Renal disease induced coagulopathy

Background

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

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. Plt transfusion
   1. Minimally effective b/c 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)

Source

• Tintinalli
• UpToDate