Half-and-half nails

A 65-year-old male with type 2 diabetes diagnosed 11 years ago presented with 1 month of persistent malaise, nausea and decreased appetite. Other medical problems include hypertension diagnosed 5 years ago. His physical examination was unremarkable except for pallor and mild peripheral edema. He also had evidence of other chronic complications of diabetes including neuropathy and retinopathy. His fingernails showed a distinctive [Figure 1] distal pinkish transverse band occupying approximately 1/3^rd total nail length with proximal dull white appearance [Figure 2]. A diagnosis of “half and half nails” was made. His laboratory investigation revealed hemoglobin 10.5 g/dl, blood urea 311 mg/dl, creatinine 11.98 mg/dl, sodium 132 mEq/L, potassium 6.8 mEq/L, blood sugar 212 mg/dl. Urine showed 2+ albumin. Ultrasound of the abdomen revealed bilateral small kidneys. He was initiated on a regular hemodialysis program.

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Figure 1

Arrow showing line of demarcation

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Figure 2

Half and half nails

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First described in 1964 by Bean,[1] half-and-half nails or Lindsay's nails are seen in 20-50% of hemodialysis patients.[2] They are characterized by red, pink or brownish discoloration of distal 20-60% nail with a dull, whitish, ground-glass appearance of the remaining nail.[2] The distinction remains even after constricting the venous return from the nail bed. It can affect a single or all nails of fingers and/or toes. The mechanism of half and half nails is still unclear. There is no known correlation of this finding with the severity or duration of renal failure.[3] It does not improve after hemodialysis, however, may regress after renal transplantation.[4]