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Kidney Week

Abstract: SA-PO599

Purpuric Rash After Starting Hemodialysis: Not the Immediate Suspect

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Kruzel Davila, Etty, Galilee Medical Center, Nahariya, North, Israel
  • Badran, Ashraf, Galilee Medical Center, Nahariya, North, Israel
  • Zeitun, Teuta, Galilee Medical Center, Nahariya, North, Israel
Introduction

Hemodialysis patients are at risk to develop vitamin C deficiency. Several factors can contribute to vitamin C deficiency, including potassium restricted diet, hemodialysis clearance of water soluble vitamins and increased oxidative stress leading to vitamin C utilization. However, clinical manifestation of scurvy is rare or overlooked. Herein, we report a case of scurvy in a hemodialysis patient.

Case Description

A 74-year-old patient with end stage kidney disease due to diabetic nephropathy has been treated with hemodialysis since 2020. During 2022, she was hospitalized several times due to pulmonary edema. A purpuric rash with perifollicular erythema was noted on her lower legs (Figure A). She also complained of gingival bleeding. Laboratory exam demonstrated undetectable vitamin C level (less than 4 mg/L), hypoalbuminemia and elevated CRP. Based on her dermatologic findings and labs results, a diagnosis of scurvy was made. After 2 months of daily vitamin C supplement, her symptoms and rash resolved, without episodes of pulmonary edema. Echocardiography demonstrated improved LV function (EF 35% improved to 45%), suggesting a therapeutic role for vitamin C repletion.

Discussion

Recommendation of Clinical Practice Guidelines for Nutrition in CKD about regular vitamin C supplementation is opinion based. The absence of rigorous recommendation stems from lack of double blind randomized controlled clinical trials that explored the potential beneficial effect of vitamin C supplementation and possible deleterious effect of calcium oxalate supersaturation, accumulation and deposition. This case is a reminder that scurvy can occur in hemodialysis patients and may contribute to cardiovascular complications. A high clinical awareness is warranted in order to diagnose this treatable devastating disease.