Snapshot A 50-year-old man with chronic kidney disease on dialysis presents with a mild but long-lasting nosebleed. On physical exam, his gums are also bleeding. An IV is inserted, which resulted in bleeding around the site. His coagulation function tests are normal, but his bleeding time is 5 minutes. He is given DDAVP, and the bleeding resolved within an hour. 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 uremic plasma factors that produce NO = likely culprit NO (endothelium-derived relaxing factor) inhibits platelet aggregation Associated conditions renal insufficiency requiring dialysis Presentation Symptoms mucocutaneous bleeding skin oral mucosa nasal mucosa increased bleeding after taking aspirin Evaluation Normal or prolonged bleeding time Normal levels of coagulation factors Normal PT and PTT Peripheral blood smear showing burr cells (echinocytes) Mild thrombocytopenia Differential Diagnosis HIT Glanzmann thrombasthenia Treatment 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