{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T16:01:41Z","timestamp":1753891301109,"version":"3.41.2"},"reference-count":47,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,11,23]],"date-time":"2023-11-23T00:00:00Z","timestamp":1700697600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Onychomycoses are fungal infections that can be seen in any component of the nail unit, including the matrix, bed, and plate, and are caused by dermatophyte fungi, non-dermatophyte fungi, and yeasts. This disease affects approximately 1 to 8% of the general population and occurs in approximately 19 to 51.9% of the patients on hemodialysis. The high incidence of onychomycosis in patients on hemodialysis is associated, mainly, with immunologic deficits and histological changes caused by uremia.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Adult patients of the S\u00e3o Francisco University Hospital Hemodialysis Center were included. The following characteristics were evaluated: age, sex, body mass index, comorbidity, and household location. All patients were clinically evaluated and those with suspected onychomycosis had subungual debris of the affected nail plate collected for the direct mycological examination and fungal culture. The onychomycosis severity for those patients with a positive result in the fungal culture examination was evaluated using the Onychomycosis Severity Index system.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The study included 151 patients, and 70 out of the 151 patients (46.4%) showed nail alteration, and among them, 31 out of the 70 patients (44.3%) had the onychomycosis diagnosis confirmed by direct mycological examination. The pathogens observed in the patients were <jats:italic>Trichophyton rubrum<\/jats:italic> [8 out of 31 (25.8%)], <jats:italic>Trichophyton mentagrophytes<\/jats:italic> [7 out of 31 (22.6%)], S<jats:italic>cytalidium<\/jats:italic> spp. [6 out of 31 (19.4%)], <jats:italic>Candida<\/jats:italic> spp. [2 out of 31 (6.45%)], <jats:italic>Rhodotorula<\/jats:italic> spp. [1 out of 31 (3.2%)], <jats:italic>Candida albicans<\/jats:italic> [1\/31 (3.2%)], <jats:italic>Penicillium marneffei<\/jats:italic> [1 out of 31 (3.22%)], and <jats:italic>T. rubrum<\/jats:italic> and <jats:italic>Rhodotorula<\/jats:italic> spp. [1 out of 31 (3.2%)]. Three participants presented negative results in the culture examination, and one did not allow the collection of material for the examination. The nail involvement severity score for the majority of them was severe [23 out of 27 (85.2%)], and only 1 out of the 27 (3.7%) and 3 out of the 27 (1.1%) patients presented moderate and mild scores, respectively. The distal subungual onychomycosis occurred in 12 out of 27 (44.4%) patients, a mixed pattern occurred in 14 out of 27 (51.9%) patients, and, white superficial occurred in only 1 out of 27 (3.7%) patients. In the bivariate analysis, a higher risk of onychomycosis was associated with the male sex [23\/31 (74.2%) vs. 56\/120 (46.7%); OR\u2009=\u20093.286 (95%CI\u2009=\u20091.362 to 7.928)] and obesity [8\/31 (25.8%) vs. 12\/120 (10.0%); OR\u2009=\u20093.130 (95%CI\u2009=\u20091.150 to 8.521)]. Patients with diabetes mellitus were more susceptible to onychomycosis attacks (<jats:italic>p<\/jats:italic>-value\u2009=\u20090.049; 16 out of 31 (51.6%) vs. 40 out of 120 (33.3%); however, OR was 2.133 (95%CI\u2009=\u20090.959 to 4.648). The patients with onychomycosis were older but without a significant difference between the groups (<jats:italic>p<\/jats:italic>-value\u2009=\u20090.073; 66\u2009years old vs. 58\u2009years old). The multivariable model using the logistic regression (backward model) confirmed our results and was able to predict (81.5%) the onychomycosis-positive diagnosis (chi-square\u2009=\u200927.73; <jats:italic>p<\/jats:italic>-value &amp;lt;0.001). The age [OR\u2009=\u20091.036; 95%CI\u2009=\u20091.004 to 1.069], male sex [OR\u2009=\u20095.746; 95%CI\u2009=\u20092.057 to 16.046], and presence of obesity [OR\u2009=\u20094.800; 95%CI\u2009=\u20091.435 to 16.055] were positive and significant in predicting the onychomycosis-positive diagnosis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>In our study, onychomycosis in patients on hemodialysis was associated with a great variety of microorganisms, mainly <jats:italic>Trichophyton<\/jats:italic> species. The nail involvement severity score for the majority of patients was severe, and distal subungual onychomycosis and mixed pattern onychomycosis were the most prevalent clinical types. The main risk factors associated with onychomycosis were male sex, older age, and the presence of obesity.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fmed.2023.1268324","type":"journal-article","created":{"date-parts":[[2023,11,23]],"date-time":"2023-11-23T10:49:17Z","timestamp":1700736557000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":5,"title":["Prevalence and risk predictors of onychomycosis in patients on hemodialysis: an observation, prospective, and unicenter study in Brazil"],"prefix":"10.3389","volume":"10","author":[{"given":"Jeanne Marie Queiroz Borges","family":"Bersano","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matheus Gobbo","family":"Cordeiro","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fernando Augusto Lima","family":"Marson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2023,11,23]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"98","DOI":"10.29271\/jcpsp.2018.02.98","article-title":"Factors affecting dermatological manifestations in patients with end stage renal disease","volume":"28","author":"Anees","year":"2018","journal-title":"J Coll Physicians Surg"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"286","DOI":"10.3109\/15569527.2012.657726","article-title":"Cutaneous changes in patients with chronic renal failure on hemodialysis","volume":"31","author":"Onelmis","year":"2012","journal-title":"Cutan Ocul Toxicol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"860","DOI":"10.1111\/j.1365-4362.1992.tb03543.x","article-title":"Cutaneous alterations in patients with chronic renal failure","volume":"31","author":"Pic\u00f3","year":"1992","journal-title":"Int J Dermatol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"119","DOI":"10.4103\/0378-6323.25636","article-title":"Cutaneous manifestations in patients with chronic renal failure on hemodialysis","volume":"72","author":"Udayakumar","year":"2006","journal-title":"Indian J Dermatol Venereol Leprol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1016\/j.amjms.2021.03.009","article-title":"Treatment of psoriasis in end-stage renal disease patients is associated with decreased mortality: a retrospective cohort study","volume":"362","author":"Schwade","year":"2021","journal-title":"Am J Med Sci"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1326","DOI":"10.1111\/j.1468-3083.2008.02826.x","article-title":"Nail changes in chronic renal failure patients under haemodialysis","volume":"22","author":"Salem","year":"2008","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"ref7","article-title":"Onychomycosis","volume-title":"StatPearlsPl","author":"Bodman","year":"2023"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"1972","DOI":"10.1111\/jdv.16394","article-title":"Onychomycosis: a review","volume":"34","author":"Gupta","year":"2020","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1177\/1203475417716362","article-title":"Onychomycosis in the 21st century: an update on diagnosis, epidemiology, and treatment","volume":"21","author":"Gupta","year":"2017","journal-title":"J Cutan Med Surg"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1159\/000475674","article-title":"Hemodialysis and kidney transplantation as predisposing conditions to onychomycosis","volume":"137","author":"Filho","year":"2017","journal-title":"Nephron"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1039","DOI":"10.1111\/jdv.12873","article-title":"The prevalence of culture-confirmed toenail onychomycosis in at-risk patient populations","volume":"29","author":"Gupta","year":"2015","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1186\/1471-2334-7-102","article-title":"The prevalance, epidemiology and risk factors for onychomycosis in hemodialysis patients","volume":"7","author":"Kuvandik","year":"2007","journal-title":"BMC Infect Dis"},{"key":"ref13","first-page":"19","article-title":"Frequency of onychomycoses in chronic renal failure patients undergoing hemodialysis in Porto Alegre, Brazil","volume":"21","author":"Lamb","year":"2013","journal-title":"Acta dermatovenerologica Iugoslavica"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1219","DOI":"10.1016\/j.jaad.2010.09.730","article-title":"Onychomycosis: a proposed revision of the clinical classification","volume":"65","author":"Hay","year":"2011","journal-title":"J Am Acad Dermatol"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1277","DOI":"10.1001\/archdermatol.2011.267","article-title":"A new classification system for grading the severity of onychomycosis: onychomycosis severity index","volume":"147","author":"Carney","year":"2011","journal-title":"Arch Dermatol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"46","DOI":"10.2307\/2286904","article-title":"Comparison of stopping rules in forward \u201cstepwise\u201d regression","volume":"72","author":"Bendel","year":"1977","journal-title":"J Am Stat Assoc"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1186\/1751-0473-3-17","article-title":"Purposeful selection of variables in logistic regression","volume":"3","author":"Bursac","year":"2008","journal-title":"Source Code Biol Med"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1093\/oxfordjournals.aje.a115101","article-title":"The impact of confounder selection criteria on effect estimation","volume":"129","author":"Mickey","year":"1989","journal-title":"Am J Epidemiol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"S47","DOI":"10.1016\/s0190-9622(08)81267-4","article-title":"The AIDS epidemic","volume":"31","author":"Conant","year":"1994","journal-title":"J Am Acad Dermatol"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"81","DOI":"10.3314\/jjmm.46.81","article-title":"Mycoses in Thailand: current concerns. Nihon Ishinkin Gakkai Zasshi Jpn","volume":"46","author":"Ungpakorn","year":"2005","journal-title":"J Med Mycol"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"269","DOI":"10.1080\/mmy.38.s1.269.279","article-title":"Mycoses associated with AIDS in the third world","volume":"38","author":"Marques","year":"2000","journal-title":"Med Mycol"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1111\/j.1346-8138.1993.tb01305.x","article-title":"Clinical manifestations of 174 AIDS cases in Maharaj Nakorn Chiang Mai hospital","volume":"20","author":"Vithayasai","year":"1993","journal-title":"J Dermatol"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"389","DOI":"10.4103\/0378-6323.37055","article-title":"Onychomycosis: Clinico-mycologic study of 130 patients from Himachal Pradesh, India","volume":"73","author":"Gupta","year":"2007","journal-title":"Indian J Dermatol Venereol Leprol"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"416","DOI":"10.1111\/j.1365-4362.1995.tb04443.x","article-title":"Ethnic and geographic differences and similarities of HIV\/AIDS-related mucocutaneous diseases","volume":"34","author":"S\u00f8ndergaard","year":"1995","journal-title":"Danida Study Groups Int J Dermatol"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1111\/myc.12537","article-title":"Epidemiology of onychomycosis in Serbia: a laboratory-based survey and risk factor identification","volume":"60","author":"Dubljanin","year":"2017","journal-title":"Mycoses"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"659","DOI":"10.1111\/myc.12396","article-title":"Epidemiology of onychomycosis in Italy: prevalence data and risk factor identification","volume":"58","author":"Papini","year":"2015","journal-title":"Mycoses"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"655","DOI":"10.1038\/jid.2014.498","article-title":"New insights into genes, immunity, and the occurrence of dermatophytosis","volume":"135","author":"Garc\u00eda-Romero","year":"2015","journal-title":"J Invest Dermatol"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"469","DOI":"10.1016\/j.semnephrol.2004.06.026","article-title":"Oxidative stress in uremia: nature, mechanisms, and potential consequences","volume":"24","author":"Vaziri","year":"2004","journal-title":"Semin Nephrol"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1038\/nrneph.2013.44","article-title":"Immune cell dysfunction and inflammation in end-stage renal disease","volume":"9","author":"Betjes","year":"2013","journal-title":"Nat Rev Nephrol"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"e1004105","DOI":"10.1371\/journal.ppat.1004105","article-title":"Fungal nail infections (onychomycosis): a never-ending story?","volume":"10","author":"Ghannoum","year":"2014","journal-title":"PLoS Pathog"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1159\/000504812","article-title":"Epidemiology of onychomycosis in an academic nail unit in South Greece during a three-year period","volume":"6","author":"Gregoriou","year":"2020","journal-title":"Skin Appendage Disord"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"1567","DOI":"10.1111\/jdv.13677","article-title":"The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30 000 patients visiting physicians\u2019 offices","volume":"30","author":"Gupta","year":"2016","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1067\/mjd.2000.104794","article-title":"Prevalence and epidemiology of onychomycosis in patients visiting physicians\u2019 offices: a multicenter Canadian survey of 15,000 patients","volume":"43","author":"Gupta","year":"2000","journal-title":"J Am Acad Dermatol"},{"key":"ref34","first-page":"665","article-title":"Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey","volume-title":"Br J Dermatol.","author":"Gupta","year":"1998"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"1480","DOI":"10.1111\/jdv.12323","article-title":"The prevalence of onychomycosis in the global population \u2013 a literature study","volume":"28","author":"Sigurgeirsson","year":"2014","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"657","DOI":"10.1590\/S0365-05962010000500009","article-title":"Dermat\u00f3fitos: intera\u00e7\u00e3o pat\u00f3geno-hospedeiro e resist\u00eancia a antif\u00fangicos","volume":"85","author":"Peres","year":"2010","journal-title":"An Bras Dermatol"},{"key":"ref37","first-page":"359","article-title":"Onychomycosis: rapid evidence review","volume":"104","author":"Frazier","year":"2021","journal-title":"Am Fam Physician"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"835","DOI":"10.1016\/j.jaad.2018.03.062","article-title":"Onychomycosis: clinical overview and diagnosis","volume":"80","author":"Lipner","year":"2019","journal-title":"J Am Acad Dermatol"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1111\/ijd.13402","article-title":"Prevalence and epidemiology of tinea pedis and toenail onychomycosis and antifungal susceptibility of the causative agents in patients with type 2 diabetes in Turkey","volume":"56","author":"Oz","year":"2017","journal-title":"Int J Dermatol"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"922","DOI":"10.3390\/jof8090922","article-title":"Prevalence of onychomycosis in diabetic patients: a case-control study performed at university hospital Policlinico in Catania","volume":"8","author":"Trovato","year":"2022","journal-title":"J Fungi Basel Switz"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1046\/j.1365-4362.1999.00009.x","article-title":"Onychomycosis in a special patient population: focus on the diabetic","volume":"38","author":"Rich","year":"1999","journal-title":"Int J Dermatol"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1177\/15347346211009409","article-title":"Onychomycosis and tinea Pedis in the feet of patients with diabetes","volume":"22","author":"Arag\u00f3n-S\u00e1nchez","year":"2023","journal-title":"Int J Low Extrem Wounds"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"467","DOI":"10.1111\/j.1365-4632.2008.03606.x","article-title":"Metabolic syndrome associated with toenail onychomycosis in Taiwanese with diabetes mellitus","volume":"47","author":"Chang","year":"2008","journal-title":"Int J Dermatol"},{"key":"ref44","first-page":"38","article-title":"Risk factors and comorbidities for onychomycosis","volume":"8","author":"Elewski","year":"2015","journal-title":"J Clin Aesthetic Dermatol"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"450","DOI":"10.7547\/87507315-92-8-450","article-title":"A prospective epidemiologic survey on the prevalence of foot disease in Hong Kong","volume":"92","author":"Chan","year":"2002","journal-title":"J Am Podiatr Med Assoc"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1016\/j.jaad.2017.09.030","article-title":"Weight change and risk of onychomycosis: a nationwide cohort study in Korea","volume":"78","author":"Ha","year":"2018","journal-title":"J Am Acad Dermatol"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"49","DOI":"10.7547\/1010049","article-title":"Prevalence of toenail onychomycosis in patients with type 2 diabetes mellitus and evaluation of risk factors","volume":"101","author":"Gulcan","year":"2011","journal-title":"J Am Podiatr Med Assoc"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2023.1268324\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,23]],"date-time":"2023-11-23T10:49:23Z","timestamp":1700736563000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2023.1268324\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11,23]]},"references-count":47,"alternative-id":["10.3389\/fmed.2023.1268324"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2023.1268324","relation":{},"ISSN":["2296-858X"],"issn-type":[{"type":"electronic","value":"2296-858X"}],"subject":[],"published":{"date-parts":[[2023,11,23]]},"article-number":"1268324"}}