Dermatologic manifestations in end stage renal disease.

Skin manifestations are commonly seen in end stage renal disease (ESRD). Skin involvement in this population can be extensive and dramatically worsen quality of life. Close observation of the skin and nails of ESRD patients by clinicians allows for timely diagnosis and treatment, which ultimately improves quality of life and reduces mortality. In this article we focus on the cutaneous changes most commonly seen in ESRD patients. PubMed/Medline database search was done for published literature on skin manifestations in ESRD patients. All the available literature was reviewed and relevant articles were used to discuss about clinical features, pathogenesis, histology and treatment of each skin disorder in ESRD patients. Most commonly encountered skin manifestations in patients with ESRD are pruritus, xerosis, pigmentation changes, nail changes, perforating disorders, calcifying disorders, bullous dermatoses and nephrogenic systemic fibrosis. Skin manifestations in ESRD can be difficult to treat and multiple comorbidities in this patient population can exacerbate these disorders. Many of the treatment options are experimental with evidence largely derived from the case reports and small clinical trials. More large-scale trials are needed to firmly establish evidence based treatment guidelines. Prompt evaluation and management of these disorders improve morbidity and quality of life in ESRD patients.

Atypical Hemolytic-Uremic Syndrome: An Update on Pathophysiology, Diagnosis, and Treatment.

Atypical hemolytic uremic syndrome (aHUS), a rare variant of thrombotic microangiopathy, is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. The condition is associated with poor clinical outcomes with high morbidity and mortality. Atypical HUS predominantly affects the kidneys but has the potential to cause multi-organ system dysfunction. This uncommon disorder is caused by a genetic abnormality in the complement alternative pathway resulting in over-activation of the complement system and formation of microvascular thrombi. Abnormalities of the complement pathway may be in the form of mutations in key complement genes or autoantibodies against specific complement factors. We discuss the pathophysiology, clinical manifestations, diagnosis, complications, and management of aHUS. We also review the efficacy and safety of the novel therapeutic agent, eculizumab, in aHUS, pregnancy-associated aHUS, and aHUS in renal transplant patients.

Anatomical Look Into OnabotulinumtoxinA Injection for Chronic Migraine Headache.

BACKGROUND AND OBJECTIVES: While existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. METHODS: Anatomically normal computed tomography scans of the head, neck, and face were randomly selected. Subjects were stratified into 4 groups based on BMI, with 30 patients in each group. Four standardized locations were chosen to obtain measurements from the skin surface to the underlying muscle fascia, including (1) frontalis, (2) temporalis, (3) semispinalis capitis, and (4) trapezius. RESULTS: Median depth for the temporalis was 12.65 mm (Q1 = 9.32 mm, Q3 = 15.08 mm) for the BMI greater than 35 kg/m group. Median depth for the semispinalis capitis was 13.77 mm (Q1 = 10.3 mm, Q3 = 15.7 mm) for the BMI 30 to 35 kg/m group, and 14.75 mm (Q1 = 11.00, Q3 = 17.00 mm) for the BMI greater than 35 kg/m group. Median depth for the trapezius was 13.95 mm (Q1 = 10.18 mm, Q3 = 19.00 mm) for the BMI greater than 35 kg/m group. These medians exceeded the length of the standard 0.5-inch (12.-mm) needle used in existing protocols. CONCLUSIONS: Our study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.