What are the causes of hematuria and hematomas in patients with End-Stage Renal Disease (ESRD)?

Causes of Hematuria and Hematomas in End-Stage Renal Disease (ESRD)

Patients with ESRD are at increased risk for hematuria and hematomas due to multiple factors related to uremic coagulopathy, dialysis treatment, and underlying comorbidities.

Uremic Coagulopathy and Platelet Dysfunction

• ESRD patients commonly experience platelet dysfunction as a result of uremia, which impairs platelet adhesion and aggregation, leading to increased bleeding tendencies 1
• Patients on hemodialysis tend to bleed due to platelet dysfunction and the use of anticoagulants during dialysis treatment 1
• The most common anticoagulants used during dialysis are low-molecular-weight heparin (half-life ~4 hours) and unfractionated heparin (half-life ~1-2 hours), which can contribute to bleeding risk 1

Dialysis-Related Factors

• Hemodialysis access thrombosis (fistulae and grafts) can occur with increased frequency as target hemoglobin levels are raised with erythropoietic-stimulating agents (ESAs) 1
• Dialysis procedures may cause hematomas at access sites, particularly in patients with underlying coagulation abnormalities 1
• Bleeding time should be measured as coagulation should be within normal limits, with bleeding times >10-15 minutes associated with high risks of hemorrhage 1

Anticoagulation Therapy

• Many ESRD patients receive oral anticoagulants for various comorbidities, significantly increasing their risk of spontaneous bleeding and hematomas 2
• A study of spontaneous renal hemorrhage in ESRD patients found that four out of eight patients were receiving oral anticoagulants at the time of bleeding 2
• Platelet transfusion should be considered if the platelet count is <50,000/mm³ to reduce bleeding risk 1

Spontaneous Renal Hemorrhage

• Spontaneous subcapsular or perinephric bleeding can occur in ESRD patients, particularly in those with acquired renal cystic disease 2
• Symptoms of spontaneous renal hemorrhage include sudden abdominal pain, vomiting, and occasionally hematuria, always associated with a hemoglobin decrease 2
• Renal rupture should be considered in cases of unexplained distress or sudden fall in hemoglobin, especially in patients on anticoagulants 2

Acquired Cystic Kidney Disease

• Acquired renal cystic disease is common in ESRD patients and can lead to spontaneous hemorrhage 2
• In a study of spontaneous renal hemorrhage in ESRD patients, six out of eight patients had acquired renal cystic disease 2
• These cysts can rupture and cause significant bleeding into the subcapsular space or retroperitoneum 2

Vascular Calcification and Fragility

• ESRD patients often develop vascular calcification due to mineral and bone disorders, making blood vessels more prone to rupture and bleeding 1
• Bone metabolism is regulated by several factors including parathormone (PTH), fibroblast growth factor 23 (FGF23), and dihydroxycholecalciferol, which are often imbalanced in ESRD 1
• These imbalances can lead to vascular fragility and increased risk of bleeding 1

Anemia Management Complications

• The use of erythropoietic-stimulating agents (ESAs) for anemia management in ESRD can lead to complications including hypertension, which may increase the risk of bleeding 1
• Pure red cell aplasia (PRCA), a rare adverse effect of ESA therapy, can cause severe anemia requiring transfusions, which may increase the risk of bleeding due to procedural complications 1
• ESA therapy may be associated with an increased risk of stroke in hemodialysis patients with higher hemoglobin targets 1

Intracerebral Hemorrhage Risk

• ESRD is one of the most critical risk factors for intracerebral hemorrhage (ICH) 3
• Patients with ESRD on hemodialysis have different patterns of perihemorrhagic edema compared to non-dialyzed patients, with dialysis potentially preventing the enlargement of edema 3
• Despite reduced edema, dialyzed patients with ICH had a higher in-hospital mortality rate (40% vs. 10%) compared to non-dialyzed patients 3

Clinical Approach to Hematuria and Hematomas in ESRD

• When hematuria or hematomas occur in ESRD patients, evaluate for:

  1. Recent dialysis and anticoagulation use 1, 2
  2. Platelet count and function 1
  3. Presence of acquired cystic kidney disease 2
  4. Blood pressure control and hypertensive episodes 1
  5. Recent changes in ESA therapy 1

• Imaging with computerized tomography is essential to confirm bleeding and determine its extent 2

• For significant hematomas, surgical intervention may be necessary, especially given the frequency of undiagnosed tumors and potential mortality from massive hematomas 2

Prevention Strategies

• Schedule invasive procedures on non-dialysis days when possible to minimize anticoagulant effects 1
• Carefully monitor and adjust anticoagulation in ESRD patients 2
• Optimize blood pressure control to reduce bleeding risk 1
• Monitor hemoglobin levels regularly and adjust ESA therapy accordingly 1
• Consider the risk-benefit ratio of anticoagulation therapy in ESRD patients with high bleeding risk 1