Uremic bleeding syndrome: Difference between revisions
No edit summary |
ClaireLewis (talk | contribs) No edit summary |
||
| (12 intermediate revisions by 4 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Bleeding diathesis | *[[coagulopathy|Bleeding diathesis]] | ||
**Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired | **Increased risk for of bleeding ([[GI bleed|GI]], [[ICH]], liver hematoma) due to impaired platelet function | ||
*Uremic toxins inhibit platelet aggregation | |||
**Disrupts vWF | |||
**PT/PTT normal, but bleeding time elevated | |||
==Clinical Features== | ==Clinical Features== | ||
*Wide range of presentations | *Wide range of presentations | ||
**Ecchymosis, purpura, epistaxis, fistula bleeding, venipuncture bleeding | **Ecchymosis, [[purpura]], [[epistaxis]], [[hemorrhage of AV fistula|fistula bleeding]], venipuncture bleeding | ||
**GI bleeding | **[[GI bleeding]] | ||
**Intracranial bleeding | **[[ICH|Intracranial bleeding]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
''Dialysis filter may cause [[thrombocytopenia]]'' | |||
{{Increased bleeding DDX}} | {{Increased bleeding DDX}} | ||
== | ==Evaluation== | ||
*Bleeding time extended past 1-7 min (small incision on finger) | *Bleeding time extended past 1-7 min (small incision on finger) | ||
*Mild thrombocytopenia but plts rarely fall below 80k | *Mild thrombocytopenia but plts rarely fall below 80k | ||
| Line 23: | Line 27: | ||
**Cryoprecipitate 10 bags over 30 min - benefit seen within 4-12 hrs in most<ref>Cryoprecipitate - Dosing and Uses. Medscape. http://reference.medscape.com/drug/cryo-cryoprecipitate-999498.</ref> | **Cryoprecipitate 10 bags over 30 min - benefit seen within 4-12 hrs in most<ref>Cryoprecipitate - Dosing and Uses. Medscape. http://reference.medscape.com/drug/cryo-cryoprecipitate-999498.</ref> | ||
**Recombinant EPO 50 - 150 u/kg IV 3x/wk | **Recombinant EPO 50 - 150 u/kg IV 3x/wk | ||
**Conjugated estrogens at 0. | **Conjugated estrogens at 0.6mg/kg IV over 30 min QD for 5 days - time to effect ~ 6 hrs, max effect at 1 wk, duration of action 2 wks | ||
#Acute [[dialysis]] | |||
#Acute dialysis | |||
#*[[pRBCs]] | #*[[pRBCs]] | ||
#**Raising HCT to above 25-30% improves bleeding time | #**Raising HCT to above 25-30% improves bleeding time | ||
# | #[[Desmopressin]] (DDAVP) | ||
# | #*Simplest and least toxic acute treatment | ||
# | #*Increases release of factor VIII:von Willebrand factor multimers | ||
# | #*0.3 mcg/kg IV (preferred) or SC (max 20mg). 3mcg/kg intranasaly is an option. | ||
# | #*Onset of action ~1hr, duration of action ~4-24hr | ||
#Estrogen | #Estrogen | ||
#*Unclear mechanism of action | #*Unclear mechanism of action | ||
| Line 68: | Line 53: | ||
#*Gelatin - Gelfoam or Surgifoam | #*Gelatin - Gelfoam or Surgifoam | ||
#*Thrombin - Floseal | #*Thrombin - Floseal | ||
==See Also== | ==See Also== | ||
*[[Coagulopathy | *[[Coagulopathy]] | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Renal]] | |||
[[Category:Heme/Onc]] | [[Category:Heme/Onc]] | ||
Latest revision as of 14:46, 17 October 2019
Background
- Bleeding diathesis
- Uremic toxins inhibit platelet aggregation
- Disrupts vWF
- PT/PTT normal, but bleeding time elevated
Clinical Features
- Wide range of presentations
- Ecchymosis, purpura, epistaxis, fistula bleeding, venipuncture bleeding
- GI bleeding
- Intracranial bleeding
Differential Diagnosis
Dialysis filter may cause thrombocytopenia
Coagulopathy
Platelet Related
- Too few
- Nonfunctional
Factor Related
- Acquired (Drug Related)
- Warfarin (Coumadin)
- Unfractionated heparin
- Low molecular weight heparin (i.e. enoxaparin (Lovenox), dalteparin)
- Factor Xa Inhibitors (e.g. rivaroxaban, apixaban, fondaparinux, edoxaban)
- Direct thrombin inhibitors (e.g. dabigatran, argatroban, bivalirudin)
- Illness induced
- Genetic
Evaluation
- Bleeding time extended past 1-7 min (small incision on finger)
- Mild thrombocytopenia but plts rarely fall below 80k
- PT and aPTT typically remain normal
Management
- Treatment = desmopressin, cryoprecipitate, conjugated estrogen, EPO, dialysis[1]
- Limited evidence for dialysis (peritoneal vs. hemodialysis) in management of acute uremic bleeding
- DDAVP 0.4 mcg/kg IV over 10 min - effects within 1 hr but increased bleeding time returns within 24 hrs[2]
- Cryoprecipitate 10 bags over 30 min - benefit seen within 4-12 hrs in most[3]
- Recombinant EPO 50 - 150 u/kg IV 3x/wk
- Conjugated estrogens at 0.6mg/kg IV over 30 min QD for 5 days - time to effect ~ 6 hrs, max effect at 1 wk, duration of action 2 wks
- Acute dialysis
- pRBCs
- Raising HCT to above 25-30% improves bleeding time
- pRBCs
- Desmopressin (DDAVP)
- Simplest and least toxic acute treatment
- Increases release of factor VIII:von Willebrand factor multimers
- 0.3 mcg/kg IV (preferred) or SC (max 20mg). 3mcg/kg intranasaly is an option.
- Onset of action ~1hr, duration of action ~4-24hr
- Estrogen
- Unclear mechanism of action
- Onset of action within 1d
- Options
- Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
- Cryoprecipitate
- Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
- 10 bags over 30 minutes
- Platelet transfusion
- Minimally effective because infused platelets quickly acquire the uremic defect
- Only use when uncontrolled hemorrhage
- Topical Hemostatic Agents
- Gelatin - Gelfoam or Surgifoam
- Thrombin - Floseal
See Also
References
- ↑ Hedges SJ et al. Evidence-based treatment recommendations for uremic bleeding. Nature Clinical Practice Nephrology (2007) 3, 138-153.
- ↑ Desmopressin (Rx) - Dosing and Uses. Medscape. http://reference.medscape.com/drug/ddavp-stimate-desmopressin-342819.
- ↑ Cryoprecipitate - Dosing and Uses. Medscape. http://reference.medscape.com/drug/cryo-cryoprecipitate-999498.