Nailed It! – Nail Abnormalities and CKD

After some discussion from the NEJM’s Image Challenge from several weeks ago. I decided to very quickly discuss the difference between Terry’s nails, Lidnsay’s nails, and Meurcke’s bands. The lunula (latin for “little moon”) is the hypopigmented semi-circle located at the base of the nail bed and is abnormal or obliterated in several conditions.
 
Lindsay’s Nails (Half-and-half nails)

In patients with chronic renal disease, the proximal portion of the nail bed can turn white, obliterating the lunula and giving a half-brown, half-white appearance, hence the name half-and-half nails. This can be even more pronounced in patient with severe CKD (ESRD) in which there is an increase in melanin in the basal layer of the epidermis, so the distal portion of the nail bed can starkly contrast the white lunula portion.

 
 
Terry’s Nails

In Terry’s nails most of the nail plate (>75%) turns white with the appearance of ground glass, and the lunula is obliterated. It may occur in one finger, but more commonly all fingers are affected. This condition was described originally in relation to severe liver disease, usually cirrhosis, CHF, hyperthyroidism and diabetes.

Meuhrcke’s Bands

Muehrcke’s bands or lines transverse the entire nail bed, which distinguishes them from Beau’s lines. They represent an abnormality of the vascular nail bed and disappear while the nail is depressed and blood is squeezed from the vessels beneath the nail. Because the lesion is in the nail bed (which distinguishes it from Mee’s lines), it does not move with nail growth. This condition is associated with hypoalbuminemia with albumin level less than 2 g/dL and disappear when the protein level normalizes. This may be present in patients with nephrotic syndrome, liver disease, and malnutrition.