Bleeding in the Patient with Renal Failure

Introduction

Over 10% of US population has some form of chronic kidney disease (CKD), and more than 350,000 persons require hemodialysis for end stage renal disease (ESRD) annually.¹
Within the next decade, the incidence of CKD is expected to nearly double.¹
Uremic bleeding is a well-known consequence of CKD and can result in significant morbidity and mortality.

No one substance has yet to be identified as the cause of uremic bleeding and the bleeding is likely to be multifactorial.
Uremic toxin accumulation causes a disruption of von Willebrand Factor (vWF), which leads to platelets’ inability to bind.
This means that typical coagulation studies on uremic bleeding patients (PT, PTT) will be normal.
Bleeding time is an indirect measure of platelet function and is almost always elevated.
Stage of kidney disease does not correlate well with bleeding risk.²

A normocytic normochromic anemia is present as early as stage 3 CKD and is almost universal by stage 4.¹ An anemia of chronic disease picture may also be seen.
These anemias are mainly due to the diseased kidney’s inability to adequately produce erythropoietin (EPO).
Despite the defective nature of platelets described above the platelet count is usually normal.

Arranged in order of frequency:³
Petechiae
Epistaxis
Bleeding following invasive procedure (such as catheter placement): Dialysis access site hemorrhage typically occurs in the setting of aneurysms, anastomosis rupture, or over-anticoagulation.⁴
Hemorrhagic pericarditis
Hemorrhagic pleural effusion
GI hemorrhage: Hemorrhage of the upper gastrointestinal tract is the second leading cause of death in patients with acute renal failure.³
Intracranial Bleed: Subdural hematomas can mimic dialysis disequilibrium syndrome
Retroperitoneal bleed: Consider hemorrhage into renal cysts in the undifferentiated hypotensive ESRD patient
Spontaneous subcapsular hematoma of the liver
Ocular hemorrhage
Uterine hemorrhage

A patient’s dialysis access is their lifeline, and its compromise should only occur if their life is in jeopardy.
Patients with ESRD on dialysis have very delicate fluid balance and fluid overload may be apparent on aggressive resuscitation.

Avoid placing a suture into a graft or fistula unless absolutely necessary.
A single stitch will often work better if there is a linear tear in the access site versus a puncture.
A tourniquet will stop the flow from a bleeding access site on the extremity but will most surely result in thrombosis of the graft or fistula.

Difficult in the actively bleeding patient
Avoid heparin
Corrects bleeding time in 65-85% of patients
In general, peritoneal dialysis patients have less bleeding risk than hemodialysis patients.

Mechanism of action not fully known: likely increases the release of factor 8 VWF polymers from the vascular endothelium => improves platelet aggregation.
Effective in about 50% of patients
Dose: 0.3 mcg/kg SC or IV; onset: 1 hour; duration: 4-8 hours
1 dose can lead to tachyphylaxis secondary to depletion of factor VIII and vWF from endothelial stores.³
Contraindications: polydipsia, unstable angina, or severe congestive heart failure due to its antidiuretic effect
Special considerations: if no IV access DDAVP can be administered intranasally at a dose of 3 mcg/kg, however IV dose is preferred.

Heparin is frequently used during dialysis. The half-life of heparin is short (1.5 hours), thus Protamine will only be effective during the first few hours.
Dose: 1 mg of Protamine for every 100 units of heparin given. If the heparin dose is unknown, 10-20 mg of protamine can be given.⁴
Contraindications: Avoid in fish allergy, caution if prior vasectomy and caution in pulmonary hypertension

Helpful when bleeding from dialysis access site.

Gelatin products	Provide a physical matrix for clotting to occur Do not require clotting cascade⁵ Gelfoam and Surgifoam
Thrombin	Provides structure for fibrin clot following activation of coagulation cascade. Requires intact coagulation cascade to be effective. Floseal

Contains Factor VIII, fibrinogen, Factor XIII, vWF, and fibronectin
Dose: Use 10 bags of Cryoprecipitate over 30 mins; should see an effect within 4-12 hours⁶

Only in cases of uncontrolled hemorrhage
Platelets become dysfunctional shortly after entering uremic environment
Use in combination with other agents (i.e. desmopressin, cryoprecipitate, and packed red blood cells).³

Transfuse to a level of around 10mg/dl; ensure that this is given along with DDAVP and platelets +/- cryoprecipitate.
Remember, anemia worsens bleeding

For an algorithm on the management of uremic bleeding, check out “Evidence-based treatment recommendations for uremic bleeding” published in Nature.²