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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1246-1248
Uremic bleeding with pericardial and subconjunctival hemorrhage


Renal Unit, Department of Medicine, University of Ilorin Teaching Hospital, P.M.B 1459, Ilorin, Nigeria

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Date of Web Publication8-Nov-2011
 

How to cite this article:
Chijioke A. Uremic bleeding with pericardial and subconjunctival hemorrhage. Saudi J Kidney Dis Transpl 2011;22:1246-8

How to cite this URL:
Chijioke A. Uremic bleeding with pericardial and subconjunctival hemorrhage. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 22];22:1246-8. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1246/87246
To the Editor,

Hemostatic failure is a recognized complication of uremia, and is largely attributed to platelet dysfunction and vascular endothelial cell abnormality. [1] The tendency to bleed is particularly severe in uremic patients with anemia, and correction of anemia by red cell transfusion or recombinant erythropoietin tends to ameliorate bleeding in many cases. [2] Abnormality in platelet function is related to uremic toxins in circulation, which include urea, creatinine, guanidinosuccinic acid, methylguanidine, phenolic acid esters, prostacyclins and nitric oxide. [3],[4] The pathogenesis of uremic bleeding has been shown from studies to result from complex abnormalities involving platelet function, vascular integrity and platelet-vessel wall interactions. [3],[4],[5]

The occurrence of hemorrhagic pericardial effusion (HPE) in chronic renal failure (CRF) is being recognized with increasing frequency since the utilization of long-term dialysis became available. [6],[7] The co-existence of pericardial and subconjuctival hemorrhage is an uncommon occurrence in CRF, although one recognizes that uremic bleeding can manifest in any part of the body. This is the first case of HPE with bilateral subconjuctival hemorrhage due to uremia being reported from Nigeria.

Mr. SA, a 27-year-old motor mechanic, was referred to the renal care center of the University of Ilorin Teaching Hospital (UITH) from a private hospital in Ilorin, Nigeria, with a working diagnosis of acute renal failure secondary to urinary tract infection. He was well until two weeks prior to presentation at the referral hospital, when he developed high-grade fever with rigors, frequent loose stools, vomiting, loin pain, dysuria and urinary frequency. There was no associated hematuria or bleeding from any of the orifices.

He was found to be acutely ill, dehydrated, febrile and mildly pale, with no peripheral edema. The pulse rate was 86/mm, regular and of good volume and blood pressure was 130/70 mmHg. Abdominal examination revealed bilateral renal angle tenderness. He was commenced on intravenous fluids, antibiotics and metochlorpramide, with which most of the presenting symptoms subsided by the 10 th day of admission. He, however, developed unusual weakness, body swelling and reduction in urine with anorexia, hiccups and passage of dark tarry stools. Results of investigations performed at the referral hospital showed the following: serum sodium of 130 mmol/L, phosphate of 1.8 mmol/L, blood urea of 26 mmol/L, serum creatinine of 780 μmol/L, calcium of 2.17 mmol/L and uric acid of 0.46 mmol/L. The packed cell volume was 28%, white blood cell count was 9,600/mm 3 , with 84% neutrophils and 15% lymphocytes. Urine analysis showed 3+ protein and urine microscopy showed numerous pus cells and 2-4 red blood cells/hpf; culture did not show any growth.

At presentation to our center, the patient had cough, breathlessness, orthopnea, chest pain, generalized pruritus and redness of the eyes. Further questioning revealed that he had recurrent episodes of facial and pedal swelling in the preceding 18 months, which responded to diuretic therapy from private clinics. Physical examination revealed a young man with puffy, pale face, bilateral subconjuctival hemorrhage, bilateral pitting pedal edema up to the knees and scratch marks on the skin. He had a pulse rate of 120/min, regular and bounding, blood pressure (BP) of 130/60 mmHg, raised jugular venous pressure, S3 gallop rhythm and pericardial friction rub. There were bilateral basal crepitations in the chest while the abdomen revealed tender hepatomegaly. The essential findings on central nervous system examination were drowsiness and flapping tremors. A diagnosis of acute-on-chronic renal failure with uremic bleeding precipitated by anemic heart failure and urosepsis was made. He was commenced on conservative management while undergoing diagnostic screen. The investigations showed leukocytosis and severe renal failure. Urine examination showed numerous white and red blood cells. Abdominal ultrasound showed that the right kidney measured 8.4 cm and the left kidney measured 7.8 cm in bipolar diameter; there was irregular outline and poor cortico-medullary differentiation.

In view of the foregoing results and continued deterioration in his clinical condition, he was commenced on hemodialysis in the second week of admission. The patient continued to complain of chest pain and breathlessness despite improvement in the packed cell volume and blood chemistry. He was noticed to have a small volume pulse and a BP of 100/60 mmHg, raised JVP with positive Kussmauls sign, poorly localized apex beat, distant S 3 gallop rhythm and reduction in intensity of pericardial friction rub. Echocardiogram [Figure 1] showed features of pericardial effusion. The patient did not give consent to taking pictures of the bloody eyes.
Figure 1: Echocardiogram showing features suggestive of pericardial effusion.

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He underwent urgent salvage pericardiocentesis with drainage of about 1.4 L of bloody fluid. He made remarkable improvement and did well on maintenance dialysis for two months after the procedure. Unfortunately, his clinical condition deteriorated in the following three weeks, the contributing factors being inability to sustain dialysis due to poor finances and severe infections. He subsequently died from severe uremia and overwhelming urosepsis.

Pericardial effusion with tamponade is a dreaded complication of pericarditis in patients with CRF, and its incidence seems to be higher with dialysis pericarditis than with uremic pericarditis. [8] The amount of effusion present, as determined by echocardiography, may not correlate with the risk of tamponade and relatively small effusion, especially those of rapid onset, have been associated with severe hemodynamic deterioration in patients with uremic pericarditis. [9] Although substantial effusion may benefit from prompt surgical drainage, [10] mild to moderate effusion have been successfully treated with adequate dialysis. [11] The patient in this report obviously had uremic bleeding, as evidenced by subconjuctival, upper gastrointestinal and pericardial hemorrhage. This is probably the first case of bilateral subconjuctival hemorrhage co-existing with hemorrhagic pericardial effusion reported from Nigeria.

Treatment with continuous ambulatory peritoneal dialysis may have been a better option for this patient than HD because of the cardiovascular instability and increased risk of bleeding from use of heparin. Platelet transfusions are generally ineffective in uremic bleeding as donor platelets become functionally abnormal soon after exposure to uremic plasma. [1] Desmopressin given intravenously or subcutaneously significantly shortens the bleeding time presumably by releasing Von Wille-brand Factor from vascular endothelium. Desmopressin is the treatment of choice for uremic bleeding when only a short-term effect is required. Cryoprecipitate infusion promptly corrects the bleeding time for as long as 24-36 hours, but carries the risk of transmitting blood-borne infections. The effect of cryoprecipitate on bleeding time is noticed one hour after infusion, and tends to wear off in 36 hours, and the mechanisms of action is not known but thought to be related to factor VIII abnormality in uremia.

The patient presented developed significant HPE and benefited from urgent salvage pericardiocentesis. Pericardiocentesis is associated with a high risk of recurrence and should probably be reserved for truly urgent situations as in the case presented. This paper highlights the difficulties in achieving adequate dialysis in chronic uremia from a resource-poor nation. It demonstrates the benefit of prompt drainage of severe pericardial effusion when inadequate dialysis has prevented successful treatment of mild to moderate effusion.


   Acknowledgments Top


The author is grateful to the staff of the Chemical Pathology, Microbiology and Radiology Departments of University of Ilorin Teaching Hospital for assisting in the investigation of this patient. The contributions of the Cardiology and Nephrology Unit staff in the management are appreciated.

 
   References Top

1.Castaldi PA. Homeostasis and Kidney disease. In Ratnoff and Forbes C eds. disorders of homeostasis. Grane and Stratton. Orlando 1994;473-83.  Back to cited text no. 1
    
2.Moia M, Vizzotto L, Cartanco M, Mannucei PM, Casati S, Ponticelli C. Improvement in the haemostatic defect on uraemia after treatment with recombinant human erythropoietin. Lancet 1987;ii:1227-9.  Back to cited text no. 2
    
3.Castillo R, Lozano T, Escolar G, et al. Defect platelet adhesion on vessel subendothelium in uraemic patients. Blood 1986;68:337-42.  Back to cited text no. 3
    
4.Romuzzi G, Perico N, Zoja C, et al. Role of endothelium-derived nitric oxide in the bleeding tendency of uraemia. J Clin Invest 1990;86:1768-71.  Back to cited text no. 4
    
5.Zwaginga JJ, Fjsseldjk MJ, Beeser-Visser N, et al. High Von Willebrand factor concentration compensates a relative adhesive defect in uraemic blood. Blood 1990;75:1498-508.  Back to cited text no. 5
    
6.Conty C, Cohen S. Shapiro F. Pericarditis in chronic uraemia and its sequele. Ann Intern Med 1971;75:1763-83.  Back to cited text no. 6
    
7.Gurland H, Brunner F, Dehr H, Harien H, Parsons F, Scharer K. Combined report on regular dialysis and transplantation in Europe. Proc. EDTA 1972;10(3):34.  Back to cited text no. 7
    
8.Shimojo H, Nishine T, Yamamto S, Jo F, Nishizawa S, Takayama Y. Cardiac tamponade complicating uraemic pericarditis-Case Report. J Cardiol 2004;44:267.  Back to cited text no. 8
    
9.Reddy PS, Curtis EI, O'Toole JE. Cardiac tamponade: Haemodynamic observations in man. Circulation 1978;58:265-72.  Back to cited text no. 9
    
10.Wray TM, Humphreys J Perry JM, et al Pericardectomy for treatment of uraemic pericarditis. Circulation 1974;49-50(suppl.2):268-71.  Back to cited text no. 10
    
11.Gunukula SR, Spodick DH. Pericardial disease in renal patients. Semin Nephrol 2001;21:52-6.  Back to cited text no. 11
    

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Correspondence Address:
Adindu Chijioke
Renal Unit, Department of Medicine, University of Ilorin Teaching Hospital, P.M.B 1459, Ilorin
Nigeria
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PMID: 22089795

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This article has been cited by
1 Subconjunctival hemorrhage: Risk factors and potential indicators
Tarlan, B. and Kiratli, H.
Clinical Ophthalmology. 2013; 7: 1163-1170
[Pubmed]



 

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