uremic bleeding

Q: 58 year old male with End Stage Renal Disease (ESRD) is back from OR after coronary artery bypass (CABG). Patient had issue with severe uremic coagulopathy in OR for which Desmopressin (DDAVP) was given twice. Also patient required pRBC transfusions along with platelets, Fresh Frozen Plasma (FFP), Four-Factor Prothrombin Complex Concentrate (4F-PCC) and Cryoprecipitate. Patient had his session of hemodialysis a night before surgery. Postoperative his coagulation profiles are in normal range. Patient is hemodynamically unstable requiring multiple vasopressors and not stable to start continuous renal replacement therapy (CRRT). Which of the following agent can be used for his uremic platelet dysfunction?

A) Factor 7 (2 mg)
B) Repeat dose of 4F-PCC
C) intravenous Estrogen
D) Repeat dose of Desmopressin
E) intrinsic Nitric oxide (iNO)



Answer: C

Though estrogen is commonly used as a long term therapy for uremic platelet disorder but there are reports of its use in acute setting. Intravenous form of estrogen can be effective within six hours, and can be used in extreme situations where all other options have been exhausted. 

Out of all of the above choices, estrogen is the only answer by exclusion.

- Factor 7 has no role in uremic bleeding. Also, it may occlude the coronary grafts (choice A). 
- Repeating 4F-PCC would not be very useful if all coagulation profiles are normal (choice B). 
- DDAVP develop tachyphylaxis quickly and is usually not effective after two doses, which patient has already received in OR (choice D). 
- iNO has no role in uremic bleeding (choice E).


#hematology
#surgicalcriticalcare
#nephrology

References:

1. Livio M, Mannucci PM, Viganò G, et al. Conjugated estrogens for the management of bleeding associated with renal failure. N Engl J Med 1986; 315:731.

2. Heunisch C et al. (1998) Conjugated estrogens for the management of gastrointestinal bleeding secondary to uremia of acute renal failure. Pharmacotherapy 18: 210-217