Spontaneous retroperitoneal hemorrhage after hemodialysis involving anticoagulant agents

Abstract

Abstract:In this paper, we described the symptoms and treatment of a patient with diabetic nephropathy accompanied by spontaneous retroperitoneal hemorrhage after hemodialysis. An elderly female patient with diabetic nephropathy presented with severe pain, numbness, and an increasing swelling in the left hip and left thigh after six sessions of hemodialysis involving the use of an antiplatelet drug and an anticoagulant agent. Her hemoglobin decreased to 46 g/L. An abdominal ultrasound showed a hematoma in the left retroperitoneal space, and computed tomography (CT) findings revealed a 6 cm×8 cm×10 cm hematoma in the left psoas muscle. After aggressive supportive therapy [the administration of packed red blood cell transfusion, carbazochrome sodium sulfonate injection, and continuous venovenous hemofiltration (CVVH)], the patient's vital signs stabilized and her hemoglobin increased to 86 g/L. Repeat CT showed that the hematoma had been partially absorbed after two weeks. Eventually, the patient was discharged with stable vital signs. Physicians should be aware of the possibility of spontaneous retroperitoneal hemorrhage, particularly in patients with diabetic nephropathy undergoing hemodialysis involving the use of anticoagulant agents.

Spontaneous calf hematoma in a patient with diabetic nephropathy receiving maintenance hemodialysis: A case report and review of the literature

“…Although LMWH is an excellent alternative to unfractionated heparin because of its higher efficacy and safety, unfortunately, LMWH therapy is not without risks of spontaneous bleeding, such as in the abdominal wall, thigh and retroperitoneum, and the spinal and epidermal hematomas. [13][14][15][16][17][18] It was also noted that there is a relatively high bleeding risk with use of LMWH in some patients, such as in elderly patients with vascular diseases and in patients with renal insufficiency, diabetes, hypertension, or antineutrophil cytoplasmic antibody-related vasculitis. 19 In addition, renal impairment may lead to over-dosage, and/or an accumulative effect of LMWH may further cause bleeding complications in ESRD patients.…”

“…19 In addition, renal impairment may lead to over-dosage, and/or an accumulative effect of LMWH may further cause bleeding complications in ESRD patients. 13,20 Certainly, spontaneous renal hemorrhage in patients with diabetes receiving HD has been described. 21 A recent study by Wang et al indicated a 1.57-fold higher incidence of subdural hematoma in a cohort of 28,045 diabetic patients compared with 56,090 subjects without diabetes.…”

“…In addition, there is also increased bleeding tendency in patients with renal failure, especially those HD patients receiving anticoagulants. 1,4,13,27,28 Considering these scenarios, it is critical to distinguish between hematoma and DVT in patients with HD. Otherwise it can lead to the initiation of empiric anticoagulation that can have serious consequences, including compartment syndrome with significant blood loss.…”

“…The diameter of the widest point of the right calf was 41 cm (left: 36 cm). Laboratory indices were as follows: white blood cell count 6.48 × 10 9 /L, the ratio of neutrophils 68%, hemoglobin 70 g/L, platelet cell count 170 × 10 9 /L, prothrombin time 16.3 seconds (normal [10][11][12][13][14], activated partial thromboplastin time 53.4 seconds (normal 28-45 seconds), bleeding time 1.5 minutes (control 1-3 minutes), coagulation factors (II, V, VII, IX, X, XI, XII) 80-110% (normal 70-130%), fibrinogen 4.45 g/L (normal <5 g/L), blood urea nitrogen 15.8 mmol/L, serum creatinine 631 μmol/L, total protein 74.5 g/L, and albumin 35.4 g/L. Alanine aminotransferase and aspartate aminotransferase were normal.…”

Three cases of spontaneous lumbar artery rupture in hemodialysis patients

“…Massive retroperitoneal hematoma mostly results from rupture due to an abdominal aortic aneurysm or malignancy of retroperitoneal organs, most often the kidneys and adrenal glands . Spontaneous lumbar artery rupture is rare, and its incidence is still unknown.…”