deamino-arginine-vasopressin and Renal-Insufficiency

Uremic bleeding syndrome is a recognized consequence of renal failure and can result in clinically significant sequelae. Although the pathophysiology of the condition has yet to be fully elucidated, it is believed to be multifactorial. This article is a review of both the 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 the complications associated with uremic bleeding syndrome. As a result of the multifactorial nature of this syndrome, prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens. Here, these 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. Lastly, we have created an evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and answered common questions related to the management of uremic bleeding.

Topics: Deamino Arginine Vasopressin; Erythropoietin; Estrogens, Conjugated (USP); Evidence-Based Medicine; Factor VIII; Fibrinogen; Hemorrhage; Humans; Practice Guidelines as Topic; Renal Dialysis; Renal Insufficiency; Uremia; von Willebrand Factor

Topics: Aged; Biopsy; Deamino Arginine Vasopressin; Hemorrhage; Humans; Pilot Projects; Renal Insufficiency

Acute heparin-induced thrombocytopenia (HIT) patients present a myriad of anticoagulation management challenges, in clinical settings where unfractionated heparin (UFH) is the traditional drug of choice. UFH use in cardiac surgery is a known entity that has been subject to rigorous research. Research has, thus, led to its unparalleled use and the development of well-established protocols for cardiac surgery. In comparison to UFH, bivalirudin use for acute HIT patients requiring urgent cardiac surgery with cardiopulmonary bypass (CPB) is still in its infancy. We describe the tailored post-CPB management of refractory bleeding in a 65-year-old infective endocarditis, acute HIT patient with renal failure who underwent urgent aortic valve replacement and mitral valve repair with bivalirudin anticoagulation. A management approach that entailed a combination of continuous venovenous haemofiltration (CVVH), 4-Factor prothrombin complex concentrate (PCC) (Beriplex), recombinant factor VIIa (rFactor VIIa) and desmopressin (DDAVP) were consecutively used post-operatively in theatre. Based on this case study experience, two modifications to institutional protocols are recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in renal failure patients or in patients where bivalirudin elimination is prolonged. Secondly, a 'rescue therapy/intervention' algorithm for the swift identification of refractory bleeding post-CPB is also recommended. Rescue therapy agents, such as a 4-Factor PCCs and rFactor VIIa, should be incorporated into the protocol after a robust evidence-based search and agreement with the haematologist. The aim of these recommendations is to reduce the risk of bleeding associated with bivalirudin use for inexperienced institutions and experienced institutions alike, until larger randomized, controlled studies provide more in-depth knowledge to expand our clinical practice.

Topics: Acute Disease; Aged; Anticoagulants; Aortic Valve; Blood Coagulation Factors; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Deamino Arginine Vasopressin; Factor VIIa; Hemorrhage; Hemostatics; Heparin; Hirudins; Humans; Male; Mitral Valve; Peptide Fragments; Recombinant Proteins; Renal Insufficiency; Thrombocytopenia

Desmopressin (DDAVP) is often used prior to procedures to minimize bleeding in patients with renal failure; however, there is little evidence to support this practice. The objectives of this study were to evaluate the practice of administration of DDAVP prior to procedures within our division and to determine the number of bleeding episodes for patients who received DDAVP compared to those who did not.. Hospital records of patients who underwent renal biopsy or central line placement between April 2006 and March 2008 were reviewed. Patients with glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) were identified and subcategorized into three groups: group A GFR <15 ml/min/1.73 m(2), group B GFR 15-29 ml/min/1.73 m(2), and group C GFR 30-60 ml/min/1.73 m(2). The number of bleeding events was noted in each group.. No significant difference was found in the number of bleeding events between those who received and did not receive DDAVP overall and in each GFR group. A possible trend towards the benefit with treatment in group A was observed.. There was no significant reduction in bleeding for those who received DDAVP which questions the validity of this practice. Patients with GFR <15 ml/min/1.73 m(2) may possibly derive benefit.

Topics: Biopsy; Catheterization, Central Venous; Child; Deamino Arginine Vasopressin; Hemostatics; Humans; Postoperative Hemorrhage; Premedication; Preoperative Care; Renal Insufficiency; Retrospective Studies; Treatment Outcome

Topics: Biopsy, Needle; Computer Systems; Deamino Arginine Vasopressin; Female; Humans; Hypertension; Kidney; Male; Nephrotic Syndrome; Prone Position; Prospective Studies; Proteinuria; Renal Insufficiency; Supine Position; Ultrasonography

A 53-yr-old man with a 33-yr history of Crohn's ileocolitis, complicated by arthritis and cologastric fistulization, was diagnosed with GI amyloidosis at the time of proctocolectomy. He had marked proteinuria (4.2 g/24 h) and moderate renal insufficiency (BUN of 35 mg/dl and serum creatinine of 2.5 mg/dl). During the operation, he had severe bleeding that required 11 U of blood. Postoperatively, desmopressin was administered, which resulted in a prompt cessation of bleeding. This case demonstrates the efficacy of desmopressin in reversing the bleeding diathesis in surgical patients with amyloidosis complicated by renal insufficiency.

Topics: Amyloidosis; Blood Transfusion; Colectomy; Crohn Disease; Deamino Arginine Vasopressin; Disease Susceptibility; Follow-Up Studies; Hemostatics; Humans; Intraoperative Complications; Male; Middle Aged; Postoperative Hemorrhage; Renal Insufficiency; Treatment Outcome