Skin Problems in Chronic Kidney Disease

Box 1.

Skin Disorders in Patients With Chronic Kidney Disease

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Gunal AI et al. (2004) Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebocontrolled, double-blind trial. Nephrol Dial Transplant 19: 3137-3139
Manenti L et al. (2005) Gabapentin in the treatment of uremic itch: an index case and pilot evaluation. J Nephrol 18: 86-91
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Imaizumi A et al. (2003) Effective treatment of pruritus on atopic dermatitis using H1 antihistamines (second-generation antihistamines): changes in blood histamine and tryptase levels. J Dermatol Sci 33: 23-29
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De Marchi S et al. (1992) Relief of pruritus and decreases in plasma histamine concentrations during erythropoietin therapy in patients with uremia. N Engl J Med 326: 969-974
Janigan DT et al. (2000) Calcified subcutaneous arterioles with infarcts of the subcutis and skin ('calciphylaxis') in chronic renal failure. Am J Kidney Dis 35: 588-597
Wilmer W et al. (2002) Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial 15: 172-186
Weenig RH et al. (2007) Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol 56: 569-579
Rogers NM et al. (2007) Calcific uremic arteriolopathy: advances in pathogenesis and treatment. Semin Dial 20: 150-157
Mazhar AR et al. (2001) Risk factors and mortality associated with calciphylaxis in end-stage renal disease. Kidney Int 60: 324-332
Essary LR et al. (2000) Cutaneous calciphylaxis: an underrecognized clinicopathologic entity. Am J Clin Pathol 113: 280-287
Bleibel W et al. (2006) A case report comparing various radiological tests in the diagnosis of calcific uremic arteriolopathy. Am J Kidney Dis 48: 659-661
Wilmer WA et al. (2001) Transcutaneous oxygen tension in patients with calciphylaxis. Am J Kidney Dis 37: 797-806
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Shroff RX et al. (2007) The vascular biology of calcification. Semin Dial 20: 103-109
Weenig RH (2008) Pathogenesis of calciphylaxis: Hans Selye to nuclear factor κB. J Am Acad Dermatol 58: 458-471
Moe SM et al. (2003) Calciphylaxis and vascular calcification: a continuum of extra-skeletal osteogenesis. Pediatr Nephrol 18: 969-975
Griethe W et al. (2003) Bone morphogenic protein-4 expression in vascular lesions of calciphylaxis. J Nephrol 16: 728-732
Ahmed S et al. (2001) Calciphylaxis is associated with hyperphosphatemia and increased osteopontin expression by vascular smooth muscle cells. Am J Kidney Dis 37: 1267-1276
Vattikuti R et al. (2004) Osteogenic regulation of vascular calcification: an early perspective. Am J Physiol Endocrinol Metab 286: E686-E696
Schafer C et al. (2003) The serum protein α2-Heremans-Schmid glycoprotein/fetuin-A is a systemically acting inhibitor of ectopy calcification. J Clin Invest 112: 357-366
Cranenburg EC et al. (2008) The circulating inactive form of Matrix Gla Protein (ucMGP) as a biomarker for cardiovascular calcification. J Vasc Res 45: 427-436
Chen NX et al. (2006) Uremic vascular calcifications. J Investig Med 54: 380-384
Girotto JA et al. (2001) Parathyroidectomy promotes wound healing and prolongs survival in patients with calciphylaxis from secondary hyperparathyroidism. Surgery 130: 645-651
Galimberti RL et al. (2005) Cutaneous necrosis by calcific uremic arteriolopathy. Int J Dermatol 44: 101-106
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Mataic D et al. (2006) Intraperitoneal sodium thiosulfate for the treatment of calciphylaxis. Ren Fail 28: 361-363
Shiraishi N et al. (2006) Successful treatment of a patient with severe calcific uremic arteriolopathy (calciphylaxis) by etidronate sodium. Am J Kidney Dis 48: 151-154
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Sidebar: Key Points

The treatment of uremic pruritus in patients with chronic kidney disease (CKD) is a difficult process of trial and error. Skin emollients, topical capsaicin and ultraviolet B phototherapy remain the first-line therapies, and systemic therapies such as gabapentin, activated charcoal and nalfurafine are reserved for therapy-resistant forms of uremic pruritus
The appearance.on the abdomen or other regions containing large amounts of subcutaneous fat.of livedo-reticularis-like skin lesions that turn into painful subcutaneous plaques or nodules, should raise clinical suspicion of calcific uremic arteriolopathy in a patient with CKD, particularly in the presence of additional risk factors such as obesity, diabetes, female sex and coumarin anticoagulation
The optimal treatment of calcific uremic arteriolopathy includes prompt and simultaneous initiation of aggressive wound care, antibiotics, optimization of dialysis therapy and rapid control of calcium and phosphate balance and secondary hyperparathyroidism; sodium thiosulfate and bisphosphonates can be administered concurrently in severe cases
Nephrogenic systemic fibrosis is highly suspected in a patient with CKD who has been exposed to gadolinium-based contrast agents and complains of painful tightening and swelling of the skin of the lower or upper extremities and has red or hyperpigmented skin plaques or nodules that become increasingly indurated
For patients with stages 4 and 5 CKD who require contrast-enhanced imaging, lowosmolar or iso-osmolar iodine-based contrast agents should be considered as an alternative to gadolinium-based contrast; if administration of gadolinium is absolutely necessary, use of low volumes of the more stable macrocyclic, ionic types of gadolinium-based contrast agent is advised

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Summary and Introduction
Uremic Pruritus
Calcific Uremic Arteriolopathy (Calciphylaxis)
Nephrogenic Systemic Fibrosis
Acquired Perforating Dermatosis
Porphyria Cutanea Tarda
Conclusions
Sidebar: Key Points

References

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Acknowledgments

The author would like to thank Professor Dr Evelyne Lerut for providing the histology microphotographs and Dr Kathleen Claes for her assistance in illustrating the clinical cases. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Reprint Address

Dirk R.J. Kuypers, Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium, Email: [email protected]

Box 1.

Skin Problems in Chronic Kidney Disease: Sidebar: Key Points

Sidebar: Key Points

Table of Contents

Acknowledgments

Reprint Address

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Author(s)

Dirk R.J. Kuypers, MD, PhD

Editor(s)

Chloe Harman

Skin Problems in Chronic Kidney Disease: Sidebar: Key Points

Sidebar: Key Points

Table of Contents

Acknowledgments

Reprint Address