MHD serves as the principal treatment approach for patients with end-stage renal disease. However, long-term MHD can lead to an array of complications [18]. Many patients on MHD experience skin-related symptoms, including pruritus, xerosis, variations in skin tone (pigmentation or pallor), nail complications, hair issues, and mucosal manifestation [19]. Management of these skin conditions involves a multidisciplinary approach, including optimal dialysis, topical treatments, systemic medications, and, in some cases, surgical intervention. The transient alterations in skin color observed in our patient diverged from those typically associated with MHD.
While bilirubin levels may be elevated in patients with end-stage renal disease (ESRD) due to decreased renal clearance, significant hyperbilirubinemia is more commonly associated with liver dysfunction or biliary obstruction [20]. The present patient demonstrated a marked elevation in serum total bilirubin levels during the initial phases. As the treatment progressed to a more advanced stage, the patient manifested a moderate anemic condition. However, the examination of the peripheral blood for the presence of fragmented red blood cells and the quantification of hemoglobin levels in the spent dialysate fluid from this patient did not provide evidence to support a diagnosis of hemolytic anemia. In addition, the development of anemia was after the improvement of several conditions, including pancreatitis and abnormal skin color. Upon the onset of moderate anemia, there was no observed elevation in the levels of total bilirubin, indirect bilirubin, or lactate dehydrogenase. In addition, the skin color of the patient was clearly different from that of jaundice. Given the clinical findings, the dermatological manifestations exhibited in this patient were deemed unlikely to be secondary to hemolytic pathology.
Weakness and myalgia are considered significant symptoms in patients with CKD or hemodialysis [21]. Thus, clinical symptoms (e.g. muscle pain, weakness) of the MHD patients would mask the diagnosis of rhabdomyolysis [11]. The patient in our case did not report significant weakness and myalgia, and his sternal and epigastric pain was considered to be due to pancreatitis. In MHD patients without urine, dark urine would not be observed. This MDH patient did not show the expected signs and symptoms of rhabdomyolysis. Additionally, his serum creatine kinase level did not elevate to the degree necessary to confirm a diagnosis of rhabdomyolysis per standard criteria [22]. However, a significant elevation in his serum myoglobin levels was observed. Additionally, the presence of myoglobin was confirmed in the waste bag from his dialysis treatment.
To the best of our knowledge, this is the first report of purplish-red skin color in acute pancreatitis undergoing MHD. The patient’s development of purplish-red skin in the early stage of this case may be related to the following potential factors. Firstly, acute pancreatitis is characterized by inflammatory response, which results not only in pancreas but also provokes alterations in remote organs. Inflammation is usually marked by classic signs like redness and warmth due to increased blood flow, and swelling from the leakage of fluid, plasma proteins, and leukocytes [23]. Owing to the rarity of skin redness among patients suffering from pancreatitis, it is insufficient to attribute the manifestation of skin redness solely to inflammation in this instance. Secondly, the abnormal skin color change observed in the early stage of the patient’s hospitalization is likely related to an increased concentration of myoglobin in the blood. This hypothesis is supported by the observations detailed below: ① In the initial stage of dermatological disease abnormalities, elevated levels of myoglobin were detected in the patient’s blood, and the presence of myoglobin was confirmed in the red dialysis residue. ② As the blood myoglobin concentration decreased, the color of the dialysis residue returned to normal. Concurrently, the patient’s purplish-red skin color reverted to its normal appearance. These findings suggest a correlation between the elevated myoglobin levels and the patient’s skin discoloration. While the patient’s elevated creatine kinase level was insufficient to meet the diagnostic criteria for rhabdomyolysis, the serum myoglobin concentration was observed to be more than tenfold above the upper limit of the established reference range. We must consider the specificity of this case as a MHD patient without urine. Under normal circumstances, a healthy kidney will excrete countless compounds. When the concentration of myoglobin in the urine exceeds 300 mg/L, visible myoglobinuria is observed [24]. However, in MHD patients who experience anuria, myoglobin cannot be excreted via the urinary pathway and consequently accumulates within the body.
In this MHD case, the treatment strategy was employed predominantly for the management of acute pancreatitis and muscle injury. The initial approach to managing acute pancreatitis involved fluid resuscitation, vigilant monitoring, and the provision of optimal nutrition. Because myoglobin has a relatively high molecular weight, it is eliminated by ultrafiltration (convection clearance), but it is poorly to eliminate by dialysis (diffusion clearance) [25]. Hemoperfusion (HA330/380) can be efficiently used in sepsis, rhabdomyolysis, pancreatitis, liver failure and so on [26]. In our case, the substantially elevated myoglobin concentrations detected in the effluent following combined CRRT and HP provide objective evidence supporting the efficacy of this therapeutic modality for the treatment of muscle injury.
In the case of the current patient with acute pancreatitis undergoing MHD, it is noteworthy to report the observation of a unique purplish-red skin discoloration. Following the implementation of standard treatment protocols, supplemented with CRRT and hemoperfusion, a significant improvement was observed in the patient’s condition. Notably, the abnormal skin color reverted to its normal state. This phenomenon may be attributable to inflammation resulting from acute pancreatitis, and the retention of myoglobin within the body. It should be pointed out that, the evidence is insufficient for definitive conclusions. Further research is needed to better understand dermatological manifestations in MHD patients with concurrent pancreatitis and muscle injury.
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