title: Skin denervation and its clinical significance in late-stage chronic kidney disease.
abstract: OBJECTIVE
  To investigate the skin innervation and its clinical significance in late-stage chronic kidney disease (CKD).
  
  
  METHODS
  Case series.
  
  
  METHODS
  National Taiwan University Hospital, Taipei, Taiwan.
  
  
  METHODS
  Forty consecutive nondiabetic patients with late-stage CKD (14 female and 26 male; mean [SD] age, 60.7 [12.3] years), including 2 cases with stage 3 CKD, 6 with stage 4 CKD, and 32 with stage 5 CKD, ie, end-stage kidney disease.
  
  
  METHODS
  Clinical evaluation of neurological deficits, nerve conduction study, autonomic function tests, and a 3-mm-diameter skin biopsy specimen taken from the distal leg.
  
  
  METHODS
  Quantitation of epidermal innervation, parameters of nerve conduction study, R-R interval variability, and sympathetic skin response.
  
  
  RESULTS
  Clinically, 21 patients (52.5%) were symptomatic with paresthesia over the limbs or autonomic symptoms. The intraepidermal nerve fiber (IENF) density was markedly reduced in patients with CKD compared with age- and sex-matched controls (mean [SD], 2.8 [2.0] vs 8.6 [2.8] fibers/mm; P < .001). Skin denervation was observed in 27 patients (67.5%). Fifteen patients (37.5%) had abnormalities on nerve conduction studies, and 29 patients (72.5%) had abnormal results on autonomic function tests. By analysis with multiple regression models, the IENF density was negatively correlated with the duration of renal disease (P = .02). Additionally, the R-R interval variability at rest was linearly correlated with the IENF density (P = .02) and the absence of sympathetic skin responses at the soles was associated with reduced IENF density (P = .03).
  
  
  CONCLUSIONS
  Small-fiber sensory and autonomic neuropathies constitute the major form of neuropathy in late-stage CKD. Furthermore, skin denervation was associated with the duration of renal disease.
authors.affiliation: Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan S Rd, Taipei 10002, Taiwan.
authors.forename: Chi-Chao
authors.initials: CC
authors.lastname: Chao
authors.forename: Vin-Cent
authors.initials: VC
authors.lastname: Wu
authors.forename: Chun-Hsiang
authors.initials: CH
authors.lastname: Tan
authors.forename: Yi-Mei
authors.initials: YM
authors.lastname: Wang
authors.forename: Ming-Tsung
authors.initials: MT
authors.lastname: Tseng
authors.forename: Pei-Chen
authors.initials: PC
authors.lastname: Wu
authors.forename: Yea-Huey
authors.initials: YH
authors.lastname: Lin
authors.forename: Whei-Min
authors.initials: WM
authors.lastname: Lin
authors.forename: Kwan-Dun
authors.initials: KD
authors.lastname: Wu
authors.forename: Sung-Tsang
authors.initials: ST
authors.lastname: Hsieh
mesh_terms: D000368:Aged; D017776:Autonomic Pathways / Q000473:pathology / Q000503:physiopathology; D001706:Biopsy; D016022:Case-Control Studies; D018450:Disease Progression; D005121:Extremities / Q000294:innervation / Q000503:physiopathology; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000473:pathology / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009412:Nerve Fibers / Q000473:pathology*; D009431:Neural Conduction; D010292:Paresthesia / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology / Q000503:physiopathology*; D012044:Regression Analysis; D012720:Severity of Illness Index; D012867:Skin / Q000294:innervation* / Q000473:pathology / Q000503:physiopathology; D013624:Taiwan / Q000453:epidemiology