View source for Uremic bleeding syndrome

==Background==
*[[coagulopathy|Bleeding diathesis]]
**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==
*Wide range of presentations
**Ecchymosis, [[purpura]], [[epistaxis]], [[hemorrhage of AV fistula|fistula bleeding]], venipuncture bleeding
**[[GI bleeding]]
**[[ICH|Intracranial bleeding]]

==Differential Diagnosis==
''Dialysis filter may cause [[thrombocytopenia]]''
{{Increased bleeding DDX}}

==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<ref>Hedges SJ et al. Evidence-based treatment recommendations for uremic bleeding. Nature Clinical Practice Nephrology (2007) 3, 138-153.</ref>
**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<ref>Desmopressin (Rx) - Dosing and Uses. Medscape. http://reference.medscape.com/drug/ddavp-stimate-desmopressin-342819.</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
**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
#[[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

==Disposition==
*Admit all patients with active uremic bleeding
*Nephrology consultation for dialysis consideration
*ICU admission for hemodynamically significant bleeding
*Discharge only if bleeding controlled and adequate outpatient dialysis access confirmed

==See Also==
*[[Coagulopathy]]

==References==
<references/>

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