Uremic bleeding syndrome: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
''Dialysis filter may cause [[thrombocytopenia]]'' | |||
{{Increased bleeding DDX}} | {{Increased bleeding DDX}} | ||
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[[Category:Nephro]] | [[Category:Nephro]] | ||
[[Category:Heme/Onc]] | |||
==Background== | ==Background== | ||
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**Disrupts vWF | **Disrupts vWF | ||
**PT/PTT normal, but bleeding time elevated | **PT/PTT normal, but bleeding time elevated | ||
==Treatment== | ==Treatment== | ||
#Acute dialysis | #Acute dialysis | ||
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#*Gelatin - Gelfoam or Surgifoam | #*Gelatin - Gelfoam or Surgifoam | ||
#*Thrombin - Floseal | #*Thrombin - Floseal | ||
Revision as of 11:48, 8 November 2015
Background
- Bleeding diathesis
- Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired platlet function
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
Diagnosis
- 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 0.6 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
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.
Background
- Uremic toxins inhibit platelet aggregation
- Disrupts vWF
- PT/PTT normal, but bleeding time elevated
Treatment
- Acute dialysis
- pRBCs
- Raising HCT to above 25-30% improves bleeding time
- Desmopressin
- 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
- pRBCs
- 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