Snapshot A 45-year-old woman presents to the emergency room with persistent bleeding after a tooth extraction. She has gone through many packs of gauze without any improvement. Her past medical history includes a nephrectomy on the right side ten years ago. While dialysis was recommended two years ago, she refused. On labs, her creatinine is 6 mg/dl with normal coagulation factor levels and normal PT/PTT. She is given desmopressin (DDAVP). Introduction Overview uremic platelet dysfunction is caused by renal dysfunction and azotemia, resulting in bleeding Epidemiology Risk factors renal insufficiency requiring dialysis chronic kidney disease etiology Pathogenesis mechanism intrinsic defect of platelet results in abnormal platelet to endothelium interaction dysfunction of GpIIb/IIIa recall GpIIb/IIIa interacts with von Willebrand factor and fibrinogen defect in adhesion and aggregation uremic toxins no correlation with degree of azotemia no correlation with risk of bleeding uremic plasma factors produce nitric oxide (NO) NO is an endothelium-derived relaxing factor that inhibits platelet aggregation Associated conditions renal insufficiency requiring dialysis Presentation Symptoms common symptoms easy bruising Physical exam inspection mucocutaneous bleeding catheter sites oral and nasal mucosa gastrointestinal tract Studies Serum labs normal or prolonged bleeding time normal coagulation factors normal PT and PTT normal or mildly decreased platelets Peripheral blood smear echinocytes, also called burr cells, are red blood cells with serrated edges Differential Glanzmann thrombasthenia key distinguishing factor mucocutaneous bleeding since childhood, without uremia Treatment Medical desmopressin (DDAVP) indications active bleeding first line treatment dialysis indication those undergoing invasive procedures blood transfusions indication anemia conjugated estrogen or cryoprecipitate indication active bleeding refractory to DDAVP Complications Life-threatening gastrointestinal bleeding Prognosis Overall prognosis is poor in patients with uremia However, uremic platelet dysfunction is not the most common cause of death