Renal disease induced coagulopathy

Background

• Uremic toxins inhibit platelet aggregation
  • Disrupts vWF
  • PT/PTT normal, but bleeding time elevated
• Dialysis filter may cause thrombocytopenia

Differential Diagnosis

Coagulopathy

Platelet Related

• Too few
  • Thrombocytopenia
• Nonfunctional
  • Aspirin
  • Von Willebrand disease

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
  • Vitamin K deficiency
  • Disseminated Intravascular Coagulation (DIC)
  • Liver disease induced coagulopathy
  • Uremic bleeding syndrome
• Genetic
  • Hemophilia
  • Factor VIII inhibitor
  • Lupus anticoagulant

Treatment

1. Acute dialysis
   1. pRBCs
      1. Raising HCT to above 25-30% improves bleeding time
   2. Desmopressin
      1. Simplest and least toxic acute treatment
      2. Increases release of factor VIII:von Willebrand factor multimers
      3. 0.3 mcg/kg IV (preferred) or SC (max 20mg). 3mcg/kg intranasaly is an option.
      4. Onset of action ~1hr, duration of action ~4-24hr
2. Estrogen
   1. Unclear mechanism of action
   2. Onset of action within 1d
   3. Options
      1. Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
3. Cryoprecipitate
   1. Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
   2. 10 bags over 30 minutes
4. Platelet transfusion
   1. Minimally effective because infused plts quickly acquire the uremic defect
   2. Only use when uncontrolled hemorrhage
5. Topical Hemostatic Agents
   1. Gelatin - Gelfoam or Surgifoam
   2. Thrombin - Floseal

See Also

• Coagulopathy (Main)