Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
December 2019 • VOL. 67 Supplement to JAPI • December 2019
Correspondence
The Spectrum of Dermatological Manifestations in Chronic Kidney Disease Patients of Uddanam Nephropathy - Is it Different?
Sir,
An increased prevalence of chronic kidney disease (CKD) has been observed in several geographical areas across the world over the past two decades including Uddanam region in India. Uddanam endemic nephropathy is prevalent in the region of Uddanam, a lush green region in Srikakulam district, Andhra Pradesh of India and is considered as nephropathies of unknown etiology.1 As reported in literature 50-100 % patients of chronic kidney disease patients have the identifiable dermatological disorder and 41% patients have specific manifestations related to the disease.2,3 We did an observational study in a tertiary care hospital in Andhra Pradesh, India to identify common dermatological mani festations in chronic kidney disease patients of Uddanam region i.e. chronic kidney disease of unknown etiology (CKD u) after excluding other possible etiologies of renal dysfunction and compared it with the patients of renal dysfunction with known etiologies. Persons residing in Uddanam region temporarily but belonging to other states were excluded. Skin biopsy for histopathological examinations of skin lesions was performed if indicated. Total 212 patients were diagnosed chronic kidney disease (CKD) during evaluation of renal dysfunction in renal OPD and out of these 80 patients had definitive etiologies of CKD like DM-2, HTN, ADPKD, Nephrolithiasis, Glomerulonephritis etc. and were treated as the control group. Only those 132 patients were included in Uddanam nephropathy group who had features suggestive of chronic tubulointerstitial disease in form of shrunken kidney sizes on USG, bland had no features suggestive of any definitive etiologies of CKD.This group was provisionally classified as chronic kidney disease of unknown etiology (CKDu). Among 132 patients in CKDu, 87 patients (66%) were male and 45 patients (34%) were females. The age distribution of the patients ranged from 24-86 yrs with a mean age of 54.6 ± SD 14.40 yrs. Majority of the patients were in the 40-59 yr group (52 %). In control group 67.5% were male and 32.5% were female with duration of kidney disease 6-94 months. If the study population was grouped as per CKD stage wise, with the severity of renal dysfunction percentage of population with cutaneous manifestations also increased. Almost all CKDu patients with CKD5D had some dermatological manifestations as compared to 88.8 % in patients with known etiologies. In CKD stage 4 of CKDu, about 82 % had dermatological manifestation as compared to 58.3% of control group which was statistically significant. In both CKDu and control group with known etiologies skin changes were predominant (more than 90% in both groups). Mucosal changes and nail changes were about 35-40 %. Hair changes were least dominant with 23-30 % of populations affected. Xerosis was the commonest pattern (52-59%) followed by pigmentation, pruritus, ichthyosis. The pattern of cutaneous manifestations in both the groups were comparable. 3 patients of Uddanam nephropathy and one diabetic patient were detected to have acquired perforating dermatosis. About 36 % of patients with CKDu and 35.1 % of the control group had involvement of nail, the majority of both groups have white nail followed by longitudinal ridges. Buccal mucosa hyperpigmentation was the predominant oral mucosal lesion followed by scrotal tongue and furred tongue.
We concluded that dermatological manifestations were as common in CKDu i.e. Uddanam nephropathy group as to control group i.e. cases of defined etiologies. Skin, nail, oral mucosa and hair changes are very common in both Uddanam nephropathy and in renal dysfunction due to other etiologies. It also stresses the fact that most of the cutaneous manifestations in chronic kidney disease have nothing to do with the underlying pathologic process that induced the renal dysfunction.
References
1. Ganguli A. Uddanam nephropathy/regional nephropathy in
India: preliminary findings and a plea for further research.
Am J Kidney Dis 2016; 68:344–8.
2. Pico MR, Lugo-Somolinos A, Sanchez JL, Burgos-Calderon R.
Cutaneous alterations in patients with chronic renal failure.
Int J Dermatol 1992; 31:860.
3. Shrestha P, Mathur M. Dermatologic manifestations in
chronic kidney disease patients on hemodialysis. NJDVL
2014; 12:34-40.
