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Uremic Platelet Dysfunction

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Topic updated on 12/27/16 8:28pm

Snapshot
  • A 50-year-old man with chronic kidney disease on dialysis presents with a mild but long-lasting nosebleed. On physical exam, his gums are also bleeding. An IV is inserted, which resulted in bleeding around the site. His coagulation function tests are normal, but his bleeding time is 5 minutes. He is given DDAVP, and the bleeding resolved within an hour.
Introduction

  • Bleeding disorder caused by renal dysfunction and azotemia
  • Pathogenesis
    • abnormal platelet-endothelium interaction
    • intrinsic defect of platelets
      • dysfunction of GpIIb/IIIa
        • recall GpIIb/IIIa interacts with von Willebrand factor and fibrinogen
      • defect of adhesion and aggregation
    • uremic toxins
      • uremic plasma factors that produce NO = likely culprit
        • NO (endothelium-derived relaxing factor) inhibits platelet aggregation
  • Associated conditions
    • renal insufficiency requiring dialysis
Presentation
  • Symptoms
    • mucocutaneous bleeding
      • skin
      • oral mucosa
      • nasal mucosa
    • increased bleeding after taking aspirin
Evaluation
  • Normal or prolonged bleeding time
  • Normal levels of coagulation factors
  • Normal PT and PTT
  • Peripheral blood smear showing burr cells (echinocytes)
  • Mild thrombocytopenia
Differential Diagnosis
  • HIT
  • Glanzmann thrombasthenia
Treatment
  • First-line therapy with desmopressin (DDAVP)
  • Dialysis indicated for those undergoing invasive procedures
  • Blood transfusions as needed for anemia
  • If refractory to desmopressin, consider
    • conjugated estrogen
    • cryoprecipitate
Prognosis, Prevention, and Complications
  • Prognosis
    • overall prognosis of patient with uremia is poor
    • however, typically will not die from uremic platelet dysfunction


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