Desmopressin (DDAVP) and Bleeding

29 Jun

RAGING HYPOTHETICAL:

You have a hemodialysis patient present with altered mental status and hematemesis.  He is found to be in metabolic disarray including acute on chronic renal failure.  You admit him to the MICU and consult the renal fellow, who advises you to start DDAVP. Why?

BASICS:

DDAVP is a synthetic analogue of antidiuretic hormone that was initially designed to treat Diabetes Insipidus.

In the 1970s, studies showed that it also increases Factor VIII and von Willebrand Factor and its use was expanded to assist in treatment of Hemophilia A and von Willibrand’s disease.  Since then, it’s use has been expanded to various bleeding conditions (congenital and acquired).

The exact mechanism of bleeding in uremic patients it unknown, but seems to be multifactorial.  Advantages of DDAVP include short time to onset of action, but a potential disadvantage is the short duration of action.  There are several studies that promote the use of DDAVP, listed below:

Reference

Study design

Sample size and characteristics

Treatment

Results

Mannucci et al. (1983)19 Retrospective, double blind, placebo controlled Patients with chronic renal failure receiving hemodialysis with prior history of bleeding and bleeding time >10 min (n = 12) Patients with increased bleeding time undergoing surgery (n = 9) One dose (0.3 g/kg i.v.) DDAVP versus placebo One dose (0.3 g/kg i.v.) DDAVP Bleeding time normalized in 5 of 12 patients 1 h postinfusion, 2 of 12 patients 4 h postinfusion, and 1 of 12 patients 8 h postinfusion No excessive blood loss during surgery
Kohler et al. (1989)73,a Prospective, randomized, double blind, placebo controlled Patients receiving hemodialysis for indication of unknown etiology with bleeding time >15 min (n = 8) One dose (0.4 g/kg subcutaneous) DDAVP Bleeding time reduced in 7 of 8 patients and normalized in 2 of 8 patients Significant increase in concentration of von Willebrand factor
Watson and Keogh (1982)74 Prospective, single center Patients with chronic renal failure and bleeding time >12 min (n = 12; 4 receiving hemodialysis, 3 receiving peritoneal dialysis) One dose (0.4 g/kg i.v.) DDAVP Bleeding time normalized in 6 of 12 patients 1 h postinfusion, 3 of 12 patients 2 h postinfusion, but 0 of 5 patients 24 h postinfusion

BOTTOM LINE:

all these are small (n=8-12) studies, but may be worth keeping desmopressin in your toolbox for bleeding renal failure patients. 

dose is 0.3-0.4 g/kg, IV/SQ, once.

Submitted by W. Brooks.

Reference(s): The use of desmopressin as a hemostatic agent: A concise review, Franchini, et. Al, American Journal of HematologyVolume 82, Issue 8, Article first published online: 9 MAY 2007;  Evidence-based treatment recommendations for uremic bleeding, Hedges, et al, Nature Clinical Practice Nephrology (2007) 3, 138-153; picture

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