Half and half nails

This 68-year-old patient with Stage 4 chronic kidney disease was reviewed in our low clearance clinic 2 months after formation of a left arteriovenous fistula. The prominent ‘half-and-half’ appearance of his nails was noted. Nail disorders are common in chronic renal failure, affecting up to 70% of haemodialysis patients [1]. Half-and-half or Lindsay nails [2], where the proximal half of the nail is white and the distal half red or brown (first described by Bean in 1964) [3], are thought to be present in up to one-third of patients starting haemodialysis [1]. The disorder does not improve with haemodialysis, but sometimes regresses after transplantation. The precise aetiology is not known but is thought to be related to uraemia. Other common nail disorders associated with chronic renal failure include absent lunula and splinter haemorrhages. This patient also demonstrates hyperaemia of his fistula hand (left), which is visibly more erythematous than the non-fistula hand. It was also noticeably warmer to the touch due to increased blood flow through the arm from the fistula.