Skin Lesions Associated with End-Stage Renal Failure
Yes, end-stage renal disease (ESRD) is associated with several distinctive skin lesions, most commonly xerosis (dry skin), uremic pruritus, calciphylaxis, porphyria-like blistering lesions, perforating disorders, and nephrogenic systemic fibrosis.
Most Common Cutaneous Manifestations
Xerosis and Pruritus
- Xerosis (dry skin) is the most common cutaneous sign in dialysis patients, occurring in 60-72% of ESRD patients 1, 2
- Uremic pruritus affects 42% of hemodialysis patients and can range from mild intermittent irritation to intractable itch that severely impacts quality of life 1, 3
- The pruritus is generalized in two-thirds of patients, while in others it primarily affects the back, face, or arteriovenous fistula arm 1, 3
- Xerosis may lower the threshold for itch even if not the primary cause of pruritus 1
Pigmentary Changes
- Cutaneous hyperpigmentation is a common manifestation in ESRD patients 4
- Hyperpigmentation was observed in 7.5% of CRF patients in one study 2
- Pallor of the skin occurs in approximately 2.5% of patients, related to anemia 2
Nail Changes
- Nail abnormalities occur in 40-48% of ESRD patients 2
- Half-and-half nails are a common manifestation specific to ESRD 4
Serious and Life-Threatening Skin Lesions
Calciphylaxis
- Calciphylaxis is a rare but life-threatening condition characterized by calcification, fibrosis, and thrombosis of small- to medium-sized dermal vessels, leading to painful necrotic skin lesions 5, 6
- This condition is seen almost exclusively in hemodialysis patients and carries a poor prognosis 6, 4
- Painful lesions on various skin surface areas are the most prominent feature, with subsequent infection of necrotic tissue carrying risk of sepsis 6
- The most important risk factor is impaired calcium-phosphate metabolism 6
Porphyria-Like Blistering Lesions
- Rarely, AIP patients with end-stage renal disease develop elevations in plasma porphyrins and blistering skin lesions resembling porphyria cutanea tarda 1
- These patients respond well to renal transplantation 1
- Blood porphyrin profiles are needed to differentiate between porphyria cutanea tarda and pseudoporphyria in ESRD patients 4
Perforating Disorders
- Acquired perforating dermatoses are seen in over 10% of hemodialysis patients 4
- These are among the specific cutaneous entities seen most frequently in ESRD, presenting with distinctive morphology 7
Nephrogenic Systemic Fibrosis
- This is a rare but serious condition specific to patients with severe renal impairment 7, 4
- Diagnosis has historically been challenging, and new diagnostic criteria have been proposed 4
Less Common Manifestations
Metastatic Calcinosis Cutis
- This is rarely reported but represents another calcification-related skin manifestation in ESRD 4
Uremic Frost
- With modern hemodialysis, uremic frost is no longer prevalent in ESRD patients, occurring in only 0.8-1% of cases 4, 2
Other Findings
- Ecchymoses have decreased in incidence with hemodialysis 4
- Ichthyosis and pityriasis versicolor each occur in approximately 7.5% of CRF patients 2
Clinical Pearls
A critical pitfall is failing to recognize calciphylaxis early, as delayed diagnosis significantly worsens prognosis 5, 6. Any painful, necrotic skin lesions in an ESRD patient on dialysis should raise immediate suspicion for this diagnosis.
When evaluating blistering lesions in ESRD patients, blood porphyrin profiles are essential to distinguish true porphyria cutanea tarda from pseudoporphyria, as management differs 4.
Overall, 89.1% of CRF patients have at least one skin problem, making dermatologic examination an essential component of care for this population 2.