Abstract
Background
The impact of nail abnormalities on prognosis in hemodialysis patients is unknown. This study investigated whether toenail opacity as a readout of nail abnormalities predicted prognosis in hemodialysis patients.
Methods
In this observational study, 494 eligible hemodialysis patients who received hemodialysis at Oyokyo Kidney Research Institute between September 2010 and December 2015 were included. The presence of nail abnormalities was objectively evaluated by big toenail opacity ratio measurement. Primary endpoint was overall survival, and secondary endpoints were lower limb amputation and determination of risk factors for poor prognosis among patient demographics, comorbidities, blood tests, and big toenail opacity. Overall survival and lower limb survival were evaluated using the Kaplan–Meier method with log-rank test. Multivariate Cox regression analyses assessed predictors for poor prognosis.
Results
Big toenail opacity was found in 259 (52%) patients. Patients with big toenail opacity were significantly older, had shorter duration of dialysis, higher prevalence rates of diabetes mellitus (DM), cardiovascular disease (CVD), and higher mortality rates than those without opacity. Presence of big toenail opacity predicted poor prognosis for both overall and lower limb survival. Multivariate Cox regression analyses revealed serum albumin, the presence of DM and big toenail opacity were independent risk factors for both poor overall and lower limb survivals.
Conclusion
The prevalence of big toenail opacity was high in hemodialysis patients. Despite the short observation period, our findings indicated that big toenail opacity had significant predictive power for poor overall and lower limb survival.
Similar content being viewed by others
References
Dyachenko P, Monselise A, Shustak A, Ziv M, Rozenman D. Nail disorders in patients with chronic renal failure and undergoing haemodialysis treatment: a case-control study. J Eur Acad Dermatol Venereol. 2007;21:340–4.
Matricciani L, Talbot K, Jones S. Safety and efficacy of tinea pedis and onychomycosis treatment in people with diabetes: a systematic review. J Foot Ankle Res. 2011;4:26.
Eggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int. 1999;56:1524–33.
Kaminski M, Frescos N, Tucker S. Prevalence of risk factors for foot ulceration in patients with end-stage renal disease on haemodialysis. Intern Med J. 2012;42:e120–8.
O’Hare AM, Bacchetti P, Segal M, Hsu CY, Johansen KL. Factors associated with future amputation among patients undergoing hemodialysis: results from the dialysis morbidity and mortality study waves 3 and 4. Am J Kidney Dis. 2003;41:162–70.
Hatakeyama S, Saito M, Ishigaki K, Yamamoto H, Okamoto A, Ishibashi Y, et al. Skin perfusion pressure is a prognostic factor in hemodialysis patients. Int J Nephrol. 2012;. doi:10.1155/2012/385274.
Kaminski MR, Raspovic A, McMahon LP, Strippoli GF, Palmer SC, Ruospo M, et al. Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrol Dial Transplant. 2015;30:1747–66.
Cheung AK, Sarnak MJ, Yan G, Dwyer JT, Heyka RJ, Rocco MV, et al. Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int. 2000;58:353–62.
Orimoto Y, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Yamada T, et al. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013;58:1291–9.
Menjo Y. Treatment of tinea unguium with heat-sensing moxibustion. J Kampo Acupunct Integr Med. 2007;2:2–3.
Akobeng AK. Understanding diagnostic tests 3: receiver operating characteristic curves. Acta Paediatr. 2007;96:644–7.
Kuvandik G, Cetin M, Genctoy G, Horoz M, Duru M, Akcali C, et al. The prevalance, epidemiology and risk factors for onychomycosis in hemodialysis patients. BMC Infect Dis. 2007;7:102.
Saunte DM, Holgersen JB, Haedersdal M, Strauss G, Bitsch M, Svendsen OL, et al. Prevalence of toe nail onychomycosis in diabetic patients. Acta Derm Venereol. 2006;86:425–8.
Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care. 2006;29:1202–7.
Salem A, Al Mokadem S, Attwa E, Abd El Raoof S, Ebrahim HM, Faheem KT. Nail changes in chronic renal failure patients under haemodialysis. J Eur Acad Dermatol Venereol. 2008;22:1326–31.
Ndip A, Rutter MK, Vileikyte L, Vardhan A, Asari A, Jameel M, et al. Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease. Diabetes Care. 2010;33:1811–6.
Gupta AK, Daigle D, Foley KA. The prevalence of culture-confirmed toenail onychomycosis in at-risk patient populations. J Eur Acad Dermatol Venereol. 2015;29:1039–44.
Turns M. Prevention and management of diabetic foot ulcers. Br J Community Nurs. 2015;Suppl Wound Care:S30, S2, S4–7.
Inlow S. The 60-second foot exam for people with diabetes. Wound Care Can. 2004;2:10–1.
Acknowledgements
We thank Daisuke Noro, Itsuto Hamaono, Kazuhisa Hagiwara, Naoki Fujita, Atsushi Imai, Hayato Yamamoto, Takahiro Yoneyama, Yasuhiro Hashimoto, Takuya Koie for their invaluable help with data collection and suggestions. The authors would like to thank Enago (http://www.enago.jp) for the English language review.
Author information
Authors and Affiliations
Contributions
Conception and design: SH, acquisition of data: OS, TM, TT, YT, SH, HK, HH, YK, KK, GA, MM, IN, RK, HS, analysis and interpretation of data: SH, drafting of the manuscript: OS, SH, critical revision of the manuscript: CO, TS, statistical analysis: SH, obtaining funding: SH, CO.
Corresponding author
Ethics declarations
Source of funding
This work was supported by a Grant-in-Aid for Scientific Research (No. 15H02563, 15K15579, 17K1118, 17K1119, 17K16768, 17K16770, and 17K16771) from the Japan Society for the Promotion of Science.
Conflict of interest
The authors declare that they have no conflicts of interest.
Human and animal rights
This retrospective observational study was performed in accordance with the ethical standards of the Declaration of Helsinki and approved by an ethics review board of Hirosaki University Graduate School of Medicine and Oyokyo Kidney Research Institute (approval no 2016-225).
Informed consent
The participants in this study provide their verbal informed consent. Pursuant to the provisions of the ethics committee and the ethic guideline in Japan, written consent was not required in exchange for public disclosure of study information in the case of retrospective and/or observational study using a material such as the existing documentation.
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Soma, O., Hatakeyama, S., Matsumoto, T. et al. Opacity of big toenail predicts poor prognosis in patients with end-stage renal disease on hemodialysis. Clin Exp Nephrol 22, 668–676 (2018). https://doi.org/10.1007/s10157-017-1495-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10157-017-1495-5