uremic bleed

 Q: Which of the following is not recommended in a patient who is bleeding due to uremic dysfunction of platelets?

A) Transfusion of fresh platelets 

B)  Dialysis

C)  Desmopressin (DDAVP) 

D)  Estrogen 

E) Cryoprecipitate

Answer: A

In uremic platelet dysfunction transfusion of fresh platelets may not be very effective though clinicians have used this modality in desperate situations. Transfused platelets quickly acquire the uremic defect (choice A). 

One modality which is effective and in use for last 50 years is heparin free hemo or peritoneal dialysis, given stability of hemodynamic (choice B). 

Another preemptive strategy which is used in uremic patients undergoing invasive procedure is the administration of DDAVP (Choice C). 

Estrogen has been used effectively in dialysis patients who are prone to chronic gastrointestinal (GI) bleeding due to angiodysplasia or colonic polyps. In acute situations intravenous estrogen has also been found to be effective. Estrogen probably acts via decreased generation of Nitric Oxide (NO) (Choice D). 

Cryoprecipitate acts by the presence of substances in cryoprecipitate that enhances platelet aggregation, such as factor VIII:von Willebrand factor multimers or fibrinogen (Choice E).

It has also been argued that increasing the hemoglobin level to or above 10 g/dL reduces the bleeding time. 

#hematology

References:

1. Stewart JH, Castaldi PA. Uraemic bleeding: a reversible platelet defect corrected by dialysis. Q J Med 1967; 36:409. 

2. Zeigler ZR, Megaludis A, Fraley DS. Desmopressin (d-DAVP) effects on platelet rheology and von Willebrand factor activities in uremia. Am J Hematol 1992; 39:90. 

3. Kim JH, Baek CH, Min JY, et al. Desmopressin improves platelet function in uremic patients taking antiplatelet agents who require emergent invasive procedures. Ann Hematol 2015; 94:1457.

4. Livio M, Gotti E, Marchesi D, et al. Uraemic bleeding: role of anaemia and beneficial effect of red cell transfusions. Lancet 1982; 2:1013. 

5. Bronner MH, Pate MB, Cunningham JT, Marsh WH. Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. An uncontrolled trial. Ann Intern Med 1986; 105:371. 

6. Viganò G, Gaspari F, Locatelli M, et al. Dose-effect and pharmacokinetics of estrogens given to correct bleeding time in uremia. Kidney Int 1988; 34:853. 

7. Janson PA, Jubelirer SJ, Weinstein MJ, Deykin D. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med 1980; 303:1318.