Nail changes in a renal patient.

A 35-year-old male presented with breathlessness and anasarca. Investigations revealed proteinuria 4.5 g/day, serum albumin 1.9 g/dl and serum creatinine 8.2 mg/dl. He had a history of herbal medicine intake in an attempt to quit alcohol and smoking. Renal biopsy suggested minimal change disease with acute interstitial nephritis. He was managed with dialysis and prednisolone. His serum creatinine stabilized at 2.8 mg/dl and proteinuria reduced to 360 mg. His nails showed the changes of both half and half nail and Muehrcke's lines.

Half-and-half nail, also called Lindsay's nail, [Figure 1] is specific for renal failure.[1] The distal 20–60% of the nail is red, pink or brown. The rest of the nail has a dull, whitish, ground-glass appearance.[2] Muehrcke's lines (white arrow) are the smooth white bands that run parallel to the lunula across the width of the nail. Muehrcke's lines occur in patients with hypoalbuminemic states and disappear when the protein level normalizes.[3] It is unusual to find both the nail changes in same patient. Muehrcke lines differ from Beau's lines, which are palpable, and Mees lines, which do not disappear on blanching.[4]

Figure 1

Half and half nail and Muehrcke's lines