Evidence-based treatment recommendations for uremic bleeding

Abstract

Uremic bleeding syndrome is a recognized consequence of renal failure and can result in clinically significant sequelae. Although the pathophysiology of the condition has yet to be fully elucidated, it is believed to be multifactorial. This article is a review of both the normal hemostatic and homeostatic mechanisms that operate within the body to prevent unnecessary bleeding, as well as an in-depth discussion of the dysfunctional components that contribute to the complications associated with uremic bleeding syndrome. As a result of the multifactorial nature of this syndrome, prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens. Here, these treatment options are compared with regard to their mechanism of action, and onset and duration of efficacy. An extensive review of the clinical trials that have evaluated each treatment is also presented. Lastly, we have created an evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and answered common questions related to the management of uremic bleeding.

Renal biopsy: Still a landmark for the nephrologist

“…To totally assess the steps of haemostasis it is useful to use the bleeding time that evaluates the time of platelet aggregation ( Figure 2). In case of advanced renal failure and/or prolonged bleeding time, the administration of desmopressin acetate -DDAVP (0.3 μg/kg), estrogen and cryoprecipitate has shown a reduction of the bleeding risk [42,43] . Antiplatelet agents and oral anticoagulants have to be withdrawn at least one week before renal biopsy [44] , the last ones until normalization of INR, and replaced with low molecular weight heparin (LMWH).…”

Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma

“…These evidence-based guidelines included recommendations on the use of CRYO for the management of uremic bleeding in 2007 (Hedges et al, 2007). Despite acknowledging that the response to CRYO administration in uremic patients can be unpredictable, CRYO was considered a reasonable therapeutic option in uremic patients at high risk for bleeding or actively bleeding.…”

Unsupervised analysis of combined lipid and coagulation data reveals coagulopathy subtypes among dialysis patients

“…Therefore, the hemostatic balance in ESRD patients receiving dialysis modalities is often a guessing game. Thus, bleeding abnormalities associated with ESRD are difficult to assess due to both the overlapping procoagulant and pro-bleeding profiles (5).…”