Uremic bleeding syndrome

Background

• Bleeding diathesis
  • Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired platlet function
• 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
  • Thrombocytopenia
• Nonfunctional
  • Aspirin
  • Von Willebrand disease

Factor Related

• Acquired (Drug Related)
  • Warfarin (Coumadin)
  • Unfractionated Heparin
  • Low Molecular Weight Heparin (Enoxaparin) (i.e. Lovenox)
• Illness induced
  • Vitamin K deficiency
  • Disseminated Intravascular Coagulation (DIC)
  • Liver disease induced coagulopathy
  • Uremic bleeding syndrome
• Genetic
  • Hemophilia
  • Factor VIII inhibitor
  • Lupus anticoagulant

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
  • 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
  • Cryoprecipitate 10 bags over 30 min - benefit seen within 4-12 hrs in most
  • 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

• Coagulopathy

References

Authors

Ross Donaldson, Kevin Lu, Neil Young, Daniel Ostermayer