Abstract
We highlight the importance of a thorough nail examination in every clinical encounter, especially in uremic patients. Absent lunula should prompt the clinician to rule out underlying kidney disease even in the absence of signs of uremia.
Keywords: absent lunula, chronic kidney disease, hemodialysis
We highlight the importance of a thorough nail examination in every clinical encounter, especially in uremic patients. Absent lunula should prompt the clinician to rule out underlying kidney disease even in the absence of signs of uremia.
1. CASE HISTORY
Thorough nails examination should be an integral part of exhaustive physical examination in uremic patients since nail disorders, as absent lunula, can serve as a marker of chronic kidney disease in the absence of more alarming signs.
A 62‐year‐old man was addressed from the nephrology department for a systematic dermatological check‐up. He reported a history of an end‐stage chronic kidney disease (CKD) due to hypertensive kidney disease. He had not been on hemodialysis yet. On close observation, the lunula of all fingernails was surprisingly absent (Figures 1, 2and1, 2). Blood investigations revealed anemia (11 g/dL), hypocalcemia (73 mg/L), and low serum iron level (0.28 mg/L).
FIGURE 1.
Absent lunula of the thumbnail
FIGURE 2.
Absent lunula of the other fingernails
The lunula is the visible portion of the nail matrix that extends beyond the proximal nail fold. 1 Absent lunula (AL) has been recorded in up to 62.9% of patients with CKD 2 but also described in chronic obstructive pulmonary disease and rheumatoid arthritis. 1 Anemia, seen in our patient, is thought to be a causative effect of AL. 3 However, other reports suggested that it reflected rather a combination of several conditions in uremic patients. 2 , 3 AL has been observed before hemodialysis. Thus, it is believed that CKD itself, not particularly hemodialysis, could play a role in the development of AL. 2
In conclusion, AL can serve as a marker of CKD in the absence of more alarming signs. Therefore, thorough nails examination should be an integral part of exhaustive physical examination in uremic patients.
CONFLICT OF INTEREST
No conflict of interest.
AUTHOR CONTRIBUTIONS
DN: helped in writing the manuscript, did literature search, and is corresponding author. AS: collected clinical data, conceptualized the article, and did final proofreading of the submission. KB: helped in writing manuscript and took clinical pictures. MKZ and MM: revised and approved the final version of the manuscript.
ACKNOWLEDGMENTS
We thank the patient for granting permission to publish this manuscript. Published with written consent of the patient.
Daadaa N, Souissi A, Ben Kaab B, Zouaghi MK, Mokni M. Absent lunula: An overlooked finding in chronic kidney disease. Clin Case Rep.2021;9:576–577. 10.1002/ccr3.3471
DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
REFERENCES
- 1. Cohen PR. The lunula. J Am Acad Dermatol. 1996;34(6):943‐953. [DOI] [PubMed] [Google Scholar]
- 2. Martinez MAR, Gregório CL, Santos VP, Bérgamo RR, Machado CDS. Nail disorders in patients with chronic renal failure undergoing hemodialysis. An Bras Dermatol. 2010;85(3):318‐323. [DOI] [PubMed] [Google Scholar]
- 3. Salem A, Mokadem S, Attwa E, Abelraoof S, Ebrahim HM, Faheem KT. Nail changes in chronic renal failure patients under haemodialysis. J Eur Acad Dermatol Venereol. 2008;22(11):1326‐1331. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.