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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 245-250

Skin changes and dermatological life quality index in chronic kidney disease patients in a tertiary hospital in Southern Nigeria


1 Department of Internal Medicine, Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
2 Department of Internal Medicine, University of Benin, Benin City, Edo State, Nigeria

Date of Acceptance31-Oct-2018
Date of Web Publication7-Feb-2019

Correspondence Address:
Dr. Oluseyi A Adejumo
Department of Medicine, University of Medical Sciences, Ondo City - 110 095, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_270_18

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   Abstract 


Background: Cutaneous changes commonly occur in chronic kidney disease (CKD), however, there is limited information on its effect on quality of life of these patients. This study determined the prevalence and pattern of skin changes in CKD patients and their effects on the dermatology life quality index (DLQI) of the patients. Materials and Methods: This was a descriptive cross-sectional study that involved stages 3–5 CKD patients who were examined for skin changes. The effects of the observed skin changes on DLQI were assessed using the standardized DLQI questionnaire. Results: One hundred and five CKD patients participated in the study consisting of 56 males and 49 females with a mean age of 51.93 ± 15.23 years. The prevalence of cutaneous changes was 94.3%. Common skin manifestations were pallor 99 (94.3%), hyperpigmentation 58 (55.2%), fluffy hair 55 (52.4%), Lindsay nails 48 (45.7%), and pruritus 44 (41.9%). The effect of dermatoses on DLQI was mild in 34 (32.4%), moderate in 13 (12.4%), and severe in 4 (3.8%).There was no significant association between dermatoses and CKD stage. There was significant positive correlation between DLQI scores and number of skin dermatoses (r = 0.522, P = <0.001), duration on maintenance hemodialysis (r = 322, P = 0.017). There was significant negative correlation between DQOL scores and packed cell volume (r = −0.232, P = 0.022). On multiple regression analysis, number of dermatoses was the only significant predictor of DLQI (P = <0.001). Conclusion: Skin changes occur commonly in CKD patients and significantly affected their DLQI. This study highlights the significant burden that skin changes add to CKD.

Keywords: Chronic kidney disease, dermatology life quality index, dermatoses


How to cite this article:
Adejumo OA, Madubuko RC, Olokor AB, Aina OT. Skin changes and dermatological life quality index in chronic kidney disease patients in a tertiary hospital in Southern Nigeria. Niger J Clin Pract 2019;22:245-50

How to cite this URL:
Adejumo OA, Madubuko RC, Olokor AB, Aina OT. Skin changes and dermatological life quality index in chronic kidney disease patients in a tertiary hospital in Southern Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Jun 16];22:245-50. Available from: http://www.njcponline.com/text.asp?2019/22/2/245/251784




   Introduction Top


The prevalence and incidence of chronic kidney disease (CKD) has been on the increase in the last few decades.[1] This disease is associated with huge financial burden and reduction in the overall quality of life (QOL).[1],[2] Dermatological changes are common in this group of patients and contribute to the burden of disease as well as reduced QOL.[3],[4],[5],[6]

The prevalence of dermatological changes in CKD ranges between 57.5% and 100% from previous reports.[7],[8],[9],[10],[11],[12],[13] Cutaneous manifestations seen in CKD patients may be because of the underlying etiology of CKD, treatment of the disease, or consequences of the disease itself.[14],[15] Some of these changes may also precede the onset of end-stage renal disease, whereas others manifest in those on renal replacement therapy (RRT) especially in those on hemodialysis. There is wide variation in severity and pattern of these skin changes. Common skin manifestations associated with CKD are pallor, xerosis, pigmentary changes, pruritus, and nail changes.[7],[8],[9],[10],[11],[12],[13],[16]

Skin diseases are common health problems that cause considerable disability and affects QOL which refers to an individual's ability to function in a manner commensurate with his needs, desires, and abilities.[17],[18] CKD patients with skin disease may experience severe symptoms such as itching, pain, and discomfort that may have profound psychological impact.[19] Skin changes in CKD are associated with depression, anxiety, poor sleep, and these may have a negative impact in the overall QOL of these patients.[3],[4] Furthermore, patients' social and physical activities, including sports and work, may be adversely affected by their skin diseases.

Most existing studies on the cutaneous manifestation of CKD are limited to the prevalence rate and pattern of the disease. There is limited information on the effects of these skin diseases on the dermatology life quality index (DLQI) of the CKD patients. Early identification of these changes and instituting appropriate treatment where indicated will help improve the QOL and overall outcome in these patients. This study determined the prevalence and pattern of skin changes in CKD and their effects on the DLQI of the patients. It also determined the factors associated with impaired DLQI.


   Materials and Methods Top


Study location and design

This was a descriptive, cross-sectional study conducted in the Department of Internal Medicine of University of Benin Teaching Hospital, Benin City, Edo State, Nigeria between May 2017 and April 2018. An average of 10 newly diagnosed CKD patients are seen in the unit monthly, while about half of this number commences maintenance hemodialysis (MHD) monthly.

Sample size and study population

The sample size was calculated using Leslie Kish formula for sample size determination in a finite population. The prevalence of skin changes in patients with CKD which was 95% from a previous study was used to calculate the sample size using a confidence interval of 95% and marginal error of 5%.[11],[20] The minimum sample size obtained after including 10% attrition rate was 80. However, 105 consecutive CKD patients who fulfilled inclusion criteria participated in the study.

Inclusion criteria for the study were adults aged ≥18 years, patients with CKD stages 3–5, and those who gave consent to participate in the study. CKD patients having primary skin problems, systemic lupus erythematosus, hepatitis B, C, or human immunodeficiency virus infection were excluded from the study.

All study subjects were interviewed using an interviewer administered questionnaire. The DLQI was assessed using the adult dermatology life index questionnaire, which is a standardized instrument.[21] This questionnaire has 10 questions, and each question is scored 0 to 3 depending on the response; not relevant or not at all is scored 0, a little is scored 1, a lot is scored 2, and very much is scored 3. The DLQI is calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. The higher the score, the more QOL is negatively affected. The study participants were examined for skin, nail, and hair changes by a dermatologist. CKD staging was according to the estimated glomerular filtration rate (GFR) as follows: stage 3 (GFR of 30-59 ml/min with or without evidence of kidney damage), stage 4 (GFR of 15-29 ml/min with or without evidence of kidney damage), and stage 5 (GFR <15 ml/min with or without evidence of kidney damage).[22]

Interpretation of DLQI scores

  • 0-1: no effect at all on patient's life
  • 2-5: small effect on patient's life
  • 6-10: moderate effect on patient's life
  • 11-20: very large effect on patient's life
  • 21-30: extremely large effect on patient's life.


Ethical consideration

Ethical approval with Protocol Number ADM/E22/A/VOL.VII/4616 was obtained from Ethics and Research Committee of University of Benin Teaching Hospital for this study. Informed consent was obtained from all subjects participating in the study. The study did not involve any therapeutic trials.

Data analysis

Data generated were analyzed using the statistical package for social sciences (SPSS) version 17.0. Results were presented in tabular form. The univariate analysis was used in the description of the characteristics of the study population. Discrete variables were presented as frequency and percentages. Continuous variables were presented as means, and the standard deviation for data that were not skewed while median and interquartile range was used to present continuous data that were skewed. The Chi-square test was used to determine the significance of observed differences for categorical variables. The Pearson's correlation was used to determine association between continuous variables that were unskewed, and the Spearman's correlation was used to determine association between skewed continuous variables. The P < 0.05 were considered significant.


   Results Top


One hundred and five CKD patients participated in the study consisting of 56 males and 49 females. The mean age of participants was 51.93 ± 15.23 years with age range between 23 and 79 years. Thirty-five (33%) participants were below 45 years, 49 (46.7%) were between 45 and 64 years, and 21 (20%) were 65 years and above. A majority of study participants were married 78 (74.3%), had secondary or tertiary level of education 87 (82.9%), and were Christians 96 (91.4%) [Table 1].
Table 1: Characteristics of study participants (n=105)

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Twenty-two (21%) were in stage 3 CKD, 22 (21%) in stage 4 CKD, and 61 in stage 5 CKD. Fifty-six (53.3%) were on MHD, and 49 (46.7%) were yet to commence hemodialysis (HD). The mean packed cell volume and MHD duration were 22.77 ± 5.12% and 11.34 ± 12.55 months, respectively [Table 1].

Ninety-nine (94.3%) of the CKD patients had at least one cutaneous change. Sixty-five patients (61.9%) had less than 6 dermatoses each, 34 patients (32.4%) had 6 or more dermatoses each, and 6 patients (5.7%) did not have any dermatosis. The effect of dermatoses on DLQI was mild in 34 (32.4%), moderate in 13 (12.4%), severe in 4 (3.8%), and absent in 54 (51.4%) [Table 1]. The common skin manifestations were pallor 99 (94.3%), hyperpigmentation 58 (55.2%), fluffy hair 55 (52.4%), Lindsay nails 48 (45.7%), pruritus 44 (41.9%), alopecia 29 (27.6%), stomatitis 21 (25%), leukonychia 19 (18.1%), and ichthyosis 16 (15.2%) [Table 2].
Table 2: Prevalence of skin changes among study participants

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There was no significant difference in the occurrence of dermatoses between CKD patients on MHD and those who were yet to commence RRT except for Lindsay nails and leukonychia. Leukonychia was significantly higher in those who were not on MHD (28.3% vs. 10.7%; P = 0.041). Lindsay nails was significantly more prevalent in those on MHD (58.9% vs. 30.4%; P = 0.014) [Table 3].
Table 3: Comparison of dermatoses between maintenance HD patients and CKD not on maintenance HD

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Some dermatological changes such as pallor, leukonychia, stomatitis, tinea versicolor, seborrheic dermatitis, and pruritus increased across CKD stages 3–5, however, only pallor reached statistical significance (P = 0.028) [Table 4].
Table 4: Association between skin dermatoses and CKD stage

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Certain dermatoses such as hyperpigmentation, pruritus, ichthyosis, tinea versicolor, stomatitis, and Lindsay nails showed significant association with DLQI scores [Table 5].
Table 5: Association between DLQI grading and skin dermatoses

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There was significant positive correlation between DLQI scores and number of dermatoses (r = 0.522, P = <0.001), duration on MHD (r = 322, P = 0.017). There was significant negative correlation between DLQI scores and packed cell volume (r = −0.232, P = 0.022) [Table 6]. On multiple linear regression, only the number of dermatoses was found to be significant predictor of QOL of the CKD patients [Table 7].
Table 6: Correlation and P values of association between DLQI, duration of HD, packed cell volume, number of dermatoses, and GFR stage

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Table 7: Multiple regression analysis showing predictor of DLQI

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   Discussion Top


The prevalence of dermatoses in this study was 94.3% which is similar to 95% and 96% reported by Chanda et al.[11] and Khanna et al.[10] respectively but higher than 57.5% reported by Oripelaye et al.[7] Thomas et al.[23] however, reported a slightly higher prevalence of 97.9%. This varied prevalence rates of dermatoses among CKD population may be because of the differences in studied participants' characteristics such as underlying etiology of CKD, stage of disease, and mode of RRT for those who had end-stage renal disease.

The mean age of the studied CKD patients was 52 ± 16 years which is similar to 50 ± 18 years reported by Oripelaye et al.[7] in a similar study conducted in Ile-Ife, Southwest Nigeria but lower than 43 ± 15 years reported by Falodun et al.[9] in Ibadan, Southwest Nigeria. This corroborates that CKD affected mostly the young and middle aged population in Nigeria unlike in the developed countries where the elderly were more affected.[1] There were more male CKD patients compared to females in this study which may be because of the fact that male gender is a risk factor for CKD. This finding is similar to some previous reports.[7],[8],[9],[11],[23],[24]

Xerosis was present in 46.6% of the CKD patients in this study which is comparable to 52% reported by Kolla et al.[24] but lower than 26.7% reported by Oripelaye et al.[7] Falodun et al.[9] and Thomas et al.[23] however, reported a higher prevalence of 60% and 66.7% in their respective studies. Xerosis in CKD patients could be because of the reduction in the number and size of eccrine sweat glands, diuretic therapy which is commonly used in this group of patients and the effect of ultrafiltration for those on dialytic therapy.[25],[26]

Pruritus was present in 41.9% of the CKD patients which is similar to 42% reported by Ghunawat et al.[27] and 40% reported by Shretha et al.[8] However, Kolla et al.[24] reported a higher prevalence of 60%. The higher prevalence of pruritus in the study by Kolla et al.[24] may be because their study involved only CKD subjects on MHD compared to our study that involved both MHD and pre-dialysis CKD patients. High levels of inflammatory markers and xerosis usually observed in HD subjects have been implicated in the pathogenesis of uremic pruritus.[28],[29],[30]

Hyperpigmentation was present in 55.2% of the CKD patients in our study which is similar to 56% reported by Levillard et al.[31] but lower than reported prevalence rates in some other studies.[7],[9],[24],[32] Increased pigmentation in CKD patients is usually because of an increased retention of melanin in the basal layer and superficial dermis because the kidneys are unable to excrete beta-melanocyte stimulating hormone.

Pallor was present in 94.3% of the CKD patients in this study which is similar to 91.5% reported by Shah et al.[33] This is high compared to 81% reported by Levillard et al.[31] This wide difference in prevalence of pallor is related to the criteria used in diagnosis of pallor. In our study, skin, palm, and nails were considered in determining pallor in our CKD patients unlike the studies that reported very low prevalence where skin pallor alone was considered. However, Falodun et al.[9] reported that pallor was present in all their study participants when mucosal pallor was considered. Reduced erythropoietin that occurs commonly in CKD is largely responsible for pallor in these patients.

The most common nail changes observed in our study was Lindsay nails (45.7%). This is comparable to 40% reported by Falodun et al.,[9] Amatya et al.[34] and Pico et al.[12] however, lower than 10.8–33% reported in some studies [7],[10],[13],[27],[31] Leukonychia was found in (18.1%) which is comparable with 16% and 20% reported by Ghunawat et al.[27] and Pico et al.[12] respectively. Shrestha et al.[8] however, reported a higher prevalence of 30% in their study that involved MHD patients.

Alopecia was present in 27.6% of the participants in our study which was higher than 10% reported by Udayakumar et al.[13] Possible reasons for hair loss in CKD include side effects of medications used in the management of the disease such as heparin. In addition, the chronicity of the disease may partly contribute to this hair loss. Ichthyosis was present in 15.2% of the study participants which is higher than 7.5% reported by Falodun et al.[9]

There was no significant difference in the occurrence of dermatoses between CKD patients on MHD and those who were not yet on HD except Lindsay nails which was significantly present in the MHD group and leukonychia which was significantly present in the pre-HD group. This finding is similar to the report by Falodun et al.[9] There was no significant difference in the occurrence of dermatoses between these two groups except higher prevalence of xerosis in the MHD group. Khana et al.[10] also reported that the frequency of dermatoses was similar in both MHD and pre-HD patients.

There was no significant association between majority of the dermatoses and CKD stages in this study except pallor. Some dermatoses such as pruritus, seborrheic dermatitis, tinea versicolor, stomatitis, and leukonychia showed increasing frequency across CKD stages 3–5, but this trend did not reach statistical significance. This is similar to the report by Oripelaye et al.[7] who also reported increasing frequency of certain dermatosis across the CKD stages which were not statistically significant.

Dermatoses such as xerosis, hyperpigmentation, pruritus, ichthyosis, tinea versicolor, stomatitis, and Lindsay nails were significantly associated with the DLQI in this study. This implied that CKD patients with these dermatoses are more likely to have impaired QOL. Among these dermatoses, only pruritus has been well studied in relation to QOL in CKD patients.[5],[6]

There was significant association between DLQI of CKD patients, packed cell volume, duration on MHD, and number of cutaneous dermatoses. There was inverse correlation between the DLQI of the CKD patients and packed cell volume. There was positive correlation between duration on MHD and DLQI; this implies that as the patients spend longer time on dialysis, they may develop more dermatoses which may impair their QOL. The number of dermatosis was the only factor that determined DLQI on linear multiple regression. Therefore, the DLQI of our patients may be improved by prevention, early detection, and management of some of these dermatoses. Moreover, adequate management of anemia may improve the DLQI of our CKD patients.

The strength of this study lies in the fact that this is the first study in Nigeria to the best of our knowledge that studied the impact of dermatoses on the DLQI, and also determined factors that were associated with DLQI in these patients.


   Conclusion Top


Skin changes occur commonly in CKD patients with similar frequency in the pre-dialytic and MHD patients. Dermatoses significantly affected DLQI in our CKD patients. This study highlights the significant burden that skin changes add to CKD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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