The skin manifestations in end-stage renal disease patients in Jordan, single-center experience

Abstract

Introduction

Patients with end-stage renal disease usually undergo hemodialysis as a way of renal function replacement therapy which comes with a wide array of systemic and cutaneous complications. The aim of this study was to evaluate the most frequent dermatological manifestations including xerosis, pruritis and other nail, hair and oral conditions, as these are a very important aspect to be considered while managing the patients psychological and physical needs to improve their outcomes and quality of life.

Methods

This retrospective cross-sectional study was performed by selecting 77 patients on hemodialysis based on a certain criteria and data was then collected on a sheet using patients database on Hakeem National E-Health Program, in addition to information from interviews with patients during their hemodialysis sessions after taking an oral informed consent and insuring patients’ privacy. Data was analyzed using IBM SPSS Statistics for Windows, Version 20.0.

Findings

83.1% (N = 64) of the participants on hemodialysis presented with one or multiple skin conditions. Generalized xerosis, generalized pruritis, pigmentary alterations and arteriovenous (AV) shunt-associated complications were found in 63.6% (N = 49), 36.4% (N = 28), 16.9% (N = 13) and 7.8% (N = 6) respectively. Terry’s nails (19.5%, N = 15) were also a common nail abnormality along with other nail disorders (18.2%, N = 14). Different oral anomalies were associated with 14.3% (N = 11) of subjects and in 22.1% (N = 17), diffuse scalp hair loss was also identified.

Conclusion

Cutaneous issues such as xerosis, pruritus, pigmentary changes, and nail abnormalities are prevalent among ESRD patients, reflecting the broader systemic effects of chronic kidney disease. Our findings underscore the urgency of early recognition, comprehensive evaluation, and tailored management strategies to improve the physical and psychological burden on patients. Moving forward, targeted research into the underlying mechanisms and innovative therapeutic approaches is essential to enhance both dermatological outcomes and overall patient well-being.

Introduction

End-Stage Renal Disease (ESRD) represents the final and most severe phase of Chronic Kidney Disease (CKD), where the kidneys can no longer perform their vital functions. As a result, many patients with ESRD resort to hemodialysis as a primary means of renal replacement therapy. This procedure, essential as it may be, unfortunately exposes patients to a plethora of complications and changes, both systemic and cutaneous.

One of the most notable repercussions of hemodialysis in ESRD patients is the emergence of various dermatological manifestations. These skin alterations cover a broad spectrum; some patients may experience the discomfort of xerosis (dry skin), or the persistent itchiness associated with pruritus. However, others might contend with more rare and severe skin conditions such as calcinosis cutis, a condition characterized by calcium deposits in the skin. These manifestations often serve as more than mere surface-level changes; they can be reflective of underlying systemic imbalances or complications arising from the hemodialysis process itself [1].

Despite the notable prevalence of pruritis in 19–90% of hemodialysis patients as shown in one study, 15–49% of patients during predialysis too have reported a similar manifestation [2]. Multiple theories as to why CKD on its own can also cause renal pruritis have been discussed as in hyperparathyroidism, hypercalcemia and hyperphosphatemia, hypervitaminosis A and the release of proinflammatory mediators (interleukin-2) [3].

Moreover, while the clinical implications of these dermatological changes are significant, the ramifications on a patient's psychosocial well-being are equally profound. For many ESRD patients, these skin changes, whether it's the unsightly appearance of hyperpigmentation or the relentless itch of pruritus, can lead to decreased self-esteem, social isolation, and overall reduced quality of life. Studies have repeatedly underscored the intimate connection between skin health and psychological well-being [4].

Given this intricate interplay between hemodialysis, skin manifestations, and patient well-being, it becomes imperative to understand these dermatological phenomena in depth. This not only aids in better clinical management but also underscores the importance of holistic care that addresses both the physical and psychological needs of ESRD patients on hemodialysis.

Materials and methods

Study design and setting

We implemented a retrospective cross-sectional research study focusing on the assessment of cutaneous manifestations in ESRD patients undergoing hemodialysis at the Prince Hamza Hospital (PHH) dialysis unit. The primary objective was to delineate the cutaneous impact of hemodialysis on these patients.

Participant selection

The study spanned from December 2022 to August 2023, encompassing patients from the PHH dialysis unit. Eligibility criteria were as follows: 1- Chronic dialysis patients registered at Prince Hamza Hospital. 2- Consistent hemodialysis treatment for a minimum duration of three months, administered thrice weekly. Based on data frequency and informational saturation, we engaged 77 participants, including 28 females and 49 males, aged between 11 and 82 years.

Data collection

A two-pronged approach was adopted for comprehensive data collection. Primary data, including patient demographics, medication history, duration and rationale for dialysis, and specific laboratory parameters (Hemoglobin (Hb), Calcium (Ca), Parathyroid Hormone (PTH), Phosphate (PO4), albumin, ferritin, total serum iron), were sourced from the Hakeem National E-Health Program. Subsequently, during their scheduled dialysis sessions, patients were interviewed for an exhaustive medical history and underwent a clinical evaluation by a duo of dermatologists. All acquired data was systematically logged in a digital spreadsheet for analysis.

Statistical analysis

Data analysis was facilitated using IBM SPSS Statistics for Windows, Version 20.0. Quantitative data interpretation employed the Chi-squared test (χ2). The one-way analysis of variance (ANOVA) was used to track the impact of age, and duration of chronic diseases on developed superficial manifestation and to compare the mean of laboratory findings based on. Statistical significance was set at a p-value of < 0.050. For determining confidence intervals, the Wilson score interval method was deployed.

Ethical considerations

All procedures performed in this study adhered to ethical standards. Before initiating data collection, participants were oriented regarding the study's objectives and their voluntary role. An oral informed consent, encompassing agreement to participate and allow data utilization, was obtained from each participant.

Results

Demographic and clinical characteristics of ESRD patients

Of the 77 ESRD patients included in this study, ages ranged from 11 to 82 years with a mean age of 48.31 ± 16.19 years. The male predominance was evident with 63.6% (N = 49) being males. The overwhelming majority, 83.1% (N = 64), had hypertension as an underlying health condition. All participants (100%, N = 77) underwent hemodialysis thrice weekly, with 66.2% (N = 51) using a left-sided fistula for access. The mean duration of hemodialysis was 2.38 ± 5.58 years, ranging from 1 month to 25 years. Hypertension was identified as the leading cause necessitating hemodialysis in 36.4% (N = 28) of patients. Notably, 87% (N = 67) of the participants had not undergone renal transplantation, with 6.49% (N = 5) having a history of allograft rejection (Table 1).

Table 1.

Demographic variables of studied population

				Frequency N (%)
Gender			Male	49 (63.6)
			Female	28 (36.4)
Suffering from chronic disease		Diabetes	Yes	20 (26.0)
			No	57 (74.0)
		Cardiac disease	Yes	19 (24.7)
			No	58 (75.3)
		Hypertension	Yes	64 (83.1)
			No	13 (16.9)
		Neurological diseases	Yes	19 (24.7)
			No	58 (75.3)
Type of IV access			Arteriovenous fistula	51 (66.2)
			Permacath	11 (14.3)
			Left graft	8 (10.4)
			Right jugular catheter	5 (6.5)
			Right subclavian catheter	2 (2.6)
Cause of renal failure			Hypertension	28 (36.4)
			IgA nephropathy	3 (3.9)
			Unknown	20 (26.0)
			Urinary retention	5 (6.5)
			Polycystic kidney disease	3 (3.9)
			Others	18 (23.4)
			mean ± SD
Age (years)			48.31 ± 16.19
Duration (Years)	Diabetes		14.20 ± 9.70
	Cardiac disease		8.67 ± 6.09
	Hypertension		12.54 ± 8.21
	Hemodialysis		2.38 ± 5.58
Laboratory results	Hemoglobin (HB) (g/dL)		10.43 ± 1.49
	Ionized Calcium (Ca+2) (mmol/ L)		2.06 ± 0.29
	Parathyroid hormone (PTH) (pg/ml)		930.94 ± 697.38
	Albumin (g/dL)		3.93 ± 0.61
	Ferritin (ng/mL)		793.00 ± 588.14
	Total iron saturation (%)		0.17 ± 0.37

N Number, % Percentage, SD Standard deviation, Normal ranges for laboratory tests: total iron saturation: 20–45%; HB:12 – 16; PTH: 15 – 68; Ca⁺²: 2.12 – 2.55; albumin: 3.40 – 5.40; Ferritin: 4.63 – 204.00

Laboratory findings

Hemoglobin and total iron saturation were discernibly reduced, registering at 10.43 ± 1.49 g/dL and 0.17 ± 0.37%, respectively. Conversely, ferritin levels were markedly elevated at fourfold the standard (793.00 ± 588.14), and PTH levels were noted at a 12-fold increase (930.94 ± 697.38) compared to typical values (Table 1).

Cutaneous manifestations in ESRD patients

Skin manifestations were predominant, with 83.1% (N = 64) of the participants presenting with one or multiple conditions. Generalized xerosis was identified in 63.6% (N = 49) of the cohort, followed by generalized pruritus at 36.4% (N = 28), pigmentary alterations in 16.9% (N = 13), and AV shunt-associated complications in 7.8% (N = 6). Evaluating nail conditions, 29.9% (N = 23) of patients showcased no nail abnormalities. Conversely, Terry's nails were present in 19.5% (N = 15), while multiple nail disorders were observed in 18.2% (N = 14) of the participants. Hair and oral findings highlighted diffuse scalp hair loss in 22.1% (N = 17) and multi-oral and tongue anomalies in 14.3% (N = 11) of the subjects (Table 2).

Table 2.

Clinical characterization of superficial manifestations in ESRD patients

			Number	Prevalence (%)	95% CI of prevalence
Skin Manifestations	Several abnormal skin manifestations		64	83.1	72.86 – 90.69
	Skin Malignancy		1	1.3	0.03 – 7.02
	Cutaneous Lentigo		2	2.6	0.32 – 9.07
	Actinic Keratosis		1	1.3	0.03 – 7.02
	Acanthosis Nigricans		1	1.3	0.03 – 7.02
	AV Shunt related complications		6	7.8	2.91 – 16.19
	Pigmentary changes		13	16.9	9.31 – 27.14
	Pruritus	Generalized	28	36.4	25.70 – 48.12
		At the fistula site	6	7.8	2.91 – 16.19
		Circumscribed	3	3.9	0.81 – 10.97
	Xerosis	Generalized	49	63.6	51.88 – 74.30
		Localized	7	9.1	3.73 – 17.84
		Feet	2	2.6	0.32 – 9.07
	No skin manifestation		2	2.6	0.32 – 9.07
Nail changes	No nail manifestation		23	29.9	19.97 – 41.38
	Multi-nail disorders		14	18.2	10.31 – 28.62
	Splinter hemorrhage		5	6.5	2.14 – 14.51
	Onycholysis		4	5.2	1.43 – 12.77
	Leukonychia		5	6.5	2.14 – 14.51
	Melanonychia		4	5.2	1.43 – 12.77
	Koilonychia		1	1.3	0.03 – 7.02
	Beau’s lines		3	3.9	0.81 – 10.97
	Longitudinal ridges		3	3.9	0.81 – 10.97
	Terrys nails		15	19.5	11.33 – 30.09
Hair	No abnormal hair manifestations		46	59.7	47.94 – 70.77
	Diffuse scalp hair loss		17	22.1	13.12 – 32.98
	Dry lustreless hair		1	1.3	0.03 – 7.02
	Body hair loss		1	1.3	0.03 – 7.02
	Multi- hair changes		12	15.6	8.32 – 26.64
Oral, and Tongue changes	No oral nor tongue changes		54	70.1	58.62 – 80.03
	Oral Candidiasis		1	1.3	0.03 – 7.02
	Xerostomia		4	5.2	1.43 – 12.77
	Fissured Tongue		3	3.9	0.81 – 10.97
	Macroglossia		2	2.6	0.32 – 9.07
	Petechial hemorrhage		1	1.3	0.03 – 7.02
	Coated tongue		1	1.3	0.03 – 7.02
	Multi- oral and tongue abnormalities		11	14.3	7.35 – 24.13

Risk factors associated with cutaneous manifestations

Elderly participants manifested a significant predisposition to skin and tongue abnormalities (p = 0.027 and p = 0.036, respectively). Pigmentary changes were notably associated with prolonged diabetes duration (7.17 ± 5.19 years, p = 0.030) and reduced albumin (2.45 ± 1.08, p = 0.006). Hypocalcemia (2.01 ± 0.23, p = 0.002) and an extended duration of diabetes (20.67 ± 7.84 years, p = 0.018) emerged as risk factors for xerosis. Additionally, hypocalcemia was linked to tongue anomalies (p = 0.046), while decreased serum iron saturation levels were associated with hair health deterioration (p = 0.046). Gender-based assessments revealed females more frequently reported multiple hair abnormalities (p = 0.001). Furthermore, diabetic patients were more prone to generalized pruritus (p = 0.040), and increased hemodialysis duration correlated significantly with Terry's nails occurrence (p = 0.017) (Table 3).

Table 3.

Impact of disease duration, and lab findings in disease manifestations

Variables		Mean ± SD
		Age	p-Value	Duration of (Years)								Laboratory findings
				Diabetes	p-Value	Cardiac disease	p-Value	Hypertension	p-Value	Hemodialysis	p-Value	Hb	p-Value
Tongue manifestations	None	46.44 ± 14.81	0.027	17.67 ± 9.21	0.220	8.88 ± 6.28	0.448	14.25 ± 9.15	0.425	2.09 ± 5.58	0.548	10.50 ± 1.48	0.382
	Xerostomia	38.5 ± 27.45		2 ± 0		6 ± 0		11.5 ± 2.12		8.5 ± 11.35		9.5 ± 1.00
	Fissured Tongue	64.67 ± 9.29				2.5 ± 2.12		7.67 ± 2.52		1.67 ± 2.08		11.5 ± 0.707
	Macroglossis	71 ± 0.00		8 ± 0.00		8 ± 0.00		7.5 ± 0.71		5 ± 5.66		11 ± 1.41
	multi-tonge disorders	53.09 ± 12.22		10.33 ± 9.33		13.33 ± 6.66		11 ± 4.80		1.91 ± 3.20		10.6 ± 1.71
Hair	None	44.48 ± 16.33	0.130	13.4 ± 9.82	0.488	10.4 ± 6.55	0.318	11.67 ± 7.53	0.461	2.04 ± 4.60	0.790	10.47 ± 1.57	0.466
	" Diffuse scalp hair loss "	54.53 ± 14.75		18 ± 7.87		5 ± 5.66		12.73 ± 8.83		3.88 ± 8.89		10.47 ± 1.51
	Dry lusterless hair	33 ± 0		1 ± 0		-		-		0 ± 0		8 ± 0
	Body hair loss	51 ± 0		-		-		-		1 ± 0		9 ± 0
	Multi-hair disorders	53.58 ± 15.48		15.4 ± 11.08		5.33 ± 2.31		16 ± 10.30		1.83 ± 3.04		10.55 ± 1.12
Nail abnormal changes	None	46.90 ± 18.25	0.520	12.2 ± 9.57	0.238	10.67 ± 9.05	0.892	8.77 ± 5.70	0.198	0.91 ± 2.03	0.470	10.39 ± 1.438	0.255
	Multi-nail disorders	46.77 ± 18.68		11 ± 11.14		9 ± 0		11.5 ± 7.79		1.79 ± 3.04		9.64 ± 1.499
	Splinter haemorrhages	57.2 ± 12.89		1.5 ± 0.71		10 ± 0		21.33 ± 6.11		1 ± 0.70		10.8 ± 1.30
	Onycholysis	53.75 ± 8.54		22 ± 0		12 ± 0		23 ± 0		0 ± 0		10 ± 1.83
	Leukonychia	45.4 ± 7.34		14 ± 0		-		11 ± 0		4.8 ± 0		11.25 ± 2.22
	Melanonychia	41.25 12.92		26 ± 0		-		15.75 ± 0		4.5 ± 0		12 ± 0.82
	Koilonychia	49 ± 0		-		-		-		0 ± 0		9 ± 0
	Beau’s lines	33.33 ± 19.22		-		5 ± 1.41		10		0.67 ± 0.577		10.5 ± 0.71
	longitudinal ridges	42.67 ± 27.97		15 ± 0		4		19.33 ± 15.82		3 ± 3.61		10.67 ± 1.16
	terrys nails	55 ± 11.87		14.5 ± 10.37		8.5 ± 0.70		12.25 ± 8.82		5.27 ± 9.60		10.6 ± 1.45
SKIN MAFFISTATION	multi-skin abnormalities	47.86 ± 14.51	0.036	17 ± 8.67	0.119	8.33 ± 5.28	0.862	12.76 ± 8.52	0.943	2.48 ± 0.59	0.720	10.53 ± 1.54	0.355
	Skin Malignancy	77 ± 0		2 ± 0		-		-		1 ± 0		10 ± 0
	cutanous Lentigo	67 ± 5.66		8 ± 0		8 ± 0		8 ± 0		0.5 ± 0		9.5 ± 0.71
	Actinic keratosis	24 ± 0		-		-		12 ± 0		12 ± 0		12 ± 0
	Acanthosis Nigricans:	33 ± 0		1 ± 0		-		-		0 ± 0		8 ± 0
	AV Shunt related complications:	54.83 ± 24.12		1 ± 0		11 ± 1.41		11.5 ± 7.33		1.17 ± 2.86		10.33 ± 1.03
	None	28.5 ± 9.19		-		-		-		1.5 ± 2.12		9 ± 0
Pigmentary changes	Yes	49.83 ± 12.32	0.723	7.17 ± 5.19	0.030	8.5 ± 0.71	0.969	11.33 ± 8.71	0.704	3.61 ± 0.83	0.384	9.92 ± 1.11	0.185
	No	48 ± 16.93		17.21 ± 9.73		8.69 ± 6.58		12.71 ± 8.2		2.125 ± 0.48		10.53 ± 1.55
Pruritus	No	45.71 ± 16.63	0.426	15 ± 12.64	0.567	7.67 ± 5.68	0.224	11.92 ± 7.25	0.783	3.73 ± 0.72	0.148	10.33 ± 1.36	0.466
	Generalized	49.96 ± 13.19		16 ± 9.01		9 ± 0		13.63 ± 0.89		0.82 ± 0.19		10.74 ± 1.53
	At the fistula site	54.17 ± 25.22		8.67 ± 6.80		21 ± 0		6 ± 0		0.33 ± 0.08		10 ± 2.28
	Circumscribed	58.5 ± 10.61		8 ± 0		8 ± 0		13 ± 1.47		3 ± 0.52		9.67 ± 1.15
Xerosis	No	44.55 ± 15.57	0.714	20.67 ± 7.84	0.018	13.67 ± 6.65	0.367	11.83 ± 8.17	0.647	3.16 ± 6.15	0.855	10.42 ± 1.71	0.961
	Generalized	49.61 ± 17.50		9.4 ± 6.76		7.11 ± 6.13		12.46 ± 8.39		2.22 ± 5.73		10.38 ± 1.43
	Localized	50.33 ± 6.86		21.67 ± 11.15		10.5 ± 2.12		12.6 ± 8.26		2 ± 3.61		10.71 ± 1.70
	Feet	46 ± 0		1 ± 0		4 ± 0		23 ± 0		0 ± 0		10.5 ± 0.71

Variables		Mean ± SD
		Laboratory findings
		Ca + 2	p-Value	PTH	p-Value	Po4	p-Value	Albumin	p-Value	Ferritin	p-Value	Total serum Protein	p-Value
Tongue manifestations	None	2.04 ± 0.28	0.046	1027.45 ± 686.35	0.304	1.49 ± 0.655	0.677	3.92 ± 0.53	0.819	725.9 ± 565.53	0.449	0.21 ± 0.41	0.551
	Xerostomia	2.33 ± 0.58		714.67 ± 1031.38		1.67 ± 0.58		4.33 ± 0.57		997.67 ± 859.57		0 ± 0.00
	Fissured Tongue	2 ± 0.00		248 ± 253.144		1.5 ± 0.71		4 ± 0.00		1553		0.5 ± 0.71
	Macroglossis	2 ± 0.00		300.5 ± 342.95		1 ± 0.00		4 ± 0.00		695 ± 718.42		0 ± 0.00
	multi-tonge disorders	2 ± 0.00		775.4 ± 665.66		1.22 ± 0.67		3.9 ± 0.99		961.22 ± 625.95		0 ± 0.00
Hair	None	2.08 ± 0.35	0.798	951.24 ± 662.80	0.963	1.38 ± 0.59	0.464	3.83 ± 0.67	0.154	773.05 ± 574.90	0.926	0.09 ± 0.29	0.046
	" Diffuse scalp hair loss "	2 ± 0		897.73 ± 789.06		1.65 ± 0.78		4 ± 0.52		786.53 ± 656.14		0.4 ± 0.51
	Dry lusterless hair	2 ± 0		-		1 ± 0		5 ± 0		1135 ± 0		0 ± 0
	Body hair loss	-		-		-		-		-		-
	Multi-hair disorders	2.1 ± 0.32		894.89 ± 791.77		1.5 ± 0.53		4.1 ± 0.32		850.3 ± 616.07		0.1 ± 0.32
Nail abnormal changes	None	2.1 ± 0.31	0.301	653.47 ± 615.42	0.726	1.39 ± 0.50	0.742	3.9 ± 0.45	0.958	539.4 ± 490.44	0.050	0.12 ± 0.33	0.821
	Multi-nail disorders	2 ± 0		1045.86 ± 806.62		1.31 ± 0.63		4 ± 0.58		1067.31 ± 592.21		0.18 ± 0.41
	Splinter haemorrhages	2 ± 0		1102.8 ± 733.89		2 ± 1.41		4 ± 0		814 ± 588.43		0.25 ± 0.50
	Onycholysis	2 ± 0		1038.33 ± 558.43		1.25 ± 0.50		4 ± 0		869.25 ± 877.2		0 ± 0
	Leukonychia	2 ± 0		972.67 ± 862.66		1.75 ± 0.50		4 ± 0		393.25 ± 245.91		0.25 ± 0.50
	Melanonychia	1.67 ± 0.58		864 ± 263.04		1.333 ± 0.577		4 ± 0		513.5 ± 518.31		0 ± 0
	Koilonychia	2 ± 0		-		2 ± 0		4 ± 0		1182		0 ± 0
	Beau’s lines	2 ± 0		1344.5 ± 785.60		1.5 ± 0.71		4 ± 0		742 ± 769.33		0 ± 0
	longitudinal ridges	2.33 ± 0.58		1750 ± 0		1.33 ± 0.58		4.33 ± 0.58		1676		0 ± 0
	terrys nails	2.14 ± 0.36		1009.07 ± 792.45		1.54 ± 0.66		3.73 ± 1.03		817.21 ± 559.82		0.33 ± 0.49
SKIN MAFFISTATION	multi-skin abnormalities	2.07 ± 0.31	0.983	970.48 ± 687.21	0.469	1.46 ± 0.66	0.678	3.88 ± 0.61	0.330	740.12 ± 570.14	0.422	0.18 ± 0.39	0.884
	Skin Malignancy	-		22 ± 0		-		-		-		-
	cutanous Lentigo	2 ± 0		58 ± 0		1.5 ± 0.71		4 ± 0		931.5 ± 1052.88		0 ± 0
	Actinic keratosis	-		-		-		-		-		-
	Acanthosis Nigricans:	2 ± 0		-		1 ± 0		5 ± 0		1135 ± 0		0 ± 0
	AV Shunt related complications:	2 ± 0		996.33 ± 950.83		1.25 ± 0.50		4.25 ± 0.50		1264.75 ± 689.05		0.25 ± 0.50
	None	2 ± 0		621 ± 0		2 ± 0		4 ± 0		1073.5 ± 635.69		0 ± 0
Pigmentary changes	Yes	2 ± 0	0.472	691 ± 74.35	0.334	1.36 ± 0.67	0.581	2.45 ± 1.08	0.006	668.75 ± 492.79		0.4 ± 0.51	0.030
	No	2.07 ± 0.32		966.68 ± 69.15		1.48 ± 0.63		4.02 ± 0.40		820.11 ± 607.57		0.12 ± 0.32
Pruritus	No	2.09 ± 0.37	0.543	841.26 ± 673.91	0.252	1.48 ± 0.56	0.803	4 ± 0.42	0.312	752.67 ± 56.27	0.941	0.2 ± 0.41	0.891
	Generalized	2 ± 0		970 ± 70.06		1.44 ± 0.77		3.88 ± 0.72		820.88 ± 63.59		0.13 ± 0.34
	At the fistula site	2.17 ± 0.41		1530.75 ± 80.67		1.33 ± 0.51		4 ± 0.63		899.33 ± 53.25		0.17 ± 0.41
	Circumscribed	2 ± 0		532 ± 43.69		2 ± 0		3.33 ± 1.15		777 ± 10.12		0 ± 0
Xerosis	No	2.01 ± 0.23	0.002	781.23 ± 566.41	0.543	1.63 ± 0.50	0.623	3.94 ± 0.24	0.331	623.12 ± 527.86	0.380	0.07 ± 0.26	0.339
	Generalized	2.07 ± 0.26		977.71 ± 748.47		1.41 ± 0.71		3.88 ± 0.73		883.85 ± 592.41		0.23 ± 0.42
	Localized	1.86 ± 0.37		853.833 ± 688.11		1.43 ± 0.53		4 ± 0		626 ± 60.91		0 ± 0
	Feet	3 ± 0		1750 ± 0		1 ± 0		5 ± 0		959 ± 101.39		0 ± 0

Discussion

End-stage renal disease (ESRD) present a myriad of systemic challenges and complications, among which cutaneous manifestations are frequent and, at times, distressing for patients. Our study, in alignment with earlier literature, underscores the significant prevalence of these dermatological problems among ESRD patients, highlighting xerosis, pruritus, pigmentary alterations, and nail changes as dominant features.

In our cohort, generalized xerosis was observed in 63.6% (N = 49, 95% CI: 51.88 – 74.30%) of the participants, supporting the findings presented by Udayakumar et al. [5]. This prevalent cutaneous manifestation among ESRD patients can be explained by the impaired functionality of both sweat and sebaceous glands, coupled with the perpetual dehydration induced by recurrent dialysis treatments [6]. Not merely a superficial dermatological condition, xerosis may also serve as a precursor to exacerbated skin-related morbidities, emphasizing the necessity of prompt detection and therapeutic intervention.

Adjacent to xerosis, our study highlighted the incidence of generalized pruritus in 36.4% (N = 28, 95% CI: 25.70 – 48.12%) of the participants. Pruritus, or itching, has been acknowledged as a profound detriment to the quality of life of CKD and ESRD patients [7] as shown in a study by Deshmukh et. al where pruritis ranked first with a prevalence of 65.71% in patients [8]. Its pathophysiology is multifaceted, with mechanisms ranging from elevated parathyroid hormone levels to the mere presence of xerosis [9]. The global assessment by Pisoni et al [7]. accentuates the ubiquity and severity of pruritus among dialysis patients, spotlighting an urgent need for efficacious therapeutic strategies. The interconnectedness of pruritus with sleep disturbances further emphasizes its effect on overall patient health.

Pigmentary changes in ESRD patients, as observed in our findings, highlight the intricate interplay of metabolic and systemic derangements. These changes were notably associated with prolonged diabetes duration and reduced serum albumin, emphasizing their multifactorial origin and clinical significance. Accumulation of urochromes due to diminished renal clearance is a primary driver behind such alterations [10]. Concurrently, hemosiderin deposition in the skin, a consequence of prolonged hemodialysis, augments the hyperpigmentation seen in these patients [11]. While these changes have noticeable cosmetic implications, the associated skin discomfort and itching magnify the clinical significance [12].

Additionally, our study sheds light on several other cutaneous abnormalities in CKD and ESRD patients, ranging from nail changes to malignancies. 70.1% (N = 54) of patients in our study showed nail abnormalities with Terry’s nail being the most frequent (19.5%, N = 15) whereas in a different study carried out by Onelmis, absence of lunula was the leading nail abnormality [13].

The distinct presentation of conditions like Lindsay's Nails, nephrogenic systemic fibrosis, and acquired perforating dermatosis illustrates the diverse dermatological repercussions of renal diseases. Their recognition, while crucial for diagnostic purposes, is equally pivotal in devising therapeutic interventions and enhancing the patient's overall well-being.

Conclusion

As the mirror to underlying systemic anomalies, the skin provides invaluable insights into the progression and complications of chronic kidney diseases. A holistic understanding of these manifestations, encompassing xerosis, pruritus, pigmentary changes, and other dermatological anomalies, is paramount for comprehensive patient care. Future research endeavours should aim at a deeper elucidation of their pathophysiology and the development of targeted treatment modalities to further investigate the possibility of improved life quality when addressing these cutaneous conditions.

Authors’ contributions

Mohammad Hassan Al-thnaibat: Conception and design, Wrote the paper. Heba Marwan Urabi: Wrote the paper, Reviewing and editing. Hadeel S. Alkofahi: Data collection. Ola Mohannad Alshriedeh: Data collection, Wrote the paper. Raneem Alshraideh: Data collection, Wrote the paper. Hanan Esmadi: Data collection. Ahmed Sheyyab: Reviewing and editing. Hanan Khaled Hasan: Data analysis. Bakri Roumi Jamal: Reviewing and editing.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The analyzed data that were used during the current article are available from the author, Heba M. Urabi, on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.