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Updated: Dec 18 2021

Uremic Platelet Dysfunction

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  • 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
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