Hemostatic abnormalities in severe renal failure: Do they bark or bite?

Abstract

Abnormal primary hemostasis is believed to be the most significant contributor to uremic bleeding. This study aimed to describe the prevalence and profile of primary and secondary hemostatic disorders in patients with chronic kidney disease (CKD) Stages 4 and 5 and to determine their association if any, with degree of uremia. Stages 4 and 5 predialysis CKD patients attending nephrology outpatient clinic were prospectively recruited and the following bleeding parameters were measured in all patients: platelet count, bleeding time (BT), Factor VIII assay, von Willebrand factor antigen (vWF:Ag), vWF:ristocetin cofactor activity (vWF:RCo), ratio of vWF:ristocetin cofactor activity to vWF antigen (vWF:RCo/vWF:Ag), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Forty-five patients (80%, males) with a mean age of 39.4 years, 82% (n = 37) in Stage 5 CKD, were recruited for the study. The prevalence of thrombocytopenia was significantly higher among patients from West Bengal (15/26, 57.7%) compared to other study patients (2/19, 10.5%; P = 0.001); however, all had macrothrombocytes with normal BT, suggestive of the Harris syndrome. Factor VIII, vWF:Ag, vWF:RCo, vWF:RCo/vWF:Ag ratio, BT, PT, and aPTT were abnormal in 0 (0%), 0 (0%), 0 (0%), 4 (8.8%), 1 (2.2%), 7 (15.6%), and 5 (11.1%) patients, respectively. Except for thrombocytopenia, the prevalence of hemostatic abnormalities did not differ between CKD Stages 4 and 5. Hemostatic abnormalities are uncommon in Stages 4–5 CKD and except for thrombocytopenia, are not associated with degree of uremia. Constitutional macrothrombocytopenia is associated with normal BT even in CKD.

Otorhinolaryngological dysfunctions induced by chronic kidney disease in pre- and post-transplant stages

“…Higher than in GP* [3] Predisposing mechanism Collection of toxins (mainly high blood urea levels) not properly removed by kidneys [3] Anemia and coagulation dysfunctions [3] Bacteria colonizing nasal cavity that decompose urea to ammonia [3] One of the most common sites of bleeding in patients with uremia [3] Nasal bleeding could be resolved/reduced after blood urea level is normalized [3] Mucormycosis (rhino-cerebral) 52-56.25% of RTRs are affected [4] Might result from [4] Cytotoxic drugs and steroids incorporation Prolonged antibiotic therapy Drug-induced granulocytopenia…”

“…Nasal bleeding (epistaxis) is a common CKD-induced symptom [3]. Nasal cavity is one of the most common sites of bleeding in patients with uremia.…”

“…In patients with CKD, epistaxis is mainly caused by the collection of toxic elements that in healthy people are eliminated by kidneys in urine. Other factors predisposing to nasal bleeding in CKD are anemia and coagulation dysfunctions [3]. It was suggested that urea was the most important cause of nasal bleeding [3].…”

“…As the prevalence of CKD continues to rise worldwide, the number of patients with CKD-related systemic dysfunctions, including otorhinolaryngological, will presumably increase as well [1]. CKD-induced effects of the body systems is a result of the accumulation of nitrogenous waste products, so-called "uremic toxins", in various tissues, electrolyte imbalance, local chemical reactions due to ammonia, immunological, vascular and coagulation changes [3]. Ototoxic and immunosuppressive drugs used in CKD therapy also lead to a number of systemic complications [3].…”

“…CKD-induced effects of the body systems is a result of the accumulation of nitrogenous waste products, so-called "uremic toxins", in various tissues, electrolyte imbalance, local chemical reactions due to ammonia, immunological, vascular and coagulation changes [3]. Ototoxic and immunosuppressive drugs used in CKD therapy also lead to a number of systemic complications [3]. It was established that immunosuppression in patients after kidney transplantation predisposes to various infections, especially opportunistic ones, and to malignancy occurrence [4,5].…”