Nail changes in end-stage renal failure patients on hemodialysis

To evaluate the fingernail changes in patients with end-stage renal failure (ESRF) on regular hemodialysis (HD), we reviewed 69 patients (male 25, female 44; age 40 +/- 14.8 years) who have been on HD at Samtah General Hospital, Gizan, Kingdom of Saudi Arabia for a mean of 4.3 +/- 3.06 years. They were free from congenital, systemic or primary skin disorders contributing to nail changes. The patients were also free from ornamental dyes like henna, traumatic injuries or infections in the fingernails. They were also clinically free from features suggestive of the carpal tunnel syndrome or vascular steal syndrome secondary to arteriovenous fistula (AVF) created for vascular access. Their nails were examined under bright day light by the authors independently. The findings consistent among all three observers were taken for analysis. Hemoglobin and serum albumin levels were also estimated. We compared these changes according to age, sex, and duration on chronic hemodialysis, AVF, and the levels of serum albumin and hemoglobin. One or more nail changes were observed in 44/69 (64%) patients. The commonest abnormality was the so-called "Half-and-half nail changes", which was observed in the finger nails of 18/69 (26%) of the study patients (males to female ratio was 2:1). Typically, the half-and-half nails are nails where the distal portion of the nail bed is red, pink or brown, occupies 20-60% of the total nail length and is always sharply demarcated with the proximal portion. The latter has a dull whitish ground glass appearance and when pressure is applied, the distal discoloration does not fade completely. Non-specific nail changes were observed 26/69 (38%) patients. The hemoglobin and serum albumin levels were not significantly different of those with 'half-and-half' nail, non-specific nail changes or no nail changes. We conclude that various fingernail changes are observed in ESRF patients on HD. These nail changes are independent of the age of the patient, duration on HD, AVF or hemoglobin or albumin levels. However, a gender dependent trend was noticed and the half-and-half nail seems to be characteristic of uremia.