Society of Diabetic Nephropathy Prevention Journal of Nephropharmacology 2345-4202 16 1 2027 01 01 The kidney, heart, and skin manifestations; a triad of systemic burden in hemodialysis patients – a narrative review e12898 e12898 10.34172/npj.12898 EN Amirhossein Derakhshandeh https://orcid.org/0009-0008-8874-9978 Kowsar Foroughi Abari https://orcid.org/0009-0002-7975-9812 Fatemeh Tayefi https://orcid.org/0000-0002-2589-187X Seyed Sepehr Marashi https://orcid.org/0009-0008-4307-660X Reihaneh Sharifi https://orcid.org/0009-0000-7864-7099 Farid Kalantari https://orcid.org/0009-0006-8922-911X Fatemeh Ranjbar https://orcid.org/0009-0005-9450-4852 Hanie Boostani https://orcid.org/0009-0003-5551-9176 Fatemeh Jenadeleh Yuldashev Botir Akhmatovich https://orcid.org/0000-0003-2442-1523 Journal Article 10.34172/npj.12898 2026 07 04 2026 08 15 End-stage renal disease (ESRD) affects a growing number of patients worldwide, and hemodialysis (HD) remains the most common form of kidney replacement therapy despite its incomplete correction of uremic physiology. Patients on maintenance HD carry a disproportionate burden of cardiovascular diseases (CVDs), which remains the leading cause of death in this population and is amplified by chronic inflammation, anemia, and accumulation of protein-bound uremic toxins such as indoxyl sulfate. Left ventricular hypertrophy, arrhythmia, and sudden cardiac death are common downstream consequences of this cardio-renal interplay. Simultaneously, the skin serves as an under-recognized but revealing organ in uremic manifestations, necrosis, pruritus, pigmentary change, and occasionally calciphylaxis. Uremic pruritus alone affects a substantial proportion of HD patients internationally and is linked to poor sleep, depression, and reduced quality of life. Emerging evidence suggests that cardiovascular and dermatological manifestations are not isolated phenomena but rather converge through shared pathways of systemic inflammation, oxidative stress, and inadequate dialysis clearance. This review synthesizes current literature describing the cardiovascular, dermatological, and interconnected systemic burden experienced by HD patients and argues for integrated, multidisciplinary models of care that jointly address nephrological, cardiological, and dermatological needs.