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Bleeding associated with uremia is a spectrum, from mild cases (e.g., bruising or prolonged bleeding from venipuncture) to life-threatening (e.g., GI or intracranial bleed). The exact pathologic mechanisms are not understood, but are likely multi-factorial (e.g., dysfunctional von Willebrand’s Factor (vWF) and factor VIII, increased NO, etc.)
Besides dialysis, treatments for uremic bleeding include:
- DDAVP (fastest)
- 0.3-0.4 micrograms/kg IV or SC
- Increases vWF and factor VIII release
- Advantages: Begins < 1 hour
- Disadvantages: Tachyphylaxis; Stored factors deplete
- Cryoprecipitate
- Replaces fibrinogen, vWF, and factor VIII
- Advantages: Works 1-4 hours
- Disadvantages: transfusion reactions, infections, pulmonary edema, etc.
- Conjugated Estrogens
- Unclear mechanism; possibly increases ADP and thromboxane activity
- 0.6 mg/kg once daily x 5 days
- Advantages: Short and long-term effects
- Disadvantages: Hot flashes (males too!)
- Recombinant Erythropoietin (slowest)
- 40-150 U/kg three times weekly
- Multiple mechanisms
- Advantages: Helps anemia (common in renal failure) as well as bleeding complications.
- Disadvantages: Up to 7 days to observe effects
References
Hedges, SJ. Evidence-based treatment recommendations for uremic bleeding.NatClinPractNephrol.2007 Mar;3(3):138-53.
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