Transdermal estradiol for the management of refractory uremic bleeding

Gonzalez, Jimmy; Bryant, Samantha; Hermes-DeSantis, Evelyn R.

doi:10.2146/ajhp170241

Cited by 8 publications

(5 citation statements)

References 43 publications

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“…Conjugated oestrogens administered via the oral, transdermal and i.v. routes have all shown efficacy in improving haemostasis by decreased bleeding times in uraemic patients 117,118 …”

Section: Discussionmentioning

confidence: 99%

“…routes have all shown efficacy in improving haemostasis by decreased bleeding times in uraemic patients. 117,118 Endocrine diseases A broad variety of endocrine disorders have been associated with coagulation-fibrinolysis abnormalities. Overt hypothyroidism appears to be associated with a bleeding tendency, whereas in other endocrine diseases, including subclinical hypothyroidism, the thrombotic tendency seems predominant.…”

Section: Renal Dysfunctionmentioning

confidence: 99%

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Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Kietaibl

Ahmed

Afshari

et al. 2023

European Journal of Anaesthesiology

101

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BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

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“…Conjugated oestrogens administered via the oral, transdermal and i.v. routes have all shown efficacy in improving haemostasis by decreased bleeding times in uraemic patients 117,118 …”

Section: Discussionmentioning

confidence: 99%

Section: Renal Dysfunctionmentioning

confidence: 99%

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Kietaibl

Ahmed

Afshari

et al. 2023

European Journal of Anaesthesiology

101

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“…The bleeding tendency in uremic patients was further complicated or exacerbated by their comorbidities and medications (e.g., hypertension, atrial fibrillation with warfarin therapy, cerebrovascular disease with anticoagulants) [318,[324][325][326]. For patients who were refractory to routine interventions for uremic bleeding, conjugated estrogens might be another option [327][328][329]. Overall, there lacks concrete data regarding the efficacy of estrogen in the prevention and treatment of bleeding in CKD patients.…”

Section: Uremic Coagulopathymentioning

confidence: 99%

Estrogen and estrogen receptors in kidney diseases

Chen

2021

Renal Failure

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Acute kidney injury (AKI) and chronic kidney disease (CKD) are posing great threats to global health within this century. Studies have suggested that estrogen and estrogen receptors (ERs) play important roles in many physiological processes in the kidney. For instance, they are crucial in maintaining mitochondrial homeostasis and modulating endothelin-1 (ET-1) system in the kidney. Estrogen takes part in the kidney repair and regeneration via its receptors. Estrogen also participates in the regulation of phosphorus homeostasis via its receptors in the proximal tubule. The ERa polymorphisms have been associated with the susceptibilities and outcomes of several renal diseases. As a consequence, the altered or dysregulated estrogen/ERs signaling pathways may contribute to a variety of kidney diseases, including various causes-induced AKI, diabetic kidney disease (DKD), lupus nephritis (LN), IgA nephropathy (IgAN), CKD complications, etc. Experimental and clinical studies have shown that targeting estrogen/ERs signaling pathways might have protective effects against certain renal disorders. However, many unsolved problems still exist in knowledge regarding the roles of estrogen and ERs in distinct kidney diseases. Further research is needed to shed light on this area and to enable the discovery of pathwayspecific therapies for kidney diseases.

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“…Even transdermal doses 50 μg daily might be effective over the long term without increasing thrombotic risk. 160 Nasal bleeding can also be stopped with an intranasal application of estrogens, which was successful in patients with von Willebrand disease and hemophilia. 161 However, the evidence on the effect of estrogens to reduce bleeding in uremia is scarce as mainly case reports and trials with low case numbers exist that do not include a comparison with other hemostatic agents.…”

Section: Vasopressin Analoguesmentioning

confidence: 99%

“…Even transdermal doses ≤ 50 μg daily might be effective over the long term without increasing thrombotic risk. 160 Nasal bleeding can also be stopped with an intranasal application of estrogens, which was successful in patients with von Willebrand disease and hemophilia. 161…”

Section: Changes In Platelet Function In Advanced Chronic Kidney Diseasementioning

confidence: 99%

Platelets in Advanced Chronic Kidney Disease: Two Sides of the Coin

Lutz¹,

Jurk

2020

Semin Thromb Hemost

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Rates of thrombosis and bleeding episodes are both increased in patients with advanced chronic kidney disease (CKD). The pathogenic mechanisms of thrombosis in these patients include platelet activation, increased formation of platelet-leukocyte conjugates, and platelet-derived microparticles, as well as effects of uremic toxins on platelets. On the other side of the coin, platelet hyporeactivity mediated by uremic toxins and anemia contributes to the increased bleeding risk in advanced CKD. Platelets also contribute to the inflammatory environment, thus increasing the risk of cardiovascular diseases in these patients. This review provides insights into the altered platelet function in advanced stages of CKD and their relationship with risks of thrombosis and bleeding. Particularly, the effect of dialysis on platelets will be discussed. Furthermore, therapeutic options with respect to thrombotic disorders as well as bleeding in patients with CKD are reviewed.

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Transdermal estradiol for the management of refractory uremic bleeding

Abstract: Patients who are refractory to routine interventions for uremic bleeding may benefit from transdermal estrogen despite the limited data. Extended therapy with low-dose transdermal estrogen (≤50 μg daily) may provide a hemostatic benefit that outweighs thrombotic risk.

Cited by 8 publications

References 43 publications

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Estrogen and estrogen receptors in kidney diseases

Platelets in Advanced Chronic Kidney Disease: Two Sides of the Coin

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