From the Guidelines
Atypical bleeding workup should prioritize a comprehensive evaluation of coagulation, complete blood count, and electrolyte levels, as patients with chronic kidney disease (CKD) are at high risk of bleeding due to platelet dysfunction and anticoagulant use during dialysis, as reported by 1. When evaluating atypical bleeding in patients with CKD, it is essential to consider the potential for bleeding complications due to coagulopathy, thrombocytopenia, or anemia.
- Key laboratory tests should include:
- Complete blood count to evaluate for anemia or thrombocytopenia
- Coagulation studies, such as bleeding time, to assess the risk of hemorrhage
- Electrolyte levels, including Na+, K+, Ca2+, Mg2+, Cl−, blood urea, creatinine, and bicarbonate levels
- Referral to a nephrologist is necessary if the test results are not normal, as reported by 1, to manage the patient's condition and minimize the risk of bleeding complications. Additional considerations in the workup for atypical bleeding in CKD patients include:
- Evaluation of bone metabolism, including parathormone (PTH), fibroblast growth factor 23 (FGF23), and dihydroxycholecalciferol (1,25(OH)2D) levels, to assess the risk of bone-related complications
- Assessment of the patient's immune system, as CKD patients are at increased risk of infections, such as candidiasis, and malignancies, such as Kaposi's sarcoma and non-Hodgkin lymphoma, as noted by 1
- Consideration of the timing of dental procedures in relation to dialysis, as surgery on non-dialysis days or the day after hemodialysis may minimize the risk of bleeding complications, as suggested by 1.
From the Research
Atypical Bleeding Workup
The workup for atypical bleeding involves a comprehensive approach to determine the underlying cause of the bleeding.
- The first step is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding 2.
- A thorough bleeding, medical, and family history is essential to determine the nature and severity of bleeding symptoms 3.
- The use of a Bleeding Assessment Tool can help obtain a comprehensive bleeding history and determine the individual bleeding score that reflects bleeding severity 3.
Laboratory Investigation
Laboratory investigation is crucial in the workup of atypical bleeding.
- Initial laboratory tests include bleeding time, platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT) 4.
- An abnormal PT, with or without an abnormal aPTT, but with normal results in the other three tests, indicates an abnormal reduction in the vitamin K-dependent clotting factors or factor V 4.
- A prolonged PT, APTT, or bleeding time may pose a diagnostic dilemma, and a practical approach to evaluation and reflexive tests is necessary 5.
Classification and Management
The etiologies of acute abnormal uterine bleeding can be classified using the PALM-COEIN system 6.
- Medical management is the initial treatment for most patients, and options include intravenous conjugated equine estrogen, multi-dose regimens of combined oral contraceptives or oral progestins, and tranexamic acid 6.
- Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management 6.