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An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing
Introduction Coagulation abnormalities are well described in patients with elevated levels of urea and/or creatinine secondary to renal failure. These range from hypercoagulable to hypocoagulable states due to a range of mechanisms well described in the literature. Conventional tests of coagulat...
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| Format: | Thesis |
| Language: | English |
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Department of Anaesthesia and Perioperative Medicine
2019
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| _version_ | 1867613627398225920 |
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| access_status_str | Open Access |
| author | Rodrigues, Jacques |
| author2 | Miller, Malcolm |
| author_browse | Miller, Malcolm Rodrigues, Jacques |
| author_facet | Miller, Malcolm Rodrigues, Jacques |
| author_sort | Rodrigues, Jacques |
| collection | Thesis |
| description | Introduction
Coagulation abnormalities are well described in patients with elevated levels of urea
and/or creatinine secondary to renal failure. These range from hypercoagulable to
hypocoagulable states due to a range of mechanisms well described in the literature.
Conventional tests of coagulation such as INR and PTT do not adequately assess these
disorders of coagulation. Thromboelastography (TEG®) has proven to be a suitable
alternative test of coagulation that serves as a dynamic test of global coagulation
including assessment of thrombus formation as well as its breakdown. TEG® and
ROTEM® assesses the visco-elastic properties of blood in vitro to define in vivo
coagulability. The standard of care in our institution to assess the bleeding risk in
patients with renal failure (defined by a raised urea and/or creatinine level) presenting
for a renal biopsy is to use the conventional tests of coagulation, including a bleeding
time if their creatinine is above 300 µmol/L. The aim of this study is to evaluate the
conventional standard laboratory tests of coagulation (including a bleeding time where
available), TEG® and ROTEM® in assessing coagulation disorders in patients with
elevated levels of urea and/or creatinine presenting for renal biopsy.
Methodology
Patients with elevated levels of urea and/or creatinine presenting for a renal biopsy will
be identified by the nephrology team responsible for their medical management. Prior to
the renal biopsy, these patients will be approached by the study team and reviewed for
inclusion into the study. Informed consent will be obtained on agreement to participate
in the study. We will collect a blood sample for the TEG® and ROTEM® and this test will
be performed by a laboratory technician in the Department of Anaesthesia. The
clinician/nephrologist performing the biopsy will not be influenced by the outcome of
these viscoelastic tests. A convenience sample of a minimum of 25 patients with renal
impairment presenting for a renal biopsy will be included in this study.
Results
A total of 44 adult participants was entered into this observational study. Results for 1
participant were excluded from this study as their biopsy was delayed, allowing their
renal function to improve and return to normal with medical management on the day
that they presented for a renal biopsy. 43 patients were worked up for a renal biopsy but
only 38 patients proceeded to a renal biopsy. Of these, only 31 patients had a bleeding
time performed on the day of their renal biopsy. The participants ages ranged from 24 to
69 years and included 24 male and 19 female participants. Renal biopsies were
cancelled by the consultant nephrologist in 5 patients on the day of their biopsy. Control
samples, from 10 members in the Department of Anaesthesia, fell within the specified
range of the various manufacturers. An interesting TEG® result was an average MA
result of 74.22 mm (normal range 64 – 72 mm), which lies above the upper limit of
normal. Two patients developed a small renal haematoma on ultrasound after the
biopsy, with 1 of these patients also developing haematuria.
Conclusion
TEG® and ROTEM® provides a global assessment of coagulation and might be helpful
in assessing coagulation defects in patients with elevated levels of urea and/or
creatinine presenting for a renal biopsy, with possible extension to the surgical patient
with abnormal renal function presenting for a surgical procedure to assess their risk of
bleeding, especially in those who are being considered for a regional or neuraxial
technique - as this could be an unacceptable risk in this population sub-group . |
| format | Thesis |
| id | oai:open.uct.ac.za:11427/30121 |
| institution | University of Cape Town (South Africa) |
| language | eng |
| last_indexed | 2026-06-10T12:39:09.420Z |
| license_str | Not specified — see source repository |
| provenance_str_mv | Harvested via OAI-PMH from UCTD — University of Cape Town Open Access Repository |
| publishDate | 2019 |
| publishDateRange | 2019 |
| publishDateSort | 2019 |
| publisher | Department of Anaesthesia and Perioperative Medicine |
| publisherStr | Department of Anaesthesia and Perioperative Medicine |
| record_format | dspace |
| source_str | UCTD — University of Cape Town Open Access Repository |
| spelling | oai:open.uct.ac.za:11427/30121 An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing Rodrigues, Jacques Miller, Malcolm Introduction Coagulation abnormalities are well described in patients with elevated levels of urea and/or creatinine secondary to renal failure. These range from hypercoagulable to hypocoagulable states due to a range of mechanisms well described in the literature. Conventional tests of coagulation such as INR and PTT do not adequately assess these disorders of coagulation. Thromboelastography (TEG®) has proven to be a suitable alternative test of coagulation that serves as a dynamic test of global coagulation including assessment of thrombus formation as well as its breakdown. TEG® and ROTEM® assesses the visco-elastic properties of blood in vitro to define in vivo coagulability. The standard of care in our institution to assess the bleeding risk in patients with renal failure (defined by a raised urea and/or creatinine level) presenting for a renal biopsy is to use the conventional tests of coagulation, including a bleeding time if their creatinine is above 300 µmol/L. The aim of this study is to evaluate the conventional standard laboratory tests of coagulation (including a bleeding time where available), TEG® and ROTEM® in assessing coagulation disorders in patients with elevated levels of urea and/or creatinine presenting for renal biopsy. Methodology Patients with elevated levels of urea and/or creatinine presenting for a renal biopsy will be identified by the nephrology team responsible for their medical management. Prior to the renal biopsy, these patients will be approached by the study team and reviewed for inclusion into the study. Informed consent will be obtained on agreement to participate in the study. We will collect a blood sample for the TEG® and ROTEM® and this test will be performed by a laboratory technician in the Department of Anaesthesia. The clinician/nephrologist performing the biopsy will not be influenced by the outcome of these viscoelastic tests. A convenience sample of a minimum of 25 patients with renal impairment presenting for a renal biopsy will be included in this study. Results A total of 44 adult participants was entered into this observational study. Results for 1 participant were excluded from this study as their biopsy was delayed, allowing their renal function to improve and return to normal with medical management on the day that they presented for a renal biopsy. 43 patients were worked up for a renal biopsy but only 38 patients proceeded to a renal biopsy. Of these, only 31 patients had a bleeding time performed on the day of their renal biopsy. The participants ages ranged from 24 to 69 years and included 24 male and 19 female participants. Renal biopsies were cancelled by the consultant nephrologist in 5 patients on the day of their biopsy. Control samples, from 10 members in the Department of Anaesthesia, fell within the specified range of the various manufacturers. An interesting TEG® result was an average MA result of 74.22 mm (normal range 64 – 72 mm), which lies above the upper limit of normal. Two patients developed a small renal haematoma on ultrasound after the biopsy, with 1 of these patients also developing haematuria. Conclusion TEG® and ROTEM® provides a global assessment of coagulation and might be helpful in assessing coagulation defects in patients with elevated levels of urea and/or creatinine presenting for a renal biopsy, with possible extension to the surgical patient with abnormal renal function presenting for a surgical procedure to assess their risk of bleeding, especially in those who are being considered for a regional or neuraxial technique - as this could be an unacceptable risk in this population sub-group . 2019-05-15T10:33:53Z 2019-05-15T10:33:53Z 2018 2019-05-15T10:31:35Z Master Thesis Masters MMed (Anaesthesia) http://hdl.handle.net/11427/30121 eng application/pdf Department of Anaesthesia and Perioperative Medicine Faculty of Health Sciences |
| spellingShingle | Rodrigues, Jacques An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| thesis_degree_str | Master's |
| title | An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| title_full | An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| title_fullStr | An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| title_full_unstemmed | An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| title_short | An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing |
| title_sort | observational study to assess coagulation abnormalities in patients with elevated levels of urea and or creatinine secondary to renal failure presenting for renal biopsy challenging conventional testing using visco elastic testing |
| url | http://hdl.handle.net/11427/30121 |
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