UMEM Educational Pearls

Category: Critical Care

Title: Controlling uremic bleeding

Keywords: uremia, bleeding, ddavp, estrogens, epogen, cryoprecipitate (PubMed Search)

Posted: 6/6/2011 by Haney Mallemat, MD (Emailed: 6/7/2011) (Updated: 6/7/2011)
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Bleeding associated with uremia is a spectrum, from mild cases (e.g., bruising or prolonged bleeding from venipuncture) to life-threatening (e.g., GI or intracranial bleed). The exact pathologic mechanisms are not understood, but are likely multi-factorial (e.g., dysfunctional von Willebrand’s Factor (vWF) and factor VIII, increased NO, etc.)

Besides dialysis, treatments for uremic bleeding include:

  1. DDAVP (fastest)
    1. 0.3-0.4 micrograms/kg IV or SC
    2. Increases vWF and factor VIII release
    3. Advantages: Begins < 1 hour
    4. Disadvantages: Tachyphylaxis; Stored factors deplete
  2. Cryoprecipitate
    1. Replaces fibrinogen, vWF, and factor VIII
    2. Advantages: Works 1-4 hours
    3. Disadvantages: transfusion reactions, infections, pulmonary edema, etc.
  3. Conjugated Estrogens
    1. Unclear mechanism; possibly increases ADP and thromboxane activity
    2. 0.6 mg/kg once daily x 5 days
    3. Advantages: Short and long-term effects
    4. Disadvantages: Hot flashes (males too!)
  4. Recombinant Erythropoietin (slowest)
    1. 40-150 U/kg three times weekly
    2. Multiple mechanisms
    3. Advantages: Helps anemia (common in renal failure) as well as bleeding complications.
    4. Disadvantages: Up to 7 days to observe effects


Hedges, SJ. Evidence-based treatment recommendations for uremic bleeding.NatClinPractNephrol.2007 Mar;3(3):138-53.

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