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with the back being the most commonly affected site&#46; Pruritus is often prolonged and severe and is exacerbated by heat&#44; sweating and xerosis&#46; Skin lesions&#44; such as excoriations&#44; lichen simplex&#44; nodular prurigo and keratotic papules&#44; may result from scratching &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In terms of treatment&#44; the main objective is to relieve itching and improve the quality of life&#46; Definitive treatment involves kidney transplantation&#46; It is important to mention that antihistamines are not effective&#44; and the majority of available treatments are only empirical and lack strong evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">General treatment consists of improving the quality of haemodialysis&#44; increasing efficiency <span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span> urea<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;4 &#40;<span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>dialysis adequacy&#46; <span class="elsevierStyleItalic">K</span>&#44; clearance&#46; <span class="elsevierStyleItalic">t</span>&#44; time&#46; <span class="elsevierStyleItalic">V</span>&#44; volume of distribution&#41; using low calcium and magnesium dialysates&#44; reducing calcium&#8211;phosphorus products and using more biocompatible membranes&#44; such as those made of polymethylmethacrylate&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Erythropoietin efficiently relieves itching by decreasing histamine levels&#46; Its effect is not associated with haemoglobin levels and it is lost when administration is discontinued&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is important to avoid xerosis&#44; sweating and heat&#46; Moisturisers constitute the first line of therapy&#44; especially those containing gamma linoleic acid&#44; glycerol and paraffin&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The addition of endocannabinoids to moisturisers has been proven effective&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Topical treatment is preferred for localised pruritus&#46; Studies have reported the efficacy of capsaicin and pramoxine&#46; Capsaicin depletes P substance from C fibres&#44; thus blocking pain and pruritus transmission&#59; it is used as 0&#46;025&#37; cream four times daily&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Pramoxine lotion&#44; a topical anaesthetic&#44; used twice daily for 1 month has been proven effective&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The use of calcineurin inhibitors is controversial and is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Systemic treatment with gabapentin&#44; a GABA agonist&#44; is effective and safe&#46; Due to its renal clearance&#44; gabapentin is administered at low doses of 300<span class="elsevierStyleHsp" style=""></span>mg after each haemodialysis session&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> The serotonin inhibitor 5 HT3 granisetron &#40;1<span class="elsevierStyleHsp" style=""></span>mg twice daily for 1 month&#41; is also effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> The opioid agonist nalfurafine has proven to be effective&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Phototherapy with narrowband UVB has been used to decrease the production of cytokines by lymphocytes and to reduce phosphorus levels in the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Among surgical treatments&#44; parathyroidectomy can be effective in cases with secondary hyperparathyroidism and high calcium&#8211;phosphorus products&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> However&#44; kidney transplantation is the definitive treatment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Acquired perforating dermatosis &#40;APD&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">APD is commonly observed in patients with end-stage CKD&#44; especially in individuals with diabetes mellitus and individuals receiving haemodialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The pathogenesis of APD is unclear&#46; APD is associated with diabetes mellitus&#44; hypothyroidism&#44; liver disease&#44; malignancies and HIV infection&#46; The mechanism involves transepidermal elimination of dermal components &#40;collagen&#44; elastin and cell detritus&#41;&#46; Proposed trigger factors include minor trauma&#44; such as scratching&#44; microvascular changes associated with diabetes mellitus&#44; skin calcium depositions with foreign body inflammatory response and genetic predisposition&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;26</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Clinical manifestations include pigmented and umbilicated dome shaped papules with a depressed and scaling centre&#44; located on the extensor surfaces of the arms and legs and less commonly&#44; on the scalp&#44; trunk and buttocks &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Koebner phenomenon may be present&#46; This condition appears in outbreaks and typically resolves in 6&#8211;8 weeks with residual pigmentation and scarring&#46; Differential diagnoses include prurigo nodularis and lichen planus&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Histopathology findings include an excavated epidermis&#44; acanthosis&#44; cup shaped plugs composed of keratin&#44; collagen and cell detritus that move from the epidermis to the exterior&#44; and a perilesional inflammatory infiltrate composed of lymphocytes and neutrophils&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Steroids &#40;topical&#44; oral or intralesional&#41; are used to decrease inflammation and keratolytics and retinoids &#40;topical or oral&#41; are used to decrease epidermal thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Allopurinol&#44; a xanthine-oxidase inhibitor&#44; is used at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg daily for 1&#8211;4 months&#59; it has been proven effective in a series of cases&#46; Allopurinol is thought to have antioxidant activity&#44; thus decreasing free radicals involved in collagen damage&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Maxacalcitol &#40;0&#46;0025&#37; ointment&#41;&#44; a D vitamin analogue&#44; was reported successful in four treated cases&#46; It is applied twice daily for 2 months&#46; Its mechanism of action remains unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">UVB narrowband phototherapy has been used with success in a series of cases&#46; Benefits are noted in 10&#8211;15 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Photodynamic therapy has also been reported to be effective&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nephrogenic systemic fibrosis &#40;NSF&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Formerly called nephrogenic fibrosing dermopathy&#44; 380 cases of this rare disease have been registered at Yale University&#44; and the first cases were recorded in 1997&#46; No differences in gender and ethnicity were noted&#46; NFS occurs in all ages&#44; but predominantly in middle age&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Ninety-five percent of the cases are associated with gadolinium&#44; a contrast medium&#44; which is used in MRI angiography in patients with low glomerular filtration rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Gadodiamide and gadopentetate are the most common causes of contrast media associated with NSF&#46; The poorer the glomerular filtration rate&#44; the longer the half-life of gadolinium&#46; In addition&#44; 73&#46;8&#37; and 92&#46;4&#37; of gadolinium is excreted in a single haemodialysis session or two sessions&#44; respectively&#44; but gadolinium is not properly excreted in peritoneal dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In patients with a genetic predisposition &#40;HLA A2&#41; or an inflammatory state&#44; a hypercoagulable state or endothelial damage&#44; gadolinium enters the tissues&#44; 35&#8211;150-fold more effectively compared with healthy patients&#46; Gadolinium is subsequently phagocytosed by macrophages&#44; which release cytokines that attract circulating fibrocytes &#40;CD34&#47;procollagen I&#43;&#41; to the tissues&#46; Once in the tissue&#44; the fibrocytes differentiate into fibroblast-like cells in the dermis&#44; leading to fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Clinical manifestations include indurated&#44; erythematous-hyperchromic plaques with an orange peel&#44; woody or cobblestone appearance&#46; Nodules and bullae may be present on the hands and feet&#44; or yellowish edematous plaques are noted on the sclera &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The lesions are bilateral and symmetrical on the legs and forearms&#46; The condition is occasionally observed on the trunk and buttocks and generally spares the face&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">A burning&#44; itching&#44; and stinging pain occurs&#46; Flexion contractures of adjacent limbs are noted&#44; days to weeks after exposure to the contrast&#44; and the condition tends to be chronic&#46; Remission is achieved in a few cases&#44; leaving atrophic and hypopigmented lesions&#59; 5&#37; of patients experience a rapid fulminant course in 2 weeks with multiple organ involvement &#40;lungs&#44; heart and oesophagus&#41;&#46; Differential diagnoses include scleromyxedema&#44; systemic sclerosis&#44; eosinophilia-myalgia syndrome&#44; toxic oil syndrome and eosinophilic fasciitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The histopathology is characterised by thickened collagen bundles with clefts&#44; mucin deposition and proliferation of spindled cells that stain positive for CD34 and procollagen 1&#46; Multinucleated cells positive for CD68 and factor VIII are also present&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;24&#44;32</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">For prevention&#44; if a macrocyclic contrast medium must be used&#44; gadoteridol is the safest option&#46; In haemodialysis patients&#44; two 4-h sessions are required to remove the contrast&#59; these sessions should be performed in the first 3<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Most treatments demonstrate efficacy in anecdotal and cases reports&#46; Steroids and immunosuppressants are generally ineffective&#46; Oral prednisone may be used with some efficacy&#44; but many adverse effects are observed&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Extracorporeal photopheresis is available in a few centres&#44; but is prohibitively expensive&#46; It has been proven to be effective in all patients&#44; increasing softening of injuries and mobility ranges&#46; Extracorporeal photopheresis enhances the suppression of signals by inducing lymphocyte apoptosis and deflecting the signal of antigen-presenting cells&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Kidney transplantation offers improvement in 54&#37; of patients and full remission has been achieved in some cases&#46; It improves mobility ranges of flexion contracture&#44; likely due to increased glomerular filtration and immunosuppression after transplantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Imatinib mesylate&#44; a tyrosine kinase inhibitor&#44; acts by inhibiting platelet-derived growth factor and c-Abl kinase&#44; thus inhibiting the synthesis of collagen and fibronectin by dermal fibroblasts&#46; Doses of 400&#8211;600<span class="elsevierStyleHsp" style=""></span>mg&#47;day are administered for 4&#8211;24 weeks&#44; achieving mild to moderate success&#46; The lesions are softened&#44; but little improvement is noted in the range of motion&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">UV-A 1 phototherapy has been proven effective in smoothing skin lesions&#44; with little improvement in range of motion&#46; It is used at 60&#8211;120<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> in 22&#8211;50 sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Plasmapheresis and immunoglobulin G exhibit anecdotal success&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Physical therapy improves the performance of daily activities and personal care&#44; with little improvement in the range of motion&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In a case report&#44; photodynamic therapy was effective along with kidney transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Calciphylaxis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Calciphylaxis occurs in patients with CKD on hemodialysis&#59; it is associated with secondary hyperparathyroidism and elevated calcium-phosphorus products&#46; Calciphylaxis is an obliterative vasculopathy caused by the deposition of calcium in the arterioles of the skin&#44; leading to thrombosis and ischaemic necrosis with ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Calciphylaxis is commonly observed in women&#44; in patients with diabetes mellitus&#44; obesity&#44; hypoalbuminemia&#44; liver cirrhosis&#44; those who use warfarin&#44; and those with systemic inflammation and malignancy&#46; Sepsis can cause up to 80&#37; mortality via skin ulcer infection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Its ethiopathogenic mechanism is unclear&#46; Predisposition plus a causal factor are necessary&#46; Calcium&#8211;phosphorus products are increased in the majority of patients&#44; but this increase is not sufficient alone to cause the condition&#46; An imbalance between inhibitors and inducers of vascular calcification is noted&#46; Osteopontin and bone morphogenic protein 2 serve as inducers&#44; whereas GI protein matrix&#44; fetuin and pyrophosphate act as inhibitors&#46; Aluminium deposition may also be an inductor&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Clinical manifestations include painful&#44; pink or purple&#44; firm nodules or plaques&#44; surrounded by livedo reticularis that progress to central and deep&#44; painful ulcers covered with black eschar and a reticulated depigmentation in the periphery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Calciphylaxis is bilateral and symmetrical and affects adipose tissue areas&#44; such as the thighs&#44; abdomen and buttocks&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Histopathologic findings include calcification of the media&#44; intimal hyperplasia of dermal and subcutaneous arterioles&#44; thrombosis of dermal and subcutaneous vessels with ischaemic necrosis in the epidermis and lobular panniculitis with fat necrosis&#46; On radiography&#44; linear calcium deposits are observed&#46; The involvement of small blood vessels &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41; is the most specific sign&#59; however&#44; many patients exhibit vascular calcification without calciphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">For therapy&#44; early total or subtotal surgical parathyroidectomy increases survival&#46; Cinacalcet is a calcium mimetic that increases sensitivity of the calcium receptor in the parathyroid gland&#44; thus reducing the production of parathyroid hormone&#46; Cinacalcet is used in cases where parathyroidectomy is delayed or contraindicated&#46; Treatment is discontinued once PTH reaches a normal level of 1&#46;5 to prevent renal osteodystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Among bisphosphonates&#44; etindronate and pamidronate have proven to be effective&#46; Prednisone is used in early unulcerated plaques&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Sodium thiosulfate is administered either orally daily or intravenously at the end of haemodialysis for 3&#8211;5 months&#46; Sodium thiosulfate offers symptomatic and radiological relief of tissue calcification&#44; displacing calcium from calcium phosphate&#44; to form calcium thiosulfate&#44; which is more soluble than other salts and is excreted either by haemodialysis or by the kidneys&#46; Sodium thiosulfate &#40;25<span class="elsevierStyleHsp" style=""></span>g&#41; is administered intravenously for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; three times a week after each haemodialysis session&#46; Metabolic acidosis is an important side effect of this drug&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Dialysis improves this condition through using low calcium dialysate and increasing the frecuency and duration of hemodialysis sessions&#46; Sevelamer is a phosphorus chelator that reduces the intestinal absorption of phosphorus&#46; Calcium&#8211;phosphorus product levels below 55<span class="elsevierStyleHsp" style=""></span>mg&#47;dl are the objective&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In wound management&#44; debridement of necrotic tissue&#44; antibiotics&#44; analgesia&#44; and vacuum dressing are important&#46; Hyperbaric oxygen therapy stimulates angiogenesis and is toxic to anaerobic bacteria&#46; It is used in daily sessions for 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min per week with 100&#37; oxygen at 2&#46;5 atmospheres of pressure&#46; Ulcer debridement is coated with partial autologous skin grafts&#46; Successful attempts have been made to coat ulcers with cultured autologous fibroblasts and keratinocytes by adding iloprost infusion &#40;vasodilator prostacyclin analogue&#41; for 35 consecutive days&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Porphyria cutanea tarda</span><p id="par0220" class="elsevierStylePara elsevierViewall">Porphyria cutanea tarda &#40;PCT&#41; occurs in 1&#46;2&#8211;18&#37; of patients with CKD and is more frequently observed in patients on haemodialysis&#46; It is a bullous dermatosis caused by phototoxicity due to uroporphyrinogen decarboxylase deficiency&#44; thus causing elevated levels of uroporphyrin and isocoproporphyrin&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">PCT is classified as Type 1 when it is sporadic and acquired&#44; and is caused by a liver enzyme deficiency&#46; It is associated with hepatitis B and C&#44; HIV-AIDS&#44; alcohol consumption&#44; oestrogen and iron&#46; Type 2 is a hereditary&#44; autosomal dominant disease caused by enzyme deficiency in all tissues&#46; A defect in heme biosynthesis is due to uroporphyrinogen decarboxylase deficiency&#46; It requires less than 30&#37; activity of the enzyme to induce clinical manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> In CKD&#44; low levels of uroporphyrins are excreted and accumulate&#44; causing phototoxicity reactions&#46; Uroporphyrins cannot be removed by haemodialysis&#44; but high-flux membranes improve elimination&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Clinical manifestations include blisters&#44; erosions and crusts that are located on exposed areas&#44; such as the back of hands and forearms and occasionally the face and feet &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; These lesions heal with scarring or milia and may be accompanied by hypertrichosis and hyperpigmentation of the face and by esclerodermoid plaques on the hands and face&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Laboratory findings include increased serum iron and ferritin&#44; high urine levels of uroporphyrins I and III&#44; and 7&#8211;8-carboxyl uroporphyrins&#44; high plasma levels of uroporphyrin and increased levels of isocoproporphyrin III in the faeces&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Histopathology reveals a subepidermal cleft with minimal inflammation and festooned papillary dermis in the base of the cleft&#46; The vessel wall is thickened&#46; Direct immunofluorescence staining indicates linear and granular deposition of immunoglobulin G and C3 in the dermal-epidermal junction and around the vessels&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">For the treatment of PCT&#44; sun exposure should be avoided&#59; the use of zinc oxide and titanium oxide-based sunscreen is recommended&#46; Treatment of comorbidities and to avoid exacerbating factors &#40;iron and alcohol consumption&#44; and estrogen using&#41; are also important&#46; Furthermore&#44; it is important to use high-flux membranes &#40;polysulfone&#41; with high-flux dialysis &#40;300<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;&#44; during 4<span class="elsevierStyleHsp" style=""></span>h of haemodialysis&#44; three times a week&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Reduce body stores of iron in body stores of iron&#46; Iron induces the enzyme 5-aminolevulinate synthase&#44; which suppresses uroporphyrinogen decarboxylase&#46; Further&#44; it increases conversion of uroporphyrinogen into porphyrins&#46; Phlebotomy is used at a low volume of 100<span class="elsevierStyleHsp" style=""></span>ml&#44; twice weekly for 8 months&#44; followed by 50<span class="elsevierStyleHsp" style=""></span>ml per week thereafter&#59; normal phlebotomy is not tolerated due to anaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Erythropoietin &#40;20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#41; is administered thrice weekly&#46; When erythropoietin is combined with phlebotomy&#44; a dose of 150&#8211;200<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#44; three times per week is used&#46; Deferoxamine &#40;2<span class="elsevierStyleHsp" style=""></span>g&#41; is administered intravenously every haemodialysis session and is associated with long-term adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In refractory cases&#44; two plasma exchange treatments&#44; separated by 48<span class="elsevierStyleHsp" style=""></span>h&#44; are applied&#46; Renal transplantation is the definitive treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pseudoporphyria</span><p id="par0255" class="elsevierStylePara elsevierViewall">Pseudoporphyria is a bullous dermatosis induced by phototoxicity that exhibits the clinical and histopathologic features of PCT&#59; however&#44; normal uroporphyrin levels are observed&#46; The condition is associated with the use of phototoxic drugs such as tetracycline&#44; furosemide&#44; naproxen&#44; amiodarone&#44; nalidixic acid and isotretinoin&#44; and exposure to ultraviolet light A&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Regarding pathogenesis&#44; phototoxic metabolites are formed&#46; Patients with CKD have decreased glutathione levels in erythrocytes&#44; making them susceptible to damage by free radicals&#46; N acetyl-cysteine&#44; a precursor of glutathione with antioxidant properties&#44; is used to effectively treat these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Clinical manifestations include blisters on the back of the hands&#44; forearms and other exposed areas that resolve with scarring and milia&#46; Hypertrichosis on the face or sclerodermoid plaques is rarely observed&#46; Uroporphyrin levels in plasma or urine are normal or slightly elevated&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Histopathology reveals a subepidermal cleft with minimal inflammation and a thick vessel wall&#46; Direct immunofluorescence staining indicates immunoglobulin G and C3 deposition at the dermal-epidermal junction and around vessels&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">N-acetyl-cysteine&#44; a precursor of glutathione with antioxidant properties&#44; has been effective therapy in several case reports&#46; An oral dose of 600&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day offers relief in 4-8 of weeks&#46; Recurrence has been reported after discontinuing medication&#46; It is recommendable to avoid exacerbating factors such as sun exposure&#44; trauma and related drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Benign nodular calcification</span><p id="par0280" class="elsevierStylePara elsevierViewall">Firm papules&#44; plaques and nodules appear in the joints and fingertips due to metastatic calcification affecting skin&#46; Von Kossa stains calcium deposits black&#46; Treatment is based on reducing calcium&#8211;phosphorus products and surgical removal&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Xerosis</span><p id="par0285" class="elsevierStylePara elsevierViewall">Xerosis is the most common skin manifestation of CKD&#44; occurring in 80&#37; of patients&#46; Etiopathogenic mechanisms include&#58; Decreased hydration of the stratum corneum&#59; decreased sweat gland and sebaceous gland size along with abnormal function related to hypervitaminosis A in dialysis patients&#44; and the use of diuretics&#46; Treatment is based on skin hydration and treatment of pruritus&#46; Repetitive bathing must be avoided and the use of soft&#44; neutral soaps is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pigmentary changes</span><p id="par0290" class="elsevierStylePara elsevierViewall">Dark brown pigmentation is caused by increased melanin production due to &#946;-melanocyte stimulating hormone accumulation&#44; which is caused by decreased excretion due to kidney failure&#46; The yellowish tinge is caused by the accumulation of carotenoids and urochrome in the skin&#46; Pallor is caused by anaemia due to ineffective erythropoiesis and increased haemolysis&#46; Treatment is based on avoiding sun exposure and involves sunscreen use for hyperpigmentation as well as erythropoietin for anaemia associated with pallor&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Skin infections</span><p id="par0295" class="elsevierStylePara elsevierViewall">Skin infections are caused by impaired cellular and humoural immunity&#46; They are more common when diabetic nephropathy is the origin&#46; The most common fungal infection is onychomycosis&#46; The most frequent viral infections are common warts&#44; herpes simplex and herpes zoster&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Uremic frost</span><p id="par0300" class="elsevierStylePara elsevierViewall">Uremic frost is currently a rare manifestation&#46; However when observed&#44; the condition is often accompanied with increased BUN&#44; ranging from 250 to 300<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; It is caused by the accumulation of urea in sweat&#46; When the sweat evaporates&#44; a crystal deposit remains on the skin that appears as a yellowish-white coating on the beard area&#44; neck and trunk&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Nail disorders</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mees lines&#46;</span> These transverse bands of leukonychia are an alteration of the nail plate that occurs during periods of stress&#46; In addition to its association with CKD&#44; this condition appears in cases of poisoning by arsenic&#44; thallium&#44; and fluorine as well as severe infections&#44; heart disease and malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Muehrcke&#39;s lines&#46;</span> Double white transverse lines are caused by hypoalbuminemia related to nephrotic syndrome&#59; Muehrcke lines are associated with serum albumin levels less than 2&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; It originates by vascular compression through local oedema&#44; which causes bleaching of the nail bed&#46; Therefore&#44; no change in position occurs as the nail grows&#46; It has also been observed in cases of cirrhosis&#44; malnutrition and chemotherapy use&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Lindsay nails &#40;half and half&#41;&#46;</span> This condition is related to azotaemia&#46; A white proximal area and a distal pink red-brown area that does not fade under pressure are observed &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; No changes are noted with nail growth because the lesion is located in the nail bed&#46; An increase in the number of capillaries in the distal nail plate and a deposit of melanin pigmentation in the distal area are observed&#46; This condition resolves with renal transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0320" class="elsevierStylePara elsevierViewall">Other nail changes observed include leukonychia&#44; koilonychia and splinter haemorrhages&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hair disorders</span><p id="par0325" class="elsevierStylePara elsevierViewall">Diffuse alopecia&#44; the most common manifestation&#44; is caused by telogen effluvium&#59; xerosis&#44; pruritus and medication use &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Sparse body hair is also present&#46; Discoloration and dryness of the hair are attributed to a decreased sebum production&#46; Treatment for hair loss is based on meeting nutritional requirements&#44; which are increased in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mucosal alterations</span><p id="par0330" class="elsevierStylePara elsevierViewall">Xerostomia is the most common abnormality and is caused by oral breathing and dehydration&#46; Macroglossia is also often observed &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Ulcerative stomatitis is observed with urea serum levels greater 150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and is associated with poor hygiene&#46; Uraemic breath is due to increased urea concentrations in saliva and its transformation into ammonium&#46; The condition is associated with urea levels &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Treatment is based on maintaining good oral hygiene and meeting nutritional requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0335" class="elsevierStylePara elsevierViewall">Skin manifestations are very common in end-stage CKD&#46; Severe renal pruritus is associated with increased mortality and a poor prognosis&#46; Nephrogenic systemic fibrosis is a relatively new preventable disease associated with gadolinium&#46; In a simple exploration of the nails&#44; some findings indicate alterations in albumin and urea levels&#46; Comorbidities such as diabetes mellitus and secondary hyperparathyroidism can lead to acquired perforating dermatosis and calciphylaxis&#44; respectively&#46; Effective and innovative treatments are available for all of these conditions&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical responsibilities</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Renal pruritus"
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          "titulo" => "Acquired perforating dermatosis &#40;APD&#41;"
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          "titulo" => "Nephrogenic systemic fibrosis &#40;NSF&#41;"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin manifestations associated with chronic kidney disease are very common&#46; Most of these conditions present in the end stages and may affect the patient&#39;s quality of life&#46; Knowledge of these entities can contribute to establishing an accurate diagnosis and prognosis&#46; Severe renal pruritus is associated with increased mortality and a poor prognosis&#46; Nail exploration can provide clues about albumin and urea levels&#46; Nephrogenic systemic fibrosis is a preventable disease associated with gadolinium contrast&#46; Comorbidities&#44; such as diabetes mellitus and secondary hyperparathyroidism&#44; can lead to acquired perforating dermatosis and calciphylaxis&#44; respectively&#46; Effective and innovative treatments are available for all of these conditions&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las manifestaciones cut&#225;neas asociadas a enfermedad renal cr&#243;nica son muy comunes&#46; La mayor&#237;a de estas enfermedades se presentan en la etapa terminal y pueden afectar la calidad de vida del paciente&#46; El conocimiento de estas condiciones puede ser &#250;til para establecer un diagn&#243;stico y pron&#243;stico preciso&#46; El prurito renal severo est&#225; asociado a un incremento en la mortalidad y a un pobre pron&#243;stico&#46; La exploraci&#243;n ungueal puede proveer datos acerca del nivel plasm&#225;tico de albumina y urea&#46; La fibrosis sist&#233;mica nefrog&#233;nica es una enfermedad prevenible asociada a contrastes con gadolinio&#46; Comorbilidades como la diabetes mellitus y el hiperparatiroidismo secundario&#44; pueden causar dermatosis perforante adquirida y calcifilaxis&#44; respectivamente&#46; Existen tratamientos efectivos e innovadores para todos estos padecimientos&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classic specific disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nonspecific disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Xerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acquired perforating dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pigmentary changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#8211;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nephrogenic systemic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calciphylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uremic frost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Porphyria cutanea tarda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nail disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pseudoporphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hair disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucosal alterations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Classification of skin manifestations of chronic kidney disease and prevalence&#46;</p>"
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      9 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">MRI&#58; magnetic resonance imaging&#44; CKD&#58; chronic kidney disease&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathogenesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histopathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Differential diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemodialysis&#44; high levels of uraemic nitrogen&#44; calcium and phosphorus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic inflammatory stateC fibres stimulation via opioids&#44; serotonin&#44; histamine and prostaglandinsAbnormal innervation patterns&#44; nerve damage and central sensitisationGenetic predisposition&#44; HLA B35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Localised or generalised pruritus&#44; with the back being the most common affected sitePruritus is often prolonged and severe and is exacerbated by heat&#44; sweating and xerosis&#46; Excoriations&#44; lichen simplex&#44; nodular prurigo result from scratching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biopsy is usually not required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other local or systemic disorders that cause pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acquired perforating dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diabetes mellitus and hemodialysisHypothyroidism&#44; liver disease&#44; malignancies and HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transepidermal elimination of dermal componentsTrigger factors include minor trauma&#44; microvascular changes and skin calcium depositionsGenetic predisposition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pigmented and umbilicated dome shaped papules with a depressed and scaling centre&#44; located in the extensor surfaces of the arms and legs&#44; and less commonly&#44; in the scalp&#44; trunk and buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acanthosis&#44; cup shaped plugs composed of keratin&#44; collagen and cell detritus that move from the epidermis to the exterior&#44; and a perilesional inflammatory infiltrate composed of lymphocytes and neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prurigo nodularis and lichen planus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nephrogenic systemic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gadolinium use as contrast medium in MRI angiographyGadodiamide and gadopentetate are the most associated contrast media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Genetic predisposition &#40;HLA A2&#41; and an inflammatory state&#44; allow gadolinium effectively enters the tissuesGadolinium is subsequently phagocytosed by macrophages&#44; which release cytokines that attract circulating fibrocytes to the tissues&#44; then the fibrocytes differentiate into fibroblast-like cells in the dermis leading to fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Indurated&#44; erythematous-hyperchromic plaques with an orange peel&#44; woody appearance&#46; The lesions are bilateral and symmetrical on the legs and forearmsFlexion contractures of adjacent limbs5&#37; of patients experience a rapid fulminant course in 2 weeks with multiple organ involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thickened collagen bundles with clefts&#44; mucin deposition and proliferation of spindled cells that stain positive for CD34 and procollagen 1&#46; Multinucleated cells positive for CD68 and factor VIII are also present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scleromyxedema&#44; systemic sclerosis&#44; eosinophilia-myalgia syndrome&#44; toxic oil syndrome and eosinophilic fasciitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calciphylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Secondary hyperparathyroidism and elevated calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased calcium&#8211;phosphorus productImbalance between inhibitors and inducers of vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Painful&#44; pink or purple&#44; firm nodules or plaques&#44; surrounded by livedo reticularis that progress to central and deep painful ulcers covered with black eschar&#46; Calciphylaxis is bilateral and symmetrical and affects thighs&#44; abdomen and buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcification of the media&#44; intimal hyperplasia of dermal and subcutaneous arterioles&#44; thrombosis of dermal and subcutaneous vessels with ischaemic necrosis in the epidermis and lobular panniculitis with fat necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic vasculitis&#44; coagulopathies&#44; occlusive vasculopathies and bacterial and fungal infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Porphyria cutanea tarda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HemodialysisType 1&#58; hepatitis B and C&#44; HIV-AIDS&#44; alcohol&#44; oestrogen and ironType 2 is a hereditary&#44; autosomal dominant disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A defect in heme biosynthesis due to uroporphyrinogen decarboxylase deficiencyIn CKD&#44; low levels of uroporphyrins are excreted&#59; their accumulation in skin causes phototoxicity reactions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blisters&#44; erosions and crusts that are located on exposed areas&#44; such as the back of hands and forearms and occasionally the face and feet&#46; These lesions heal with scarring or milia and may be accompanied of hypertrichosis and hyperpigmentation and esclerodermoid plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subepidermal cleft with minimal inflammation and festooned papillary dermis&#46; Direct immune-fluorescence indicates linear and granular deposition of immunoglobulin G and C3 in the dermal-epidermal junction and around the vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pseudoporphyria&#44; other hereditary porphyrias drug-related phototoxic reactions&#44; epidermolysis bullosa acquisita&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pseudo-porphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototoxic drugs&#44; such as tetracycline&#44; furosemide&#44; naproxen&#44; amiodarone&#44; nalidixic acid and isotretinoin&#44; and exposure to ultraviolet light A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototoxic metabolites are formed&#46; Patients with CKD have decreased glutathione levels in erythrocytes&#44; making them susceptible to damage by free radicals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blisters on the back of hands&#44; forearms and other exposed areas that resolve with scarring and milia&#46; Hypertrichosis on the face or sclerodermoid plaques are rarely observed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subepidermal cleft with minimal inflammation&#46; Direct immunofluorescence staining indicates immunoglobulin G and C3 deposition at the dermal-epidermal junction and around vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hereditary porphyrias&#44; drug-related phototoxic reactions&#44; epidermolysis bullosa acquisita&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summary of classic specific disorders&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment option&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Action mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="11" align="left" valign="top">Renal pruritus</td><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing efficiency <span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span> urea<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;4&#44; using low calcium and magnesium dialysates and using more biocompatible membranes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reduce calcium&#8211;phosphorus products&#46; Membranes of polymethylmethacrylate absorb and eliminate cytokines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythropoietin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg is administered thrice weekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decreasing histamine levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Moisturiser &#40;gamma linoleic acid&#44; glycerol and paraffin&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three times a day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevent xerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Capsaicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;025&#37; cream four times daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depletes P substance from C fibres&#44; thus blocking pain and pruritus transmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pramoxine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Twice daily for 1 month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical anaesthetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gabapentin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">300<span class="elsevierStyleHsp" style=""></span>mg after each hemodialysis session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GABA agonist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Granisetron&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg twice daily for 1 month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Serotonin inhibitor 5 HT3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nalfurafine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#956;g thrice weekly by intravenous infusion&#44; immediately after each hemodialysis for 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opioid agonist&#46; Inhibit C fibres by &#954; receptor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Narrowband UVB phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three sessions per week&#46; Initial dose of 200<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#44; increasing 100<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> at every session&#44; until a maximum dose of 1500<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease the production of cytokines by lymphocytes and phosphorus levels in the skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Parathyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Effective in cases with secondary hyperparathyroidism and high calcium-phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased glomerular filtration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Acquired perforating dermatosis</td><td class="td" title="table-entry  " align="left" valign="top">Steroids &#40;topical&#44; oral or intralesional&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Keratolytics and retinoids &#40;topical or oral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease epidermal thickness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Allopurinol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mg daily for 1&#8211;4 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Xanthine-oxidase inhibitor&#46; It acts by an antioxidant action&#44; thus decreasing free radicals involved in collagen damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Maxacalcitol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Twice daily for 2 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D vitamin analogue&#46; Mechanism of action remains unclear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Narrowband UVB phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It begins at 400<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> until a therapeutic range of 700&#8211;1600<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> is achieved&#46; Three sessions per week&#46; After improvement is achieved&#44; 1&#8211;2 sessions a week for maintenance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anti-proliferative and anti-inflammatory effects&#59; relief of pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Photodynamic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single session with 5-aminolevulinic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Production of reactive oxygen species with cell apoptosis and necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="8" align="left" valign="top">Nephrogenic Systemic Fibrosis</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gadoteridol is the safest option&#46; In hemodialysis patients&#44; two 4-h sessions should be performed in the first 3<span class="elsevierStyleHsp" style=""></span>h to remove the contrast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Extracorporeal photopheresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two treatments on consecutive days every 2 weeks for 6 months&#44; then two treatments on consecutive days every 4 weeks for 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enhances the suppression of signals by inducing lymphocytes apoptosis and deflecting the signal of antigen-presenting cells&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased glomerular filtration and immunosuppression in transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Imatinib mesylate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">400&#8211;600<span class="elsevierStyleHsp" style=""></span>mg&#47;day are administered&#44; for 4&#8211;24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tyrosine kinase inhibitor&#44; acts by inhibiting platelet-derived growth factor and c-Abl kinase&#44; thus inhibiting the synthesis of collagen and fibronectin by dermal fibroblasts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">UV-A 1 phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three sessions per week&#44; at 60&#8211;120<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> in 22&#8211;50 sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alters the cytokine levels relating to fibrocytes to promote a less fibrotic environment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Physical therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improves the performance of daily activities and personal care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Plasmapheresis&#44; immunoglobulin G and photodynamic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anecdotal success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="12" align="left" valign="top">Calciphylaxis</td><td class="td" title="table-entry  " align="left" valign="top">Total or subtotal surgical parathyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reducing the production of parathyroid hormone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cinacalcet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;60<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcium mimetic that increases sensitivity of the calcium receptor in the parathyroid gland&#44; thus reducing the production of parathyroid hormone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Etindronate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally for 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inhibit vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pamidronate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>mg intravenously for five treatments over a period of 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inhibit vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;50<span class="elsevierStyleHsp" style=""></span>mg orally every 24<span class="elsevierStyleHsp" style=""></span>h&#44; for 3&#8211;5 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sodium thiosulfate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>g is administered intravenously for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; three times a week after each hemodialysis session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Displacing calcium from calcium phosphate&#44; to form calcium thiosulfate&#44; which is more soluble&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing the frequency and duration of hemodialysis through the use of low calcium dialysate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reduce calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sevelamer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phosphorus chelator that reduces the intestinal absorption of phosphorus&#46; Reduce calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">General wound management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Debridement of necrotic tissue&#44; antibiotics&#44; analgesia&#44; cures and vacuum dressing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To prevent infection and sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hyperbaric oxygen therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Daily sessions for 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min per week with 100&#37; oxygen at 2&#46;5 atmospheres of pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stimulates angiogenesis and is toxic to anaerobic bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cultured autologous fibroblasts and keratinocytes&#44; adding iloprost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35 consecutive days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To coat ulcers&#46; Iloprost is a vasodilator prostacyclin analogue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ulcer debridement&#44; coated with partial autologous skin grafts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To prevent infection and sepsis&#44; and to coat ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Porphyria cutanea tarda</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid sun exposure&#44; use zinc oxide and titanium oxide-based sunscreen&#44; avoid alcohol&#44; estrogens&#44; iron and treat comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoiding exacerbating factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To use high-flux membranes &#40;polysulfone&#41; with high flux dialysis &#40;300<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;&#44; during 4<span class="elsevierStyleHsp" style=""></span>h of hemodialysis&#44; three times a week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Removing high plasma levels of uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Phlebotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low volume of 100<span class="elsevierStyleHsp" style=""></span>ml&#44; twice weekly for 8 months&#44; followed by 50<span class="elsevierStyleHsp" style=""></span>ml per week thereafter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease in body stores of iron&#46; Activating uroporphyrinogen decarboxylase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythropoietin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg is administered thrice weekly&#46; When erythropoietin is combined with phlebotomy&#44; a dose of 150&#8211;200<span class="elsevierStyleHsp" style=""></span>U&#47;kg is used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease in body stores of iron&#46; Activating uroporphyrinogen decarboxylase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Deferoxamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>g is administered intravenously every hemodialysis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chelating agent used to remove iron&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Plasmapheresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two sessions&#44; separated by 48<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Removing high plasma levels of uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing glomerular filtration&#44; thus excreting uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Pseudo-porphyria</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid sun exposure&#44; trauma and related drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoiding exacerbating factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">N-acetyl-cysteine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally for weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Precursor of glutathione with antioxidant properties&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Treatment of classic specific disorders associated to chronic kidney disease&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
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Review
Skin manifestations of chronic kidney disease
Manifestaciones Cutáneas de la Enfermedad Renal Crónica Skin manifestations of Chronic Kidney Disease
J.C. Robles-Mendez, O. Vazquez-Martinez, J. Ocampo-Candiani
Autor para correspondencia
Jocampo2000@yahoo.com.mx

Corresponding author.
Dermatology Department, University Hospital “José Eleuterio González”, Autonomous University of Nuevo León, Monterrey, Mexico
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effective and innovative treatments are available for these conditions &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">By definition&#44; CKD comprises a structural renal injury &#40;which may be evident in urine&#44; blood&#44; imaging studies or tissue biopsies&#41; or a functional impairment &#40;manifested as a decreased glomerular filtration rate of less than 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41; over a period of 3 months&#46; Most skin manifestations of renal impairment occur in patients with end-stage CKD &#40;stage 5&#41; with a glomerular filtration rate less than 15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Renal pruritus</span><p id="par0020" class="elsevierStylePara elsevierViewall">Renal pruritus is observed in 50&#8211;90&#37; 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have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Renal pruritus is considered to be a manifestation of a chronic inflammatory state&#44; which involves cytokines such as TNF&#44; IFN-&#947;&#44; and IL2 and acute phase reactants such as C-reactive protein&#46; Pruritus is transmitted by C fibres&#46; Opioids stimulate C fibres through &#956; receptors and inhibit C fibres through &#954; receptors&#46; C fibre stimulation via serotonin&#44; histamine and prostaglandins might also play an important role&#46; Abnormal innervation patterns&#44; nerve damage and central sensitisation are additional proposed mechanisms&#46; A genetic predisposition particularly associated with HLA B35 has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical manifestations include localised or generalised pruritus&#44; 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increasing efficiency <span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span> urea<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;4 &#40;<span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>dialysis adequacy&#46; <span class="elsevierStyleItalic">K</span>&#44; clearance&#46; <span class="elsevierStyleItalic">t</span>&#44; time&#46; <span class="elsevierStyleItalic">V</span>&#44; volume of distribution&#41; using low calcium and magnesium dialysates&#44; reducing calcium&#8211;phosphorus products and using more biocompatible membranes&#44; such as those made of polymethylmethacrylate&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Erythropoietin efficiently relieves itching by decreasing histamine levels&#46; Its effect is not associated with haemoglobin levels and it is lost when administration is discontinued&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is important to avoid xerosis&#44; sweating and heat&#46; Moisturisers constitute the first line of therapy&#44; especially those containing gamma linoleic acid&#44; glycerol and paraffin&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The addition of endocannabinoids to moisturisers has been proven effective&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Topical treatment is preferred for localised pruritus&#46; Studies have reported the efficacy of capsaicin and pramoxine&#46; Capsaicin depletes P substance from C fibres&#44; thus blocking pain and pruritus transmission&#59; it is used as 0&#46;025&#37; cream four times daily&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Pramoxine lotion&#44; a topical anaesthetic&#44; used twice daily for 1 month has been proven effective&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The use of calcineurin inhibitors is controversial and is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Systemic treatment with gabapentin&#44; a GABA agonist&#44; is effective and safe&#46; Due to its renal clearance&#44; gabapentin is administered at low doses of 300<span class="elsevierStyleHsp" style=""></span>mg after each haemodialysis session&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> The serotonin inhibitor 5 HT3 granisetron &#40;1<span class="elsevierStyleHsp" style=""></span>mg twice daily for 1 month&#41; is also effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> The opioid agonist nalfurafine has proven to be effective&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Phototherapy with narrowband UVB has been used to decrease the production of cytokines by lymphocytes and to reduce phosphorus levels in the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Among surgical treatments&#44; parathyroidectomy can be effective in cases with secondary hyperparathyroidism and high calcium&#8211;phosphorus products&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> However&#44; kidney transplantation is the definitive treatment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Acquired perforating dermatosis &#40;APD&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">APD is commonly observed in patients with end-stage CKD&#44; especially in individuals with diabetes mellitus and individuals receiving haemodialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The pathogenesis of APD is unclear&#46; APD is associated with diabetes mellitus&#44; hypothyroidism&#44; liver disease&#44; malignancies and HIV infection&#46; The mechanism involves transepidermal elimination of dermal components &#40;collagen&#44; elastin and cell detritus&#41;&#46; Proposed trigger factors include minor trauma&#44; such as scratching&#44; microvascular changes associated with diabetes mellitus&#44; skin calcium depositions with foreign body inflammatory response and genetic predisposition&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;26</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Clinical manifestations include pigmented and umbilicated dome shaped papules with a depressed and scaling centre&#44; located on the extensor surfaces of the arms and legs and less commonly&#44; on the scalp&#44; trunk and buttocks &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Koebner phenomenon may be present&#46; This condition appears in outbreaks and typically resolves in 6&#8211;8 weeks with residual pigmentation and scarring&#46; Differential diagnoses include prurigo nodularis and lichen planus&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Histopathology findings include an excavated epidermis&#44; acanthosis&#44; cup shaped plugs composed of keratin&#44; collagen and cell detritus that move from the epidermis to the exterior&#44; and a perilesional inflammatory infiltrate composed of lymphocytes and neutrophils&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Steroids &#40;topical&#44; oral or intralesional&#41; are used to decrease inflammation and keratolytics and retinoids &#40;topical or oral&#41; are used to decrease epidermal thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Allopurinol&#44; a xanthine-oxidase inhibitor&#44; is used at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg daily for 1&#8211;4 months&#59; it has been proven effective in a series of cases&#46; Allopurinol is thought to have antioxidant activity&#44; thus decreasing free radicals involved in collagen damage&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Maxacalcitol &#40;0&#46;0025&#37; ointment&#41;&#44; a D vitamin analogue&#44; was reported successful in four treated cases&#46; It is applied twice daily for 2 months&#46; Its mechanism of action remains unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">UVB narrowband phototherapy has been used with success in a series of cases&#46; Benefits are noted in 10&#8211;15 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Photodynamic therapy has also been reported to be effective&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nephrogenic systemic fibrosis &#40;NSF&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Formerly called nephrogenic fibrosing dermopathy&#44; 380 cases of this rare disease have been registered at Yale University&#44; and the first cases were recorded in 1997&#46; No differences in gender and ethnicity were noted&#46; NFS occurs in all ages&#44; but predominantly in middle age&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Ninety-five percent of the cases are associated with gadolinium&#44; a contrast medium&#44; which is used in MRI angiography in patients with low glomerular filtration rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Gadodiamide and gadopentetate are the most common causes of contrast media associated with NSF&#46; The poorer the glomerular filtration rate&#44; the longer the half-life of gadolinium&#46; In addition&#44; 73&#46;8&#37; and 92&#46;4&#37; of gadolinium is excreted in a single haemodialysis session or two sessions&#44; respectively&#44; but gadolinium is not properly excreted in peritoneal dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In patients with a genetic predisposition &#40;HLA A2&#41; or an inflammatory state&#44; a hypercoagulable state or endothelial damage&#44; gadolinium enters the tissues&#44; 35&#8211;150-fold more effectively compared with healthy patients&#46; Gadolinium is subsequently phagocytosed by macrophages&#44; which release cytokines that attract circulating fibrocytes &#40;CD34&#47;procollagen I&#43;&#41; to the tissues&#46; Once in the tissue&#44; the fibrocytes differentiate into fibroblast-like cells in the dermis&#44; leading to fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Clinical manifestations include indurated&#44; erythematous-hyperchromic plaques with an orange peel&#44; woody or cobblestone appearance&#46; Nodules and bullae may be present on the hands and feet&#44; or yellowish edematous plaques are noted on the sclera &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The lesions are bilateral and symmetrical on the legs and forearms&#46; The condition is occasionally observed on the trunk and buttocks and generally spares the face&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">A burning&#44; itching&#44; and stinging pain occurs&#46; Flexion contractures of adjacent limbs are noted&#44; days to weeks after exposure to the contrast&#44; and the condition tends to be chronic&#46; Remission is achieved in a few cases&#44; leaving atrophic and hypopigmented lesions&#59; 5&#37; of patients experience a rapid fulminant course in 2 weeks with multiple organ involvement &#40;lungs&#44; heart and oesophagus&#41;&#46; Differential diagnoses include scleromyxedema&#44; systemic sclerosis&#44; eosinophilia-myalgia syndrome&#44; toxic oil syndrome and eosinophilic fasciitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The histopathology is characterised by thickened collagen bundles with clefts&#44; mucin deposition and proliferation of spindled cells that stain positive for CD34 and procollagen 1&#46; Multinucleated cells positive for CD68 and factor VIII are also present&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;24&#44;32</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">For prevention&#44; if a macrocyclic contrast medium must be used&#44; gadoteridol is the safest option&#46; In haemodialysis patients&#44; two 4-h sessions are required to remove the contrast&#59; these sessions should be performed in the first 3<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Most treatments demonstrate efficacy in anecdotal and cases reports&#46; Steroids and immunosuppressants are generally ineffective&#46; Oral prednisone may be used with some efficacy&#44; but many adverse effects are observed&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Extracorporeal photopheresis is available in a few centres&#44; but is prohibitively expensive&#46; It has been proven to be effective in all patients&#44; increasing softening of injuries and mobility ranges&#46; Extracorporeal photopheresis enhances the suppression of signals by inducing lymphocyte apoptosis and deflecting the signal of antigen-presenting cells&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Kidney transplantation offers improvement in 54&#37; of patients and full remission has been achieved in some cases&#46; It improves mobility ranges of flexion contracture&#44; likely due to increased glomerular filtration and immunosuppression after transplantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Imatinib mesylate&#44; a tyrosine kinase inhibitor&#44; acts by inhibiting platelet-derived growth factor and c-Abl kinase&#44; thus inhibiting the synthesis of collagen and fibronectin by dermal fibroblasts&#46; Doses of 400&#8211;600<span class="elsevierStyleHsp" style=""></span>mg&#47;day are administered for 4&#8211;24 weeks&#44; achieving mild to moderate success&#46; The lesions are softened&#44; but little improvement is noted in the range of motion&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">UV-A 1 phototherapy has been proven effective in smoothing skin lesions&#44; with little improvement in range of motion&#46; It is used at 60&#8211;120<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> in 22&#8211;50 sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Plasmapheresis and immunoglobulin G exhibit anecdotal success&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Physical therapy improves the performance of daily activities and personal care&#44; with little improvement in the range of motion&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In a case report&#44; photodynamic therapy was effective along with kidney transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Calciphylaxis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Calciphylaxis occurs in patients with CKD on hemodialysis&#59; it is associated with secondary hyperparathyroidism and elevated calcium-phosphorus products&#46; Calciphylaxis is an obliterative vasculopathy caused by the deposition of calcium in the arterioles of the skin&#44; leading to thrombosis and ischaemic necrosis with ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Calciphylaxis is commonly observed in women&#44; in patients with diabetes mellitus&#44; obesity&#44; hypoalbuminemia&#44; liver cirrhosis&#44; those who use warfarin&#44; and those with systemic inflammation and malignancy&#46; Sepsis can cause up to 80&#37; mortality via skin ulcer infection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Its ethiopathogenic mechanism is unclear&#46; Predisposition plus a causal factor are necessary&#46; Calcium&#8211;phosphorus products are increased in the majority of patients&#44; but this increase is not sufficient alone to cause the condition&#46; An imbalance between inhibitors and inducers of vascular calcification is noted&#46; Osteopontin and bone morphogenic protein 2 serve as inducers&#44; whereas GI protein matrix&#44; fetuin and pyrophosphate act as inhibitors&#46; Aluminium deposition may also be an inductor&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Clinical manifestations include painful&#44; pink or purple&#44; firm nodules or plaques&#44; surrounded by livedo reticularis that progress to central and deep&#44; painful ulcers covered with black eschar and a reticulated depigmentation in the periphery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Calciphylaxis is bilateral and symmetrical and affects adipose tissue areas&#44; such as the thighs&#44; abdomen and buttocks&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Histopathologic findings include calcification of the media&#44; intimal hyperplasia of dermal and subcutaneous arterioles&#44; thrombosis of dermal and subcutaneous vessels with ischaemic necrosis in the epidermis and lobular panniculitis with fat necrosis&#46; On radiography&#44; linear calcium deposits are observed&#46; The involvement of small blood vessels &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41; is the most specific sign&#59; however&#44; many patients exhibit vascular calcification without calciphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">For therapy&#44; early total or subtotal surgical parathyroidectomy increases survival&#46; Cinacalcet is a calcium mimetic that increases sensitivity of the calcium receptor in the parathyroid gland&#44; thus reducing the production of parathyroid hormone&#46; Cinacalcet is used in cases where parathyroidectomy is delayed or contraindicated&#46; Treatment is discontinued once PTH reaches a normal level of 1&#46;5 to prevent renal osteodystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Among bisphosphonates&#44; etindronate and pamidronate have proven to be effective&#46; Prednisone is used in early unulcerated plaques&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Sodium thiosulfate is administered either orally daily or intravenously at the end of haemodialysis for 3&#8211;5 months&#46; Sodium thiosulfate offers symptomatic and radiological relief of tissue calcification&#44; displacing calcium from calcium phosphate&#44; to form calcium thiosulfate&#44; which is more soluble than other salts and is excreted either by haemodialysis or by the kidneys&#46; Sodium thiosulfate &#40;25<span class="elsevierStyleHsp" style=""></span>g&#41; is administered intravenously for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; three times a week after each haemodialysis session&#46; Metabolic acidosis is an important side effect of this drug&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Dialysis improves this condition through using low calcium dialysate and increasing the frecuency and duration of hemodialysis sessions&#46; Sevelamer is a phosphorus chelator that reduces the intestinal absorption of phosphorus&#46; Calcium&#8211;phosphorus product levels below 55<span class="elsevierStyleHsp" style=""></span>mg&#47;dl are the objective&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In wound management&#44; debridement of necrotic tissue&#44; antibiotics&#44; analgesia&#44; and vacuum dressing are important&#46; Hyperbaric oxygen therapy stimulates angiogenesis and is toxic to anaerobic bacteria&#46; It is used in daily sessions for 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min per week with 100&#37; oxygen at 2&#46;5 atmospheres of pressure&#46; Ulcer debridement is coated with partial autologous skin grafts&#46; Successful attempts have been made to coat ulcers with cultured autologous fibroblasts and keratinocytes by adding iloprost infusion &#40;vasodilator prostacyclin analogue&#41; for 35 consecutive days&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Porphyria cutanea tarda</span><p id="par0220" class="elsevierStylePara elsevierViewall">Porphyria cutanea tarda &#40;PCT&#41; occurs in 1&#46;2&#8211;18&#37; of patients with CKD and is more frequently observed in patients on haemodialysis&#46; It is a bullous dermatosis caused by phototoxicity due to uroporphyrinogen decarboxylase deficiency&#44; thus causing elevated levels of uroporphyrin and isocoproporphyrin&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">PCT is classified as Type 1 when it is sporadic and acquired&#44; and is caused by a liver enzyme deficiency&#46; It is associated with hepatitis B and C&#44; HIV-AIDS&#44; alcohol consumption&#44; oestrogen and iron&#46; Type 2 is a hereditary&#44; autosomal dominant disease caused by enzyme deficiency in all tissues&#46; A defect in heme biosynthesis is due to uroporphyrinogen decarboxylase deficiency&#46; It requires less than 30&#37; activity of the enzyme to induce clinical manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> In CKD&#44; low levels of uroporphyrins are excreted and accumulate&#44; causing phototoxicity reactions&#46; Uroporphyrins cannot be removed by haemodialysis&#44; but high-flux membranes improve elimination&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Clinical manifestations include blisters&#44; erosions and crusts that are located on exposed areas&#44; such as the back of hands and forearms and occasionally the face and feet &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; These lesions heal with scarring or milia and may be accompanied by hypertrichosis and hyperpigmentation of the face and by esclerodermoid plaques on the hands and face&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45&#44;46</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Laboratory findings include increased serum iron and ferritin&#44; high urine levels of uroporphyrins I and III&#44; and 7&#8211;8-carboxyl uroporphyrins&#44; high plasma levels of uroporphyrin and increased levels of isocoproporphyrin III in the faeces&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Histopathology reveals a subepidermal cleft with minimal inflammation and festooned papillary dermis in the base of the cleft&#46; The vessel wall is thickened&#46; Direct immunofluorescence staining indicates linear and granular deposition of immunoglobulin G and C3 in the dermal-epidermal junction and around the vessels&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">For the treatment of PCT&#44; sun exposure should be avoided&#59; the use of zinc oxide and titanium oxide-based sunscreen is recommended&#46; Treatment of comorbidities and to avoid exacerbating factors &#40;iron and alcohol consumption&#44; and estrogen using&#41; are also important&#46; Furthermore&#44; it is important to use high-flux membranes &#40;polysulfone&#41; with high-flux dialysis &#40;300<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;&#44; during 4<span class="elsevierStyleHsp" style=""></span>h of haemodialysis&#44; three times a week&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Reduce body stores of iron in body stores of iron&#46; Iron induces the enzyme 5-aminolevulinate synthase&#44; which suppresses uroporphyrinogen decarboxylase&#46; Further&#44; it increases conversion of uroporphyrinogen into porphyrins&#46; Phlebotomy is used at a low volume of 100<span class="elsevierStyleHsp" style=""></span>ml&#44; twice weekly for 8 months&#44; followed by 50<span class="elsevierStyleHsp" style=""></span>ml per week thereafter&#59; normal phlebotomy is not tolerated due to anaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Erythropoietin &#40;20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#41; is administered thrice weekly&#46; When erythropoietin is combined with phlebotomy&#44; a dose of 150&#8211;200<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#44; three times per week is used&#46; Deferoxamine &#40;2<span class="elsevierStyleHsp" style=""></span>g&#41; is administered intravenously every haemodialysis session and is associated with long-term adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In refractory cases&#44; two plasma exchange treatments&#44; separated by 48<span class="elsevierStyleHsp" style=""></span>h&#44; are applied&#46; Renal transplantation is the definitive treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pseudoporphyria</span><p id="par0255" class="elsevierStylePara elsevierViewall">Pseudoporphyria is a bullous dermatosis induced by phototoxicity that exhibits the clinical and histopathologic features of PCT&#59; however&#44; normal uroporphyrin levels are observed&#46; The condition is associated with the use of phototoxic drugs such as tetracycline&#44; furosemide&#44; naproxen&#44; amiodarone&#44; nalidixic acid and isotretinoin&#44; and exposure to ultraviolet light A&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Regarding pathogenesis&#44; phototoxic metabolites are formed&#46; Patients with CKD have decreased glutathione levels in erythrocytes&#44; making them susceptible to damage by free radicals&#46; N acetyl-cysteine&#44; a precursor of glutathione with antioxidant properties&#44; is used to effectively treat these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Clinical manifestations include blisters on the back of the hands&#44; forearms and other exposed areas that resolve with scarring and milia&#46; Hypertrichosis on the face or sclerodermoid plaques is rarely observed&#46; Uroporphyrin levels in plasma or urine are normal or slightly elevated&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Histopathology reveals a subepidermal cleft with minimal inflammation and a thick vessel wall&#46; Direct immunofluorescence staining indicates immunoglobulin G and C3 deposition at the dermal-epidermal junction and around vessels&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">N-acetyl-cysteine&#44; a precursor of glutathione with antioxidant properties&#44; has been effective therapy in several case reports&#46; An oral dose of 600&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day offers relief in 4-8 of weeks&#46; Recurrence has been reported after discontinuing medication&#46; It is recommendable to avoid exacerbating factors such as sun exposure&#44; trauma and related drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Benign nodular calcification</span><p id="par0280" class="elsevierStylePara elsevierViewall">Firm papules&#44; plaques and nodules appear in the joints and fingertips due to metastatic calcification affecting skin&#46; Von Kossa stains calcium deposits black&#46; Treatment is based on reducing calcium&#8211;phosphorus products and surgical removal&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Xerosis</span><p id="par0285" class="elsevierStylePara elsevierViewall">Xerosis is the most common skin manifestation of CKD&#44; occurring in 80&#37; of patients&#46; Etiopathogenic mechanisms include&#58; Decreased hydration of the stratum corneum&#59; decreased sweat gland and sebaceous gland size along with abnormal function related to hypervitaminosis A in dialysis patients&#44; and the use of diuretics&#46; Treatment is based on skin hydration and treatment of pruritus&#46; Repetitive bathing must be avoided and the use of soft&#44; neutral soaps is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pigmentary changes</span><p id="par0290" class="elsevierStylePara elsevierViewall">Dark brown pigmentation is caused by increased melanin production due to &#946;-melanocyte stimulating hormone accumulation&#44; which is caused by decreased excretion due to kidney failure&#46; The yellowish tinge is caused by the accumulation of carotenoids and urochrome in the skin&#46; Pallor is caused by anaemia due to ineffective erythropoiesis and increased haemolysis&#46; Treatment is based on avoiding sun exposure and involves sunscreen use for hyperpigmentation as well as erythropoietin for anaemia associated with pallor&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Skin infections</span><p id="par0295" class="elsevierStylePara elsevierViewall">Skin infections are caused by impaired cellular and humoural immunity&#46; They are more common when diabetic nephropathy is the origin&#46; The most common fungal infection is onychomycosis&#46; The most frequent viral infections are common warts&#44; herpes simplex and herpes zoster&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Uremic frost</span><p id="par0300" class="elsevierStylePara elsevierViewall">Uremic frost is currently a rare manifestation&#46; However when observed&#44; the condition is often accompanied with increased BUN&#44; ranging from 250 to 300<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; It is caused by the accumulation of urea in sweat&#46; When the sweat evaporates&#44; a crystal deposit remains on the skin that appears as a yellowish-white coating on the beard area&#44; neck and trunk&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Nail disorders</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mees lines&#46;</span> These transverse bands of leukonychia are an alteration of the nail plate that occurs during periods of stress&#46; In addition to its association with CKD&#44; this condition appears in cases of poisoning by arsenic&#44; thallium&#44; and fluorine as well as severe infections&#44; heart disease and malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Muehrcke&#39;s lines&#46;</span> Double white transverse lines are caused by hypoalbuminemia related to nephrotic syndrome&#59; Muehrcke lines are associated with serum albumin levels less than 2&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; It originates by vascular compression through local oedema&#44; which causes bleaching of the nail bed&#46; Therefore&#44; no change in position occurs as the nail grows&#46; It has also been observed in cases of cirrhosis&#44; malnutrition and chemotherapy use&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Lindsay nails &#40;half and half&#41;&#46;</span> This condition is related to azotaemia&#46; A white proximal area and a distal pink red-brown area that does not fade under pressure are observed &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; No changes are noted with nail growth because the lesion is located in the nail bed&#46; An increase in the number of capillaries in the distal nail plate and a deposit of melanin pigmentation in the distal area are observed&#46; This condition resolves with renal transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0320" class="elsevierStylePara elsevierViewall">Other nail changes observed include leukonychia&#44; koilonychia and splinter haemorrhages&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hair disorders</span><p id="par0325" class="elsevierStylePara elsevierViewall">Diffuse alopecia&#44; the most common manifestation&#44; is caused by telogen effluvium&#59; xerosis&#44; pruritus and medication use &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Sparse body hair is also present&#46; Discoloration and dryness of the hair are attributed to a decreased sebum production&#46; Treatment for hair loss is based on meeting nutritional requirements&#44; which are increased in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mucosal alterations</span><p id="par0330" class="elsevierStylePara elsevierViewall">Xerostomia is the most common abnormality and is caused by oral breathing and dehydration&#46; Macroglossia is also often observed &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Ulcerative stomatitis is observed with urea serum levels greater 150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and is associated with poor hygiene&#46; Uraemic breath is due to increased urea concentrations in saliva and its transformation into ammonium&#46; The condition is associated with urea levels &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Treatment is based on maintaining good oral hygiene and meeting nutritional requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0335" class="elsevierStylePara elsevierViewall">Skin manifestations are very common in end-stage CKD&#46; Severe renal pruritus is associated with increased mortality and a poor prognosis&#46; Nephrogenic systemic fibrosis is a relatively new preventable disease associated with gadolinium&#46; In a simple exploration of the nails&#44; some findings indicate alterations in albumin and urea levels&#46; Comorbidities such as diabetes mellitus and secondary hyperparathyroidism can lead to acquired perforating dermatosis and calciphylaxis&#44; respectively&#46; Effective and innovative treatments are available for all of these conditions&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical responsibilities</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Renal pruritus"
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          "titulo" => "Acquired perforating dermatosis &#40;APD&#41;"
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          "titulo" => "Nephrogenic systemic fibrosis &#40;NSF&#41;"
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          "titulo" => "Calciphylaxis"
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          "titulo" => "Porphyria cutanea tarda"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin manifestations associated with chronic kidney disease are very common&#46; Most of these conditions present in the end stages and may affect the patient&#39;s quality of life&#46; Knowledge of these entities can contribute to establishing an accurate diagnosis and prognosis&#46; Severe renal pruritus is associated with increased mortality and a poor prognosis&#46; Nail exploration can provide clues about albumin and urea levels&#46; Nephrogenic systemic fibrosis is a preventable disease associated with gadolinium contrast&#46; Comorbidities&#44; such as diabetes mellitus and secondary hyperparathyroidism&#44; can lead to acquired perforating dermatosis and calciphylaxis&#44; respectively&#46; Effective and innovative treatments are available for all of these conditions&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las manifestaciones cut&#225;neas asociadas a enfermedad renal cr&#243;nica son muy comunes&#46; La mayor&#237;a de estas enfermedades se presentan en la etapa terminal y pueden afectar la calidad de vida del paciente&#46; El conocimiento de estas condiciones puede ser &#250;til para establecer un diagn&#243;stico y pron&#243;stico preciso&#46; El prurito renal severo est&#225; asociado a un incremento en la mortalidad y a un pobre pron&#243;stico&#46; La exploraci&#243;n ungueal puede proveer datos acerca del nivel plasm&#225;tico de albumina y urea&#46; La fibrosis sist&#233;mica nefrog&#233;nica es una enfermedad prevenible asociada a contrastes con gadolinio&#46; Comorbilidades como la diabetes mellitus y el hiperparatiroidismo secundario&#44; pueden causar dermatosis perforante adquirida y calcifilaxis&#44; respectivamente&#46; Existen tratamientos efectivos e innovadores para todos estos padecimientos&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classic specific disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nonspecific disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Xerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acquired perforating dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pigmentary changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#8211;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nephrogenic systemic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calciphylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uremic frost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Porphyria cutanea tarda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nail disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pseudoporphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hair disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucosal alterations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Classification of skin manifestations of chronic kidney disease and prevalence&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">MRI&#58; magnetic resonance imaging&#44; CKD&#58; chronic kidney disease&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathogenesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histopathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Differential diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hemodialysis&#44; high levels of uraemic nitrogen&#44; calcium and phosphorus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic inflammatory stateC fibres stimulation via opioids&#44; serotonin&#44; histamine and prostaglandinsAbnormal innervation patterns&#44; nerve damage and central sensitisationGenetic predisposition&#44; HLA B35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Localised or generalised pruritus&#44; with the back being the most common affected sitePruritus is often prolonged and severe and is exacerbated by heat&#44; sweating and xerosis&#46; Excoriations&#44; lichen simplex&#44; nodular prurigo result from scratching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biopsy is usually not required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other local or systemic disorders that cause pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acquired perforating dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diabetes mellitus and hemodialysisHypothyroidism&#44; liver disease&#44; malignancies and HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transepidermal elimination of dermal componentsTrigger factors include minor trauma&#44; microvascular changes and skin calcium depositionsGenetic predisposition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pigmented and umbilicated dome shaped papules with a depressed and scaling centre&#44; located in the extensor surfaces of the arms and legs&#44; and less commonly&#44; in the scalp&#44; trunk and buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acanthosis&#44; cup shaped plugs composed of keratin&#44; collagen and cell detritus that move from the epidermis to the exterior&#44; and a perilesional inflammatory infiltrate composed of lymphocytes and neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prurigo nodularis and lichen planus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nephrogenic systemic fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gadolinium use as contrast medium in MRI angiographyGadodiamide and gadopentetate are the most associated contrast media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Genetic predisposition &#40;HLA A2&#41; and an inflammatory state&#44; allow gadolinium effectively enters the tissuesGadolinium is subsequently phagocytosed by macrophages&#44; which release cytokines that attract circulating fibrocytes to the tissues&#44; then the fibrocytes differentiate into fibroblast-like cells in the dermis leading to fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Indurated&#44; erythematous-hyperchromic plaques with an orange peel&#44; woody appearance&#46; The lesions are bilateral and symmetrical on the legs and forearmsFlexion contractures of adjacent limbs5&#37; of patients experience a rapid fulminant course in 2 weeks with multiple organ involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thickened collagen bundles with clefts&#44; mucin deposition and proliferation of spindled cells that stain positive for CD34 and procollagen 1&#46; Multinucleated cells positive for CD68 and factor VIII are also present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scleromyxedema&#44; systemic sclerosis&#44; eosinophilia-myalgia syndrome&#44; toxic oil syndrome and eosinophilic fasciitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calciphylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Secondary hyperparathyroidism and elevated calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased calcium&#8211;phosphorus productImbalance between inhibitors and inducers of vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Painful&#44; pink or purple&#44; firm nodules or plaques&#44; surrounded by livedo reticularis that progress to central and deep painful ulcers covered with black eschar&#46; Calciphylaxis is bilateral and symmetrical and affects thighs&#44; abdomen and buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcification of the media&#44; intimal hyperplasia of dermal and subcutaneous arterioles&#44; thrombosis of dermal and subcutaneous vessels with ischaemic necrosis in the epidermis and lobular panniculitis with fat necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic vasculitis&#44; coagulopathies&#44; occlusive vasculopathies and bacterial and fungal infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Porphyria cutanea tarda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HemodialysisType 1&#58; hepatitis B and C&#44; HIV-AIDS&#44; alcohol&#44; oestrogen and ironType 2 is a hereditary&#44; autosomal dominant disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A defect in heme biosynthesis due to uroporphyrinogen decarboxylase deficiencyIn CKD&#44; low levels of uroporphyrins are excreted&#59; their accumulation in skin causes phototoxicity reactions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blisters&#44; erosions and crusts that are located on exposed areas&#44; such as the back of hands and forearms and occasionally the face and feet&#46; These lesions heal with scarring or milia and may be accompanied of hypertrichosis and hyperpigmentation and esclerodermoid plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subepidermal cleft with minimal inflammation and festooned papillary dermis&#46; Direct immune-fluorescence indicates linear and granular deposition of immunoglobulin G and C3 in the dermal-epidermal junction and around the vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pseudoporphyria&#44; other hereditary porphyrias drug-related phototoxic reactions&#44; epidermolysis bullosa acquisita&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pseudo-porphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototoxic drugs&#44; such as tetracycline&#44; furosemide&#44; naproxen&#44; amiodarone&#44; nalidixic acid and isotretinoin&#44; and exposure to ultraviolet light A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototoxic metabolites are formed&#46; Patients with CKD have decreased glutathione levels in erythrocytes&#44; making them susceptible to damage by free radicals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blisters on the back of hands&#44; forearms and other exposed areas that resolve with scarring and milia&#46; Hypertrichosis on the face or sclerodermoid plaques are rarely observed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subepidermal cleft with minimal inflammation&#46; Direct immunofluorescence staining indicates immunoglobulin G and C3 deposition at the dermal-epidermal junction and around vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hereditary porphyrias&#44; drug-related phototoxic reactions&#44; epidermolysis bullosa acquisita&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summary of classic specific disorders&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment option&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Action mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="11" align="left" valign="top">Renal pruritus</td><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing efficiency <span class="elsevierStyleItalic">Kt</span>&#47;<span class="elsevierStyleItalic">V</span> urea<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;4&#44; using low calcium and magnesium dialysates and using more biocompatible membranes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reduce calcium&#8211;phosphorus products&#46; Membranes of polymethylmethacrylate absorb and eliminate cytokines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythropoietin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg is administered thrice weekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decreasing histamine levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Moisturiser &#40;gamma linoleic acid&#44; glycerol and paraffin&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three times a day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevent xerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Capsaicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;025&#37; cream four times daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depletes P substance from C fibres&#44; thus blocking pain and pruritus transmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pramoxine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Twice daily for 1 month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical anaesthetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gabapentin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">300<span class="elsevierStyleHsp" style=""></span>mg after each hemodialysis session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GABA agonist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Granisetron&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg twice daily for 1 month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Serotonin inhibitor 5 HT3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nalfurafine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#956;g thrice weekly by intravenous infusion&#44; immediately after each hemodialysis for 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opioid agonist&#46; Inhibit C fibres by &#954; receptor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Narrowband UVB phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three sessions per week&#46; Initial dose of 200<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#44; increasing 100<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> at every session&#44; until a maximum dose of 1500<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease the production of cytokines by lymphocytes and phosphorus levels in the skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Parathyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Effective in cases with secondary hyperparathyroidism and high calcium-phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased glomerular filtration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Acquired perforating dermatosis</td><td class="td" title="table-entry  " align="left" valign="top">Steroids &#40;topical&#44; oral or intralesional&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Keratolytics and retinoids &#40;topical or oral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease epidermal thickness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Allopurinol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mg daily for 1&#8211;4 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Xanthine-oxidase inhibitor&#46; It acts by an antioxidant action&#44; thus decreasing free radicals involved in collagen damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Maxacalcitol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Twice daily for 2 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D vitamin analogue&#46; Mechanism of action remains unclear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Narrowband UVB phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It begins at 400<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> until a therapeutic range of 700&#8211;1600<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span> is achieved&#46; Three sessions per week&#46; After improvement is achieved&#44; 1&#8211;2 sessions a week for maintenance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anti-proliferative and anti-inflammatory effects&#59; relief of pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Photodynamic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single session with 5-aminolevulinic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Production of reactive oxygen species with cell apoptosis and necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="8" align="left" valign="top">Nephrogenic Systemic Fibrosis</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gadoteridol is the safest option&#46; In hemodialysis patients&#44; two 4-h sessions should be performed in the first 3<span class="elsevierStyleHsp" style=""></span>h to remove the contrast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Extracorporeal photopheresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two treatments on consecutive days every 2 weeks for 6 months&#44; then two treatments on consecutive days every 4 weeks for 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enhances the suppression of signals by inducing lymphocytes apoptosis and deflecting the signal of antigen-presenting cells&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased glomerular filtration and immunosuppression in transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Imatinib mesylate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">400&#8211;600<span class="elsevierStyleHsp" style=""></span>mg&#47;day are administered&#44; for 4&#8211;24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tyrosine kinase inhibitor&#44; acts by inhibiting platelet-derived growth factor and c-Abl kinase&#44; thus inhibiting the synthesis of collagen and fibronectin by dermal fibroblasts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">UV-A 1 phototherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three sessions per week&#44; at 60&#8211;120<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> in 22&#8211;50 sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alters the cytokine levels relating to fibrocytes to promote a less fibrotic environment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Physical therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improves the performance of daily activities and personal care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Plasmapheresis&#44; immunoglobulin G and photodynamic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anecdotal success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="12" align="left" valign="top">Calciphylaxis</td><td class="td" title="table-entry  " align="left" valign="top">Total or subtotal surgical parathyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reducing the production of parathyroid hormone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cinacalcet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;60<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcium mimetic that increases sensitivity of the calcium receptor in the parathyroid gland&#44; thus reducing the production of parathyroid hormone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Etindronate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally for 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inhibit vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pamidronate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>mg intravenously for five treatments over a period of 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inhibit vascular calcification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;50<span class="elsevierStyleHsp" style=""></span>mg orally every 24<span class="elsevierStyleHsp" style=""></span>h&#44; for 3&#8211;5 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sodium thiosulfate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>g is administered intravenously for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; three times a week after each hemodialysis session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Displacing calcium from calcium phosphate&#44; to form calcium thiosulfate&#44; which is more soluble&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing the frequency and duration of hemodialysis through the use of low calcium dialysate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reduce calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sevelamer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phosphorus chelator that reduces the intestinal absorption of phosphorus&#46; Reduce calcium&#8211;phosphorus products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">General wound management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Debridement of necrotic tissue&#44; antibiotics&#44; analgesia&#44; cures and vacuum dressing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To prevent infection and sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hyperbaric oxygen therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Daily sessions for 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min per week with 100&#37; oxygen at 2&#46;5 atmospheres of pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stimulates angiogenesis and is toxic to anaerobic bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cultured autologous fibroblasts and keratinocytes&#44; adding iloprost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35 consecutive days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To coat ulcers&#46; Iloprost is a vasodilator prostacyclin analogue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ulcer debridement&#44; coated with partial autologous skin grafts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To prevent infection and sepsis&#44; and to coat ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Porphyria cutanea tarda</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid sun exposure&#44; use zinc oxide and titanium oxide-based sunscreen&#44; avoid alcohol&#44; estrogens&#44; iron and treat comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoiding exacerbating factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Improving the quality of hemodialysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To use high-flux membranes &#40;polysulfone&#41; with high flux dialysis &#40;300<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;&#44; during 4<span class="elsevierStyleHsp" style=""></span>h of hemodialysis&#44; three times a week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Removing high plasma levels of uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Phlebotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low volume of 100<span class="elsevierStyleHsp" style=""></span>ml&#44; twice weekly for 8 months&#44; followed by 50<span class="elsevierStyleHsp" style=""></span>ml per week thereafter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease in body stores of iron&#46; Activating uroporphyrinogen decarboxylase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythropoietin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;50<span class="elsevierStyleHsp" style=""></span>U&#47;kg is administered thrice weekly&#46; When erythropoietin is combined with phlebotomy&#44; a dose of 150&#8211;200<span class="elsevierStyleHsp" style=""></span>U&#47;kg is used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease in body stores of iron&#46; Activating uroporphyrinogen decarboxylase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Deferoxamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>g is administered intravenously every hemodialysis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chelating agent used to remove iron&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Plasmapheresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two sessions&#44; separated by 48<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Removing high plasma levels of uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Renal transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing glomerular filtration&#44; thus excreting uroporphyrins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Pseudo-porphyria</td><td class="td" title="table-entry  " align="left" valign="top">Preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid sun exposure&#44; trauma and related drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoiding exacerbating factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">N-acetyl-cysteine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day orally for weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Precursor of glutathione with antioxidant properties&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Treatment of classic specific disorders associated to chronic kidney disease&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:53 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation and management of chronic kidney disease&#58; synopsis of the kidney disease&#58; improving global outcomes 2012 clinical practice guideline"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;E&#46; Stevens"
                            1 => "A&#46; Levin"
                            2 => "Kidney Disease&#58; Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-158-11-201306040-00007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2013"
                        "volumen" => "158"
                        "paginaInicial" => "825"
                        "paginaFinal" => "830"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23732715"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatological disease in patients with CKD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "U&#46;C&#46; Brewster"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.ajkd.2007.09.024"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Kidney Dis"
                        "fecha" => "2008"
                        "volumen" => "51"
                        "paginaInicial" => "331"
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