What causes hair loss in patients with Chronic Kidney Disease (CKD) on Hemodialysis (HD)?

Hair Loss in CKD Patients on Hemodialysis

Hair loss in CKD patients on hemodialysis is multifactorial, primarily caused by uremic toxin accumulation, anemia from decreased erythropoietin production, and potential medication effects—particularly anticoagulants like warfarin and the antipruritic drug nalfurafine.

Primary Pathophysiologic Mechanisms

Uremic Toxin Accumulation

• Uremic toxins accumulate progressively as kidney function declines, particularly in advanced CKD stages (G4 and G5), directly affecting hair follicle function and contributing to hair loss 1
• These toxins trigger systemic inflammation through polymorphonuclear lymphocyte stimulation, leading to inflammatory cytokine release and oxidative stress via reactive oxygen species (ROS) production, which damages hair follicles 1
• Hair abnormalities occur in 47.9-74.3% of CKD patients, with significantly higher rates in those not yet on hemodialysis (74.3%) compared to those on maintenance hemodialysis (47.9%), suggesting dialysis may partially ameliorate this complication 2

Anemia and Erythropoietin Deficiency

• Anemia develops from decreased erythropoietin (EPO) production by failing kidneys, which is one of the most common systemic manifestations of CKD 3
• Uremic toxins like indoxyl sulfate directly induce premature red blood cell death (eryptosis) through oxidative stress mechanisms, worsening anemia 1
• The resulting anemia contributes to impaired oxygen delivery to hair follicles, affecting hair growth cycles 3

Hypothyroidism

• Hypothyroidism may be involved in hair loss among chronically dialyzed patients, though this requires further investigation 4

Medication-Induced Hair Loss

Anticoagulants (Warfarin)

• Warfarin therapy is a rare but documented cause of alopecia in hemodialysis patients, thought to promote the "resting phase" of hair follicles 5
• When warfarin-induced alopecia is suspected after excluding other causes, conversion to apixaban with close monitoring can alleviate hair loss, though this requires careful consideration given renal excretion concerns 5
• This should only be attempted with nephrologist consultation, as direct oral anticoagulants typically undergo renal excretion 5

Nalfurafine (Antipruritic Agent)

• Nalfurafine, commonly prescribed for uremic pruritus in dialysis patients, can cause systemic hair loss through κ-opioid receptor activation 6
• The mechanism involves blood capillary regression around hair follicles, leading to cessation of hair growth and subsequent hair fallout 6
• Hair loss typically begins within 1 month of nalfurafine initiation and completely resolves within 5 months of discontinuation 6

Clinical Evaluation Algorithm

Step 1: Assess Dialysis Adequacy

• Measure blood urea nitrogen (BUN) levels—inadequate dialysis with elevated uremic toxins directly affects hair follicles 7
• Check Na+, K+, Ca2+, Mg2+, Cl−, blood urea, creatinine, and bicarbonate to assess hemodialysis adequacy 7
• Discuss with nephrologist whether increasing frequency or duration of hemodialysis may improve uremic toxin clearance 7

Step 2: Evaluate for Anemia

• Obtain complete blood count to assess for anemia, which is present in the majority of CKD patients 3
• Consider EPO replacement therapy if not already prescribed, as this addresses one of the fundamental causes of hair loss 3

Step 3: Medication Review

• Review all medications added after dialysis initiation, particularly warfarin and nalfurafine 5, 6
• For warfarin-induced alopecia: Consider conversion to apixaban only with close nephrologist monitoring, as this is off-label in severe CKD 5
• For nalfurafine-induced alopecia: Discontinue the medication and reassess in 1-2 months 6
• Review immunosuppressants if patient is post-transplant, as cyclosporine can affect hair growth 3

Step 4: Assess Nutritional and Endocrine Status

• Evaluate for vitamin D deficiency (47-79% of CKD patients in stages 3-4 have levels below 26 ng/mL), which affects keratinocyte function 1
• Screen for hypothyroidism, which may contribute to hair loss in dialysis patients 4

Clinical Prevalence and Expectations

• Hair changes occur in 59% of all CKD patients, with significantly higher rates (74.3%) in pre-dialysis patients compared to those on maintenance hemodialysis (47.9%) 2
• Hair loss is part of a broader spectrum of mucocutaneous manifestations affecting 89-100% of chronic renal failure patients 1
• Adequate dialysis and management of anemia can partially improve hair loss, though complete resolution typically requires restoration of kidney function through transplantation 1

Common Pitfalls to Avoid

• Do not dismiss hair loss as merely cosmetic—it profoundly impacts quality of life and warrants thorough investigation 5
• Failing to consider medication-induced causes, particularly newly initiated drugs after dialysis commencement 6
• Overlooking the need for dialysis optimization when BUN levels remain elevated 7
• Not screening for reversible causes like vitamin D deficiency and hypothyroidism 1, 4