Snapshot A 45-year-old woman presents to the emergency room with unretractable 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 DDAVP. Introduction Bleeding disorder caused by renal dysfunction and azotemia Pathogenesis abnormal platelet-endothelium interaction intrinsic defect of platelets dysfunction of GpIIb/IIIa recall GpIIb/IIIa interacts with von Willebrand factor and fibrinogen defect of adhesion and aggregation uremic toxins no correlation with degree of azotemia and risk of bleeding uremic plasma factors that produce NO = likely culprit NO (endothelium-derived relaxing factor) inhibits platelet aggregation NO production increased in uremic patients Associated conditions renal insufficiency requiring dialysis Presentation Symptoms mucocutaneous bleeding skin oral mucosa nasal mucosa GI tract easy bruising increased bleeding after taking aspirin degree of azotemia does not correlate with bleeding risk Evaluation Normal or prolonged bleeding time Normal levels of coagulation factors Normal PT and PTT Peripheral blood smear showing echinocytes Mild thrombocytopenia Differential Diagnosis HIT Glanzmann thrombasthenia Treatment Treat only with active bleeding first-line therapy with desmopressin (DDAVP) dialysis indicated for those undergoing invasive procedures blood transfusions as needed for anemia if refractory to desmopressin, consider conjugated estrogen cryoprecipitate Prognosis, Prevention, and Complications Prognosis overall prognosis of patient with uremia is poor however, typically will not die from uremic platelet dysfunction