Minimizing hemorrhagic complications in dialysis patients.

Renal failure is associated with an increased incidence of hemorrhage from a variety of sites, particularly in patients undergoing surgical procedures. The primary factors in the pathogenesis of bleeding in renal failure are platelet biochemical abnormalities and alterations in platelet vessel wall interactions. Hemodialysis improves hemostatic abnormalities in uremia, but the need for heparinization during the procedure may increase the bleeding risk. The risk of bleeding may be minimized by using peritoneal dialysis or alternative means to routine heparinization to prevent clotting in the extracorporeal circulation during hemodialysis. These include use of minimal heparin, prostacyclin, regional citrate anticoagulation, and no anticoagulation. Continuous arteriovenous hemodialysis may also be performed with regional citrate anticoagulation. There are several nondialytic therapies that may be used to prevent or treat hemorrhage in renal failure patients. These include administration of cryoprecipitate, 1-deamino-8-arginine vasopressin, estrogens, red blood cells, and erythropoietin. A clinical strategy to minimize bleeding complications in dialysis patients is presented.