Palabras clave
insuficiencia renal crónica
lesión renal aguda
uremia
diálisis renal
tromboelastografía
enfocada en la cabecera del paciente
lesión renal aguda
uremia
diálisis renal
tromboelastografía
enfocada en la cabecera del paciente
Cómo citar
1.
Torres Serrano RE, Benavides Tamayo HE. Alteraciones tromboelastográficas en pacientes con urgencia dialítica. Rev. Colomb. Nefrol. [Internet]. 16 de febrero de 2021 [citado 15 de marzo de 2025];8(2):e542. Disponible en: https://revistanefrologia.org/index.php/rcn/article/view/542
Resumen
Antecedentes: La enfermedad renal cursa con alteraciones de la hemostasia aumentando el riesgo de eventos trombóticos y hemorrágicos.
Objetivo: Describir las anormalidades de la coagulación en pacientes con urgencia dialítica según tromboelastografía y pruebas convencionales.
Materiales y métodos: Serie de casos de 60 pacientes adultos con urgencia dialítica. Se tomaron muestras de sangre previo al implante de catéter de hemodiálisis o de diálisis peritoneal, se procesaron para tromboelastografía y pruebas convencionales.
Resultados: En la interpretación global del tromboelastograma se identificó estado hipercoagulable en 60% de los pacientes. En el análisis individual de parámetros del trazado se demostraron alteraciones en la fase enzimática con ángulo-alfa aumentado en el 61.7% y tiempo R acortado en el 58.3% de los casos, alteraciones en la fase celular con MA y G aumentados en cerca del 45% y alteraciones en la estabilidad con hiperfibrinolisis en el 18%. El aPTT estaba prolongado en 23.7%.
Conclusiones: En la interpretación global de la tromboelastografía de pacientes con urgencia dialítica el hallazgo mas frecuente es el estado hipercoagulable. En el análisis individual se encontraron alteraciones en todas las fases de la coagulación, siendo la mas frecuente la formación acelerada del coágulo, seguida por aumento de la fuerza del mismo. La tromboelastografía debería ser considerada como una prueba enfocada en la cabecera del paciente para la valoración de la hemostasia en estos pacientes.
Palabras clave: insuficiencia renal crónica; lesión renal aguda; uremia; diálisis renal; tromboelastografía; enfocada en la cabecera del paciente
Citas
1. Romagnani P, Remuzzi G, Glassock R, et al. Chronic kidney disease. Nat Rev Dis Primers. 2017;(3):17088.
https://doi.org/10.1038/nrdp.2017.88
2. Meyer TW, Hostetter TH. Uremia. N Engl J Med. 2007;357(13):1316-25.
https://doi.org/10.1056/NEJMra071313
3. International Society of Nephrology. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. 2012;2(1):1-138.
4. Hoffman M, Monroe DM 3rd. A Cell-based Model of Hemostasis. Thromb Haemost. 2001;85(6):958-65.
https://doi.org/10.1055/s-0037-1615947
5. Furie B, Furie BC. Mechanisms of Thrombus Formation. N Engl J Med. 2008;359(9):938-49.
https://doi.org/10.1056/NEJMra0801082
6. Roberts HR, Monroe DM, Escobar MA. Current Concepts of Hemostasis. Anesthesiology. 2004;100(3):722-30.
https://doi.org/10.1097/00000542-200403000-00036
7. Alvarado Ivan Mauricio. Fisiología de la coagulación nuevos conceptos aplicados al cuidado perioperatorio. Univ.Méd. 2013;54(3):338-52.
https://doi.org/10.11144/Javeriana.umed54-3.fcnc
8. Cesarman-Maus G, Hajjar KA. Molecular mechanisms of fibrinolysis. Br J Haematol. 2005;129(3):307-21.
https://doi.org/10.1111/j.1365-2141.2005.05444.x
9. Saran R, Li Y, Robinson B, Ayanian J, Balkrishnan R, Bragg-Gresham J, et al. US Renal Data System 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2015;66(1): suppl(1):S1-S305.
https://doi.org/10.1053/j.ajkd.2015.07.013
10. Cuenta de alto costo. Situación de la enfermedad renal crónica, la hipertensión arterial y la diabetes mellitus. Cuenta alto costo. 2017;280. Available from:
https://cuentadealtocosto.org/site/images/Publicaciones/2018/Libro_Situacion_ERC_en_Colombia_2017.pdf
11. Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost. 2010;36(1):34-40.
https://doi.org/10.1055/s-0030-1248722
12. Pavord S, Myers B. Bleeding and thrombotic complications of kidney disease. Blood Rev. 2011;25(6):271-8
https://doi.org/10.1016/j.blre.2011.07.001
13. Mielke CH Jr, Rapaport SI et al. The standardized normal Ivy bleeding time and its prolongation by aspirin. Blood. 1969;34(2):204-15
https://doi.org/10.1182/blood.V34.2.204.204
14. Toukh M, Siemens DR, Black A, Robb S, Leveridge M, Graham CH, et al. Thromboelastography identifies hypercoagulablilty and predicts thromboembolic complications in patients with prostate cancer. Thromb Res. 2014;133(1):88-95.
https://doi.org/10.1016/j.thromres.2013.10.007
15. Hunt BJ. Bleeding and Coagulopathies in Critical Care. N Engl J Med. 2014;370(9):847-59.
https://doi.org/10.1056/NEJMra1208626
16. Boccardo P, Remuzzi G, Galbusera M. Platelet dysfunction in renal failure. Semin Thromb Hemost. 2004;30(5):579-89.
https://doi.org/10.1055/s-2004-835678
17. Kaw D, Malhotra D. Platelet dysfunction and end-stage renal disease. Semin Dial. 2006;19(4):317-22.
https://doi.org/10.1111/j.1525-139X.2006.00179.x
18. Molino D, De Lucia D, De Santo NG. Coagulation disorders in uremia. Semin Nephrol. 2006;26(1):46-51.
https://doi.org/10.1016/j.semnephrol.2005.06.011
19. Hassan AA, Kroll MH. Acquired Disorders of Platelet Function. Hematology Am Soc Hematol Educ Program 2005:403-8.
https://doi.org/10.1182/asheducation-2005.1.403
20. Sohal AS, Gangji AS, Crowther MA, Treleaven D. Uremic bleeding: Pathophysiology and clinical risk factors. Thromb Res. 2006;118(3):417-22.
https://doi.org/10.1016/j.thromres.2005.03.032
21. Galbusera M, Remuzzi G, Boccardo P. Treatment of bleeding in dialysis patients. Semin Dial. 2009;22(3):279-86.
https://doi.org/10.1111/j.1525-139X.2008.00556.x
22. Lutz J, Menke J, Sollinger D, Schinzel H, Thürmel K. Haemostasis in chronic kidney disease. Nephrol Dial Transplant. 2014;29(1):29-40.
https://doi.org/10.1093/ndt/gft209
23. Rochon AG, Shore-Lesserson L. Coagulation Monitoring. Anesthesiology Clinics of North America. 2006;24(4):839-856
https://doi.org/10.1016/j.atc.2006.08.003
24. Soyoral YU, Demir C, Begenik H, Esen R, Kucukoglu ME, Aldemir MN, et al. Skin bleeding time for the evaluation of uremic platelet dysfunction and effect of dialysis. Clin Appl Thromb. 2012;18(2):185-8.
https://doi.org/10.1177/1076029611427438
25. Maleki A, Rashidi N, Almasi V, Montazeri M, Forughi S, Alyari F. Normal range of bleeding time in urban and rural areas of Borujerd, west of Iran. ARYA Atheroscler. 2014;10(4):199-202.
26. Lipets EN, Ataullakhanov FI. Global assays of hemostasis in the diagnostics of hypercoagulation and evaluation of thrombosis risk. Thromb J. 2015;13(1):4.
https://doi.org/10.1186/s12959-015-0038-0
27. Nguyen A, Dasgupta A, Wahed A. Coagulation-Based Tests and Their Interpretation. Manag Hemost Coagulopathies Surg Crit Ill Patients. 2016;1-16.
https://doi.org/10.1016/B978-0-12-803531-3.00001-X
28. Othman M, Kaur H. Thromboelastography (TEG). Methods Mol Biol. 2017; 1646:533-543
https://doi.org/10.1007/978-1-4939-7196-1_39
29. Raffán F, Ramírez FJ, Cuervo JA, y cols. Tromboelastografía. Rev Colomb Anestesiol. 2005;33(3):181
30. Luddington RJ. Thrombelastography / thromboelastometry. 2005;81-90.
https://doi.org/10.1111/j.1365-2257.2005.00681.x
31. Salooja N, Perry DJ. Thrombelastography. 2001;12(5):327-37.
https://doi.org/10.1097/00001721-200107000-00001
32. Levi M, Hunt BJ. A critical appraisal of point-of-care coagulation testing in critically ill patients. J Thromb Haemost 2015;13(11):1960-1967.
https://doi.org/10.1111/jth.13126
33. Wikkelsø A, Wetterslev J, et al. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev. 2016;(8):CD007871.
https://doi.org/10.1002/14651858.CD007871.pub3
34. Dai Y, Lee A, Critchley LAH, White PF. Does thromboelastography predict postoperative thromboembolic events? a systematic review of the literature. Anesth Analg. 2009;108(3):734-42.
https://doi.org/10.1213/ane.0b013e31818f8907
35. Chitlur M, Sorensen B, Rivard GE, Young G, Ingerslev J, Othman M, et al. Standardization of thromboelastography: A report from the TEG-ROTEM working group. Haemophilia. 2011;17(3):532-7.
https://doi.org/10.1111/j.1365-2516.2010.02451.x
36. Holloway DS, Vagher JP, Caprini JA, et al. Thrombelastography of blood from subjects with chronic renal failure. Thromb Res 1987;45:817-25.
https://doi.org/10.1016/0049-3848(87)90091-0
37. Nunns GR, Moore EE, Chapman MP, Moore HB, Stettler GR, Peltz E, et al. The hypercoagulability paradox of chronic kidney disease: The role of fibrinogen. Am J Surg. 2017;214(6):1215-8.
https://doi.org/10.1016/j.amjsurg.2017.08.039
38. Meier K, Saenz DM, Torres GL, Cai C, Rahbar MH, McDonald M, et al. Thrombelastography Suggests Hypercoagulability in Patients with Renal Dysfunction and Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis. 2018;27(5):1350-6.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.12.026
39. Darlington A, Ferreiro JL, Ueno M, Suzuki Y, Desai B, Capranzano P, et al. Haemostatic profiles assessed by thromboelastography in patients with end-stage renal disease. Thromb Haemost. 2011;106(1):67-74.
https://doi.org/10.1160/TH10-12-0785
40. Huang M jie, Wei R bao, Li Q ping, Yang X, Cao C ming, Su T yu, et al. Hypercoagulable state evaluated by thromboelastography in patients with idiopathic membranous nephropathy. J Thromb Thrombolysis. 2016;41(2):321-7.
https://doi.org/10.1007/s11239-015-1247-x
41. Huang MJ, Wei RB, Wang ZC, Xing Y, Gao YW, Li MX, et al. Mechanisms of hypercoagulability in nephrotic syndrome associated with membranous nephropathy as assessed by thromboelastography. Thromb Res. 2015;136(3):663-8.
https://doi.org/10.1016/j.thromres.2015.06.031
42. Huang MJ, Wei RB, Wang Y, Su TY, Di P, Li QP, et al. Blood coagulation system in patients with chronic kidney disease: A prospective observational study. BMJ Open. 2017;7(5):7-13.
https://doi.org/10.1136/bmjopen-2016-014294
43. Chapman M, Moore EE, et al. Thrombelastographic Pattern Recognition in Renal Disease and Trauma. J Surg Res. 2015;194(1):1-7.
https://doi.org/10.1016/j.jss.2014.12.012
44. Zambruni A, Thalheimer U, Leandro G, Perry D, Burroughs AK. Thromboelastography with citrated blood: comparability with native blood, stability of citrate storage and effect of repeated sampling. Blood Coagul Fibrinolysis. 2004;15(1):103-7.
https://doi.org/10.1097/00001721-200401000-00017
45. Gurbel PA, Bliden KP, Tantry US, Monroe AL, Muresan AA, Brunner NE, et al. First report of the point-of-care TEG: A technical validation study of the TEG-6S system. Platelets. 2016;27(7):642-9.
https://doi.org/10.3109/09537104.2016.1153617
https://doi.org/10.1038/nrdp.2017.88
2. Meyer TW, Hostetter TH. Uremia. N Engl J Med. 2007;357(13):1316-25.
https://doi.org/10.1056/NEJMra071313
3. International Society of Nephrology. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. 2012;2(1):1-138.
4. Hoffman M, Monroe DM 3rd. A Cell-based Model of Hemostasis. Thromb Haemost. 2001;85(6):958-65.
https://doi.org/10.1055/s-0037-1615947
5. Furie B, Furie BC. Mechanisms of Thrombus Formation. N Engl J Med. 2008;359(9):938-49.
https://doi.org/10.1056/NEJMra0801082
6. Roberts HR, Monroe DM, Escobar MA. Current Concepts of Hemostasis. Anesthesiology. 2004;100(3):722-30.
https://doi.org/10.1097/00000542-200403000-00036
7. Alvarado Ivan Mauricio. Fisiología de la coagulación nuevos conceptos aplicados al cuidado perioperatorio. Univ.Méd. 2013;54(3):338-52.
https://doi.org/10.11144/Javeriana.umed54-3.fcnc
8. Cesarman-Maus G, Hajjar KA. Molecular mechanisms of fibrinolysis. Br J Haematol. 2005;129(3):307-21.
https://doi.org/10.1111/j.1365-2141.2005.05444.x
9. Saran R, Li Y, Robinson B, Ayanian J, Balkrishnan R, Bragg-Gresham J, et al. US Renal Data System 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2015;66(1): suppl(1):S1-S305.
https://doi.org/10.1053/j.ajkd.2015.07.013
10. Cuenta de alto costo. Situación de la enfermedad renal crónica, la hipertensión arterial y la diabetes mellitus. Cuenta alto costo. 2017;280. Available from:
https://cuentadealtocosto.org/site/images/Publicaciones/2018/Libro_Situacion_ERC_en_Colombia_2017.pdf
11. Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost. 2010;36(1):34-40.
https://doi.org/10.1055/s-0030-1248722
12. Pavord S, Myers B. Bleeding and thrombotic complications of kidney disease. Blood Rev. 2011;25(6):271-8
https://doi.org/10.1016/j.blre.2011.07.001
13. Mielke CH Jr, Rapaport SI et al. The standardized normal Ivy bleeding time and its prolongation by aspirin. Blood. 1969;34(2):204-15
https://doi.org/10.1182/blood.V34.2.204.204
14. Toukh M, Siemens DR, Black A, Robb S, Leveridge M, Graham CH, et al. Thromboelastography identifies hypercoagulablilty and predicts thromboembolic complications in patients with prostate cancer. Thromb Res. 2014;133(1):88-95.
https://doi.org/10.1016/j.thromres.2013.10.007
15. Hunt BJ. Bleeding and Coagulopathies in Critical Care. N Engl J Med. 2014;370(9):847-59.
https://doi.org/10.1056/NEJMra1208626
16. Boccardo P, Remuzzi G, Galbusera M. Platelet dysfunction in renal failure. Semin Thromb Hemost. 2004;30(5):579-89.
https://doi.org/10.1055/s-2004-835678
17. Kaw D, Malhotra D. Platelet dysfunction and end-stage renal disease. Semin Dial. 2006;19(4):317-22.
https://doi.org/10.1111/j.1525-139X.2006.00179.x
18. Molino D, De Lucia D, De Santo NG. Coagulation disorders in uremia. Semin Nephrol. 2006;26(1):46-51.
https://doi.org/10.1016/j.semnephrol.2005.06.011
19. Hassan AA, Kroll MH. Acquired Disorders of Platelet Function. Hematology Am Soc Hematol Educ Program 2005:403-8.
https://doi.org/10.1182/asheducation-2005.1.403
20. Sohal AS, Gangji AS, Crowther MA, Treleaven D. Uremic bleeding: Pathophysiology and clinical risk factors. Thromb Res. 2006;118(3):417-22.
https://doi.org/10.1016/j.thromres.2005.03.032
21. Galbusera M, Remuzzi G, Boccardo P. Treatment of bleeding in dialysis patients. Semin Dial. 2009;22(3):279-86.
https://doi.org/10.1111/j.1525-139X.2008.00556.x
22. Lutz J, Menke J, Sollinger D, Schinzel H, Thürmel K. Haemostasis in chronic kidney disease. Nephrol Dial Transplant. 2014;29(1):29-40.
https://doi.org/10.1093/ndt/gft209
23. Rochon AG, Shore-Lesserson L. Coagulation Monitoring. Anesthesiology Clinics of North America. 2006;24(4):839-856
https://doi.org/10.1016/j.atc.2006.08.003
24. Soyoral YU, Demir C, Begenik H, Esen R, Kucukoglu ME, Aldemir MN, et al. Skin bleeding time for the evaluation of uremic platelet dysfunction and effect of dialysis. Clin Appl Thromb. 2012;18(2):185-8.
https://doi.org/10.1177/1076029611427438
25. Maleki A, Rashidi N, Almasi V, Montazeri M, Forughi S, Alyari F. Normal range of bleeding time in urban and rural areas of Borujerd, west of Iran. ARYA Atheroscler. 2014;10(4):199-202.
26. Lipets EN, Ataullakhanov FI. Global assays of hemostasis in the diagnostics of hypercoagulation and evaluation of thrombosis risk. Thromb J. 2015;13(1):4.
https://doi.org/10.1186/s12959-015-0038-0
27. Nguyen A, Dasgupta A, Wahed A. Coagulation-Based Tests and Their Interpretation. Manag Hemost Coagulopathies Surg Crit Ill Patients. 2016;1-16.
https://doi.org/10.1016/B978-0-12-803531-3.00001-X
28. Othman M, Kaur H. Thromboelastography (TEG). Methods Mol Biol. 2017; 1646:533-543
https://doi.org/10.1007/978-1-4939-7196-1_39
29. Raffán F, Ramírez FJ, Cuervo JA, y cols. Tromboelastografía. Rev Colomb Anestesiol. 2005;33(3):181
30. Luddington RJ. Thrombelastography / thromboelastometry. 2005;81-90.
https://doi.org/10.1111/j.1365-2257.2005.00681.x
31. Salooja N, Perry DJ. Thrombelastography. 2001;12(5):327-37.
https://doi.org/10.1097/00001721-200107000-00001
32. Levi M, Hunt BJ. A critical appraisal of point-of-care coagulation testing in critically ill patients. J Thromb Haemost 2015;13(11):1960-1967.
https://doi.org/10.1111/jth.13126
33. Wikkelsø A, Wetterslev J, et al. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev. 2016;(8):CD007871.
https://doi.org/10.1002/14651858.CD007871.pub3
34. Dai Y, Lee A, Critchley LAH, White PF. Does thromboelastography predict postoperative thromboembolic events? a systematic review of the literature. Anesth Analg. 2009;108(3):734-42.
https://doi.org/10.1213/ane.0b013e31818f8907
35. Chitlur M, Sorensen B, Rivard GE, Young G, Ingerslev J, Othman M, et al. Standardization of thromboelastography: A report from the TEG-ROTEM working group. Haemophilia. 2011;17(3):532-7.
https://doi.org/10.1111/j.1365-2516.2010.02451.x
36. Holloway DS, Vagher JP, Caprini JA, et al. Thrombelastography of blood from subjects with chronic renal failure. Thromb Res 1987;45:817-25.
https://doi.org/10.1016/0049-3848(87)90091-0
37. Nunns GR, Moore EE, Chapman MP, Moore HB, Stettler GR, Peltz E, et al. The hypercoagulability paradox of chronic kidney disease: The role of fibrinogen. Am J Surg. 2017;214(6):1215-8.
https://doi.org/10.1016/j.amjsurg.2017.08.039
38. Meier K, Saenz DM, Torres GL, Cai C, Rahbar MH, McDonald M, et al. Thrombelastography Suggests Hypercoagulability in Patients with Renal Dysfunction and Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis. 2018;27(5):1350-6.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.12.026
39. Darlington A, Ferreiro JL, Ueno M, Suzuki Y, Desai B, Capranzano P, et al. Haemostatic profiles assessed by thromboelastography in patients with end-stage renal disease. Thromb Haemost. 2011;106(1):67-74.
https://doi.org/10.1160/TH10-12-0785
40. Huang M jie, Wei R bao, Li Q ping, Yang X, Cao C ming, Su T yu, et al. Hypercoagulable state evaluated by thromboelastography in patients with idiopathic membranous nephropathy. J Thromb Thrombolysis. 2016;41(2):321-7.
https://doi.org/10.1007/s11239-015-1247-x
41. Huang MJ, Wei RB, Wang ZC, Xing Y, Gao YW, Li MX, et al. Mechanisms of hypercoagulability in nephrotic syndrome associated with membranous nephropathy as assessed by thromboelastography. Thromb Res. 2015;136(3):663-8.
https://doi.org/10.1016/j.thromres.2015.06.031
42. Huang MJ, Wei RB, Wang Y, Su TY, Di P, Li QP, et al. Blood coagulation system in patients with chronic kidney disease: A prospective observational study. BMJ Open. 2017;7(5):7-13.
https://doi.org/10.1136/bmjopen-2016-014294
43. Chapman M, Moore EE, et al. Thrombelastographic Pattern Recognition in Renal Disease and Trauma. J Surg Res. 2015;194(1):1-7.
https://doi.org/10.1016/j.jss.2014.12.012
44. Zambruni A, Thalheimer U, Leandro G, Perry D, Burroughs AK. Thromboelastography with citrated blood: comparability with native blood, stability of citrate storage and effect of repeated sampling. Blood Coagul Fibrinolysis. 2004;15(1):103-7.
https://doi.org/10.1097/00001721-200401000-00017
45. Gurbel PA, Bliden KP, Tantry US, Monroe AL, Muresan AA, Brunner NE, et al. First report of the point-of-care TEG: A technical validation study of the TEG-6S system. Platelets. 2016;27(7):642-9.
https://doi.org/10.3109/09537104.2016.1153617
Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-SinDerivadas 4.0.
Derechos de autor 2021 Revista Colombiana de Nefrología