SECTION 18: SKIN SIGNS OF RENAL INSUFFICIENCY

CLASSIFICATION OF SKIN CHANGES

• Acute renal failure

  • Edema

  • Uremic frost (deposition of urea crystals on the skin's surface in severe uremia)

• Chronic renal failure

  • Edema

  • Uremic frost

  • Calciphylaxis

  • Bullous disease of hemodialysis (pseudoporphyria, see Section 23)

  • Nephrogenic fibrosing dermopathy

  • Acquired perforating dermatosis

CALCIPHYLAXIS ICD-10: E83.59

• Calciphylaxis is characterized by progressive cutaneous necrosis associated with small- and medium-sized vessel vasculitis, calcification, and thrombosis.

• It occurs in the setting of end-stage renal disease, diabetes mellitus, and secondary hyperparathyroidism. Most often follows initiation of hemo or peritoneal dialysis.

• Precipitating factors: glucocorticosteroids, albumin infusions, IM tobramycin, iron dextran complex, calcium heparinate, and vitamin D.

• Preinfarctive lesions show mottling or a livedo reticularis pattern, dusky red (Fig. 18-1A).

• Turn into black, leathery eschar (Fig. 18-1B) and ulcer with tightly adherent black or leathery slough. Ulcers enlarge over weeks to months; when debrided reach down to fascia and beyond; areas of plate-like induration can be palpated surrounding infarcted or ulcerated lesions (Fig. 18-2).

• Extremely painful.

• Lower extremities, abdomen, buttocks, and penis.

• Azotemia. Calcium X phosphate ion product usually elevated. Parathormone levels usually but not always elevated. Dermatopathology: Calcification of media of small- and medium-sized blood vessels in dermis and subcutaneous tissues.

• Slowly progressive, despite therapy. Ulcers become secondarily infected.

• Management: Treatment of renal failure, partial parathyroidectomy when indicated, and debridement of necrotic tissue.

NEPHROGENIC FIBROSING DERMOPATHY (NFD) ICD-10: L90.8

• NFD is a fibrosing disorder in patients with acute or chronic renal failure.

• Most patients receive hemodialysis or peritoneal dialysis; in acute renal failure, NFD occurs without dialysis.

• It is part of a wider spectrum of nephrogenic systemic fibrosis involving the heart, lungs, diaphragm, skeletal muscle, liver, genitourinary tract, and central nervous system.

• Etiology unknown but exposure to gadodiamide containing contrast media for MR angiography is a strong association. Gadodiamide is found only in lesions and not in normal tissue.

• NFD is characterized by acute onset, brawny indurations, plaque-like or nodular, bound down upon palpation (Fig. 18-3); up to 20 cm and more in diameter, ...