse body hair (27%). Oral changesincluded macroglossia (42%), xerostomia(35%), coated tongue (27%), angular cheilitis(15%) and ulcerative stomatitis (9%). Somerare manifestations of CRF like calciphylaxiswas found in 2% (Figures 7,8) and acquired

perforating dermatosis secondary to CRF wasfound in 3% of patients (Figure 9).

Biopsies from lesional skin in patients withCRF with acquired perforating dermatosisshowed broad crater in epidermis withdegenerated collagen in dermis with starting

transepidermal elimination (Figure 10).Skin, nail and oral manifestations in relation

to causes of CRF are shown in tables 3, 4 and5 respectively.

Table 4. Percentage of nail changes in relation to etiology.

Nail HTN DM Obstructive Analgesic FMF Polycystic R UTI Reux SLE Wegener

Koilonychia 40.00 35.71 57.14 40.00 100.00 50.00 50.00 - 33.33 -

Half & half 33.33 35.71 28.57 20.00 - - 50.00 - 66.67 -

Splinter hemorrhage 16.67 7.14 14.29 - - - - - - -

Subungual hyperkeratosis 13.33 - 14.29 - - 50.00 - - - -

Muehrcke’s line 10.00 14.29 14.29 - - 50.00 - - - -

Mees’ line 8.33 - - - - - - - - -

Brown nail 6.67 - - 40.00 - - - - - -

Beau’s line 3.33 - - - - - - - - -

Oncholysis 1.67 7.14 14.29 - - - - - - -

HTN: hypertension, DM: diabetes mellitus, FMF: familial mediterranean fever, RUTI: recurrent urinary tract infection, SLE:systemic lupus

erythematosus.

Table 5. Percentage of oral changes in relation to etiology.

Oral HTN DM Obstructive Analgesic FMF Polycystic R UTI Reux SLE Wegener

Macroglossia 36.67 42.86 28.57 60.00 100.00 50.00 100.00 - - 100.00

Xerostomia 36.67 35.71 57.14 40.00 100.00 50.00 100.00 - 33.33 100.00

Coated tongue 23.33 50.00 28.57 80.00 100.00 - - - - 100.00

Angular cheilitis 18.33 7.14 - 20.00 - - - - - 100.00

Ulcerative stomatitis 11.67 7.14 - - - 50.00 - - - 100.00

HTN: hypertension, DM: diabetes mellitus, FMF: familial mediterranean fever, RUTI: recurrent urinary tract infection, SLE: systemic lupus

erythematosus.

Figure 1. Chronic scratching resulting from uremic pruritus.

Figure 2. Diffuse hyperpigmentation of the face.

Figure 3. Extensive wrinkling as a sign of actinic elastosis in 42 aged female.





52


Figure 4. Koilonychia secondary to chronic renal failure.

Figure 5. Half and half nail secondary to chronic renal failure.

Figure 6. Mees’ line (white transverse band) secondary to chronic

renal failure.

Figure 7. Calciphylaxis secondary to chronic renal failure.

Figure 8. Calciphylaxis secondary to chronic renal failure, causing loss

of little toe and distal phalanx of the 2nd toe.

Figure 9. Acquired perforating dermatosis (Kyrle’s) secondary to

chronic renal failure.





DISCUSSIONPruritus was the most common cutaneous

abnormality (55%) in Egyptian CRF patients onhemodialysis. Its prevalence among hemodialysis

patients ranges from 19 to 90% in the other previousstudies5,7. Udayakumar et al.17 reported pruritus in53% of indian patients while Avermaete et al.3 reported

pruritus in 48% of patients with CRF. It is one of themost characteristic and annoying cutaneous symptomsof CRF6. It is not present in acute renal failure anddoes not necessarily subside with dialysis although itimproves with kidney transplantation7. The etiology

of pruritus in CRF is unknown. However, it has beenassociated with the degree of renal insufciency (urineoutput of < 500 mL)8. Hypervitaminosis A may bea cause as CRF patients exhibit increased epidermallevels of retinol (pre-formed vitamin A). The regular ingestion of fat-soluble vitamins (i.e. vitamin A) asreplacement for what is lost with dialysis, placesthe patient at increased risk for accumulation andtoxicity secondary to impaired excretion9. Another

proposed origin for pruritus in CRF patients is dryskin. In a study by Kato et al.10 the skin water contentwas quantied by using hygrometer, nal analysis

concluded that dialysis patients have less water content in the stratum corneum of their skin. Retentionof middle molecules (molecular weight range 300 -12.000 daltons) is thought to cause pruritic symptoms

in CRF patients. Beta2

microglobulin, advancedglycosylation end products and parathyroid hormoneare middle molecules that have been evaluated buttheir role is still uncertain11. A study by Chou et al.12 examined the effect of parathyroidectomy on uremic

pruritus and found that the best indicator was thelevel of calcium and phosphate product (Ca x P). Ahigher Ca x P was associated with a greater degree of

pruritus after parathyroidectomy. Neuronal theory isalso considered a probable cause for CRF pruritus.There is an abnormal pattern of cutaneous innervationin end stage renal failure and this led to the neurogenichypothesis of uremic pruritus. Neuron-specic,enolase-positive bres may sprout throughout theepidermis in uremic patients in contrast to healthycontrols, in whom these nerve endings reachedonly the stratum basale. Many patients on dialysissuffer from peripheral neuropathy and are prone to

nerve damage. Itching may be a manifestation of theuremic neuropathy13. Another suggested cause of uremic prutitus is increased serum histamine levelswhich may be due to allergic sensitization to variousdialyzer membrane components and due to impairedrenal excretion of histamine. So, UVB radiationis effective in uremic pruritus by suppressinghistamine-releasing factors in the sera of uremic

patients. Also, it reduces vitamin A levels in theepidermis. Lastly, other possible causes for pruritusinclude increased serum levels of magnesium andalbumin (due to inadequate excretion by the failing

kidneys), iron deciency anemia which are presentin CRF patients14.Xerosis was found in 54% of patients in the

present study as observed in previous reports (46-90%)9,15,16. Xerosis was predominantly seen over the extensor surfaces of the forearms, legs andthighs. The abdomen and chest showed ne scaling.The etiology of xerosis in CRF may be due tocomplication of diabetes; a reduction in the size of eccrine sweat glands may be contributory althoughhigh dose diuretic regimens are also implicated16.

Two types of pigmentary changes were observedin the present study: hyperpigmentation seen in

54% and a yellowish tinge to the skin (22%). Inthe present study, the result of hyperpigmentationis higher than other studies (20 - 43%)5,6,9,17.Diffuse hyperpigmentation on sun-exposed areas isattributed to an increase in melanin in the basal layer and supercial dermis due to failure of the kidneysto excrete beta-melanocyte stimulating hormone(β-MSH)18. A yellowish tinge to the skin has beenreported in 22% in the current study; whereas other studies reported it in 10 %17 and 40% 5. Yellow tingemay be due to accumulation of carotenoids andnitrogenous pigments (urochromes) in the dermis19

or the presence of lipochromes and carotenoids in theepidermis and subcutaneous tissues20.

Pallor was seen in 45% of patients, which is lessthan the result of Udayakumar et al.17 which was

Figure 10. Acquired perforating dermatosis. Epidermis shows broad

crater and the dermis shows degenerated collagen with starting

transepidermal elimination (H&E x200).





54


60% in the indian patients. Pallor is due to anemiawhich was reported as the hallmark of CRF. Anemiais primarily the result of inadequate erythropoietin

production by the failing kidneys. Other contributoryfactors of anemia in CRF patients include irondeciency, folic acid or vitamin B12 deciency anddecreased erythrocyte survival11.

Skin infections were seen in 40% of patients in thisstudy, fungal (33%), bacterial (5%) and viral (2%).Udayakumar et al.17 reported skin infections in 67%of patients while Bencini et al.8 reported the fungalinfection only in 67% of CRF patients. Skin infectionsin CRF patients may be due to associated diabetesmellitus, low albumin, elevated intracellular calcium,acidosis21, iron overload17, inhibition of chemotacticfactors and repetitive vascular procedures21. Also,CRF patient´s host defence response is disrupted bydepressed neutrophil function, leucopenia related

to complement activation, impaired phagocytosis,diminished T and B lymphocytes function and areduction in natural killer cell activity. In additionto these, the presence of inammation has beensuggested as a cause for reduced immunity.Inammation in hemodialysis patients may be dueto the use of non sterile dialysate, non biocompatiblemembranes and evidenced by accumulation of pro-inammatory agents5.

Ecchymosis was seen in 27% of hemodialysis patients and petichae in 19% in the current study. Thecauses may be due to defects in primary hemostasis

like increased vascular fragility, abnormal plateletfunction and the use of heparin during dialysis22.Early wrinkles which occurred at the age of 38

- 45 years were seen in 40% of CRF patients of the present study. It occurs due to early occurrence of actinic elastoses in patients undergoing long-termhaemodialysis3.

Koilonychia was the most common nailabnormality (39%) followed by half and half nail(28%). The results of the present study disagreedwith Amatya et al.1 who found white nail the mostcommon followed by brown and half and half nail;while Udayakumar et al.17 and Salem et al.23 found

half and half nail the most common in 21% and 20%respectively. The highest prevalence of koilonychiain patients of the present study may be due to thelong duration of the disease as 55% of patients of the present study were on hemodialysis more than5 years. In half and half nail, the white appearanceof proximal half of the nail is due to nail bed edemaassociated with a dilated capillary while the other half of the nail bed appears normal21. Salem et al.23,in an Egyptian study, concluded that the cause of nailchanges in uremic patients undergoing hemodialysisremained obscure and could not be traced to a

particular abnormality in the renal condition,medication or the procedure itself.

In the present study, brittle and lusterless hair wasfound in 47% of patients, sparse scalp hair was found

in 46% and sparse body hair was found in 27% of CRF patients while, Udayakumar et al.17found sparse

body hair in 30%, sparse scalp hair in 11% and dryhair in 16% of CRF patients. This higher incidenceof sparse scalp hair in the Egyptian patients of the

present study in comparison with the Indian patientsof Udayakumar et al.17 study may be due to racialvariation.

Oral mucosal changes have been reported in upto 90% of patients with CRF24. Teeth marking withmacroglossia (tongue sign of uremia) was seen in42% of patients compared with Udayakumar et al.17 result which was 35%. This nding was rst described

by Mattew et al. in 92% of patients with CRF25.Xerostomia was found in 35% compared with 31% inUdayakumar et al.17 study. It was attributed to mouth

breathing and dehydration. Ulcerative stomatitiswas found in 9% which is less than that reported by

Udayakumar et al.17 (29%). The high percentage of ulcerative stomatitis was attributed to elevated bloodurea levels which were more than 150 mg/100 ml intheir patients and due to bad oral hygiene24. Angular cheilitis was found in 15% while Udayakumar et al.17 study reported angular cheilitis in 12%. Coated tonguewas found in 27% which is much higher than thatreported by Udayakumar et al.17(11%). This differencemay be due to associated candidal infection whichmay be due to cigarette smoking26 and associatedxerostomia27 which showed high percentage in the

present study.

Perforating disorders such as perforatingfolliculitis, Kyrle’s disease and reactive perforatingcollagenosis have been described in CRF3. Perforatingdisorder of renal disease or acquired perforatingdisorders has been used to describe the hyperkeratoticfollicular papules present in these patients. Acquired

perforating disorders was seen in 3% of the presentstudy patients while other studies showed acquired

perforating disorders in 4.5 – 17% 5,15,17 of patientson hemodialysis. The exact pathophysiologicalmechanism of acquired perforating disorders in CRF

patients is unknown, but it may occur as a resultof dermal connective tissue dysplasia and decay.

Microvascular deposition of calcium may interrupt blood ow to connective tissue in the dermal layer causing death and necrosis. Trauma to the skin in

patients with pruritus secondary to CRF could bethe inciting agent in producing these lesions28.

Calciphylaxis was seen in 2% of the patientsin the current study. This result is in concordancewith the international prevalence of calciphylaxisin end stage renal disease patients which is1- 4 % 29. It is primarily described in patientswith CRF associated with hemodialysis. It ischaracterized by local calcinosis, inammation and

necrosis. Calciphylaxis results from secondary or tertiary hyperparathyroidism. Abnormal elevatedlevel of parathyroid hormone triggers depositionof crystalline calcium pyrophosphate in the dermis,





subcutaneous fat or arterial wall. Calcied vesselsmay thrombose acutely, resulting in calciphylaxis30.

ConclusionAt least one cutaneous manifestation is found in

all CRF patients. The most prevalent ndings were pruritus followed by xerosis and hyper-pigmentationthen pallor. With the advent of hemodialysis, the lifeexpectancy of these patients has increased giving timefor more and newer cutaneous changes to manifest.The aetiology of CRF does not affect the developmentof cutaneous, nail or hair abnormalities.

REFERENCES

1. Amatya B, Agrawal S, Dhali T, Sharma S, Pandey SS. Pattern of

skin and nail changes in chronic renal failure in Nepal: a hospital-

based study. J Dermatol 2008; 35: 140 - 5.

2. Mazuryk HA, Brodkin RH. Cutaneous clues to renal disease.Cutis 1991; 47:241 - 8.

3. Avermaete A, Altmeyer P, Bacharach Buhles M. Skin changes

in dialysis patients: a review. Nephrol Dial Transplant 2001; 16:

2293 - 6.

4. Nunley JR. Dermatologic manifestations of renal disease. eMed

J 2002: 550 - 5.

5. Pico MR, Lugo Somolinos A, Sanchez JL, Burgos Calderon R.

Cutaneous alterations in patients with chronic renal failure. Int J

Dermatol 1992; 31: 860 - 3.

6. Ponticelli C, Bencini PL. The skin in uremia. In: Massry

SG, Glassock RJ, editors. Massry and Glassock Textbook of

nephrology. 2nd ed.: williams & Wilkins; 1989. p. 1422 - 6.

7. Gupta AK, Gupta MA, Cardella CJ, Haberman HF. Cutaneous

associations of chronic renal failure and dialysis. Int J Dermatol

1986; 25: 498 - 504.

8. Bencini PL, Montagnino G, Citterio A, Graziani G, Crosti C,

Ponticelli C. Cutaneous abnormalities in uremic patients. Nephron

1985; 40: 316 - 21.

9. Morton CA, Lafferty M, Hau C, Henderson I, Jones M, Lowe

JG. Pruritus and skin hydration during dialysis. Nephrol Dial

Transplant 1996; 11: 2031 - 6.

10. Kato A, Hamada M, Maruyama T, Maruyama Y, Hishida A.

Pruritus and hydration state of stratum corneum in hemodialysis

patients. Am J Nephrol 2000; 20: 437 - 42.

11. Graham RM, Cox NH. Systemic disease and the skin. In: Burns

DA, Breathnach SM, Cox N, Grifths CE, editors. Rook´s

textbook of dermatology. 7th ed.: wiley-Blackwell; 2004. p. 59

- 75.

12. Chou FF, Ho JC, Huang SC, Sheen Chen SM. A study on pruritus

after parathyroidectomy for secondary hyperparathyroidism. J

Am Coll Surg 2000; 190: 65 - 70.

13. Etter L, Myers SA. Pruritus in systemic disease: Mechanisms and

management. Dermatol Clin 2002; 20: 459,72.

14. Imazu LE, Tachibana T, Danno K, Tanaka M, Imamura S.

Histamine-releasing factor(s) in sera of uraemic pruritus patients

in a possible mechanism of UVB therapy. Arch Dermatol Res 1993;

285: 423 - 7.

15. Tawade YV, Gokhale BB. Dermatological manifestations of

chronic renal failure. Indian J Dermatol Venereol Leprol 1996;

62: 155 - 6.

16. Siddappa K, Nair BK, Ravindra K, Siddesh ER. Skin in systemic

disease. In: valia RG, Valia AR, editors. IADVL Textbook and

Atlas of Dermatology. 2nd ed. Mumbai: bhalani Publishing

House; 2000. p. 938 - 84.

17. 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.

18. Smith AG, Shuster S, Thody AJ, Alvarez Ude F, Kerr DN.

Role of the kidney in regulating plasma immunoreactive beta-

melanocyte-stimulating hormone. Br Med J 1976; 1: 874 - 6.19. Sweeny S, Cropley TG. Cutaneous changes in renal disorders.

In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA,

Katz SI, editors. Fitzpatrick´s Dermatology in General Medicine.

6th ed. New York, McGraw-Hill; 2003. p. 1622 - 34.

20. Comaish JS, Ashcroft T, Kerr DNS. The pigmentation of chronic

renal failure. Acta Dermato-Venereol 1975; 55: 215 - 7.

21. Headley CM, Wall B. ESRD-associated cutaneous manifestations

in a hemodialysis population. Nephrol Nurs J 2002; 29: 525 - 39.

22. Remuzzi G. Bleeding in renal failure. Lancet 1988; 1: 1205 - 8.

23. Salem A, Al Mokadem S, Attwa E, Abd El Raoof S, Ebrahim HM,

Faheem KT. Nail changes in chronic renal failure patients under

haemodialysis. J Eur Acad Dermatol Venereol 2008; 22:1326 - 31.

24. Cohen GS. Renal disease. In: Lynch MA, editor. Burkett´s

Oral Medicine: diagnosis and treatment . 9th ed. Philadelphia:

Lippincott-Raven; 1997. p. 487 - 9.

25. Mathew MT, Rajarathnam K, Rajalaxmi PC, Jose L. The tongue

sign of CRF: Further clinical and histopathological features of this

new clinical sign of chronic renal failure. J Assoc Phy Ind 1986; 34 - 52.

26. Al Karaawi ZM, Manfredi M, Waugh AC, McCullough MJ, Jorge J,

Scully C, et al. Molecular characterization of Candida spp. isolated from

the oral cavities of patients from diverse clinical settings. Oral Microbiol

Immunol 2002; 17: 44 - 9.

27. Scully C, el Kabir M, Samaranayake LP. Candida and oral candidosis: a

review. Crit Rev Oral Biol Med 1994; 5: 125 - 57.

28. Dyachenko P, Shustak A, Rozenman D. Hemodialysis-related pruritus

and associated cutaneous manifestations. Int J Dermatol 2006; 45:

664 - 7.

29. Julia R. Calciphyalxis. e medicine Dermatology 2009: http://emedicine.

medscape.com/article/109548-overview.

30. Rustad OJ, Vance JC. Punctate keratoses of the palms and soles and

keratotic pits of the palmar creases. J Am Acad Dermatol 1990; 22:

468 - 76.

Cutaneous Manifestations in Egyptian Patients with Chronic Renal Failure on Regular Hemodialysis

Documents