Uremic bleeding syndrome: Difference between revisions
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==Background==
==Background==
*Bleeding diathesis
*[[coagulopathy|Bleeding diathesis]]
**Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired platlet function
**Increased risk for of bleeding ([[GI bleed|GI]], [[ICH]], liver hematoma) due to impaired platelet function
*Uremic toxins inhibit platelet aggregation
*Uremic toxins inhibit platelet aggregation
**Disrupts vWF
**Disrupts vWF
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==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==
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{{Increased bleeding DDX}}
{{Increased bleeding DDX}}


==Diagnosis==
==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
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**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 0.6 mg/kg IV over 30 min QD for 5 days - time to effect ~ 6 hrs, max effect at 1 wk, duration of action 2 wks
**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]]
#[[Desmopressin]] (DDAVP)
#**Simplest and least toxic acute treatment
#*Simplest and least toxic acute treatment
#**Increases release of factor VIII:von Willebrand factor multimers
#*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.
#*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
#*Onset of action ~1hr, duration of action ~4-24hr
#Estrogen
#Estrogen
#*Unclear mechanism of action
#*Unclear mechanism of action
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<references/>
<references/>


[[Category:Nephro]]
[[Category:Renal]]
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Latest revision as of 14:46, 17 October 2019

Background

  • Bleeding diathesis
    • Increased risk for of bleeding (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

Differential Diagnosis

Dialysis filter may cause thrombocytopenia

Coagulopathy

Platelet Related

Factor Related

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


  1. Acute dialysis
    • pRBCs
      • Raising HCT to above 25-30% improves bleeding time
  2. 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
  3. Estrogen
    • Unclear mechanism of action
    • Onset of action within 1d
    • Options
      • Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
  4. Cryoprecipitate
    • Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
    • 10 bags over 30 minutes
  5. Platelet transfusion
    • Minimally effective because infused platelets quickly acquire the uremic defect
    • Only use when uncontrolled hemorrhage
  6. Topical Hemostatic Agents
    • Gelatin - Gelfoam or Surgifoam
    • Thrombin - Floseal

See Also

References

  1. ↑ Hedges SJ et al. Evidence-based treatment recommendations for uremic bleeding. Nature Clinical Practice Nephrology (2007) 3, 138-153.
  2. ↑ Desmopressin (Rx) - Dosing and Uses. Medscape. http://reference.medscape.com/drug/ddavp-stimate-desmopressin-342819.
  3. ↑ Cryoprecipitate - Dosing and Uses. Medscape. http://reference.medscape.com/drug/cryo-cryoprecipitate-999498.
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