One discussion this week involved the treatment for uremic bleeding.

Reference: Hedges SJ, et al. Evidence-based treatment recommendations for uremic bleeding. National Clinical Practice. Nephrology. 2007 Mar;3(3):138-153.

Summary: Hedges et al (2007) provide a review of 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 complications associated with uremic bleeding syndrome. Prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens.

The article cited is worth a full text read because:

• 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 (Tables 3, 4, 5).
• An evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and address common questions related to the management of uremic bleeding.

Uremic bleeding in patients with chronic renal failure is extremely complex. One factor contributing to this complexity is the incomplete elucidation of its pathophysiology. Because the mechanisms underlying uremic bleeding are not fully understood, prevention and treatment for many different clinical scenarios are not clearly defined (p.150).

• EPO works to increase the number of red blood cells, allowing platelets to travel in closer proximity to the endothelium.
• Cryoprecipitate and desmopressin work to increase the proportion of normal or functional factors that might be dysfunctional in patients with uremic bleeding.
• Estrogens are thought to work by decreasing NO levels, thereby increasing concentrations of TxA2 and ADP.

Multiple interventions that simultaneously affect different aspects of the pathophysiology of uremic bleeding might most effectively prevent bleeding in high-risk patients and limit active bleeding in those for who cessation of blood loss is more pressing.

By determining which patients are most at risk, clinicians can utilize dialysis and EPO in the early stages of uremic bleeding, and employ desmopressin, cryoprecipitate and/or estrogens prior to a surgical procedure, thereby possibly preventing bleeding secondary to uremic platelet dysfunction.