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Three Part Question

In [patients with life threatening haematuria] does [tranexamic acid] [improve outcomes]

Clinical Scenario

A 70yr old man is rushed into resus with a BP of 60/30. He has been passing blood and clots in the urine for the last 24 hours. As you commence fluid resuscitation you wonder whether tranexamic acid may have a role in his manageemnt

Search Strategy

Medline using NHS evidence date of searching 20 November 2014: [exp tranexamic acid/OR tranexamic AND acid.ti,ab OR txa.ti,ab] AND [exp hematuria/ OR haematuria. ti, ab].

Embase using NHS evidence SAFETY SEARCH: [*tranexamic acid/] AND [*hematuria/OR haematuria. ti, ab].

The Cochrane Library Issue 11 of 12, November 2014: MeSH descriptor: [Tranexamic Acid] explode all trees AND MeSH descriptor: [Hematuria] explode all trees.

Search Outcome

Sixteen papers were found, of which four provided the best evidence to answer the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Vujkovac B.,Sabovic M. 2006 Slovenia	One patient with autosomal dominant polycystic kidney disease (ADPKD)	Case report	Nephrectomy	Bilateral Nephrectomies avoided	Case report.
			Thromboembolism	Ureters obstructed by clots requiring J stents
			Mortality	Patient survived
Peces R et al 2012 Spain	8 patients with autosomal dominant polycystic kidney disease (ADPKD)	Prospective observational study	Cessation of haematuria	Stopped within 2-5 days in all patients	Only 8 patients. All patients had ADPKD.
			Renal function	Remained stable
			Haemoglobin	Remained stable
			Mortality	All patients survived
			Thromboembolism	No cases of thromboemblism
Alameel T, West M 2011 Canada	One patient with autosomal dominant polycyctic kidney disease (ADPKD) with recurrent episodes of life threatening haematuria.	Case report	Haematuria	Stopped within 24-36hrs	Case report.
			Renal function	Improved to baseline
			Thromboembolism	No incidence of thromboembolism
			Mortality	Patient survived
Davies N et al 2010 Ireland	Female patient with sickle cell anaemia and haematuria requiring blood transfusion	Case report	Haematuria	Stopped within 4 days of treatment	Case report.
			Haemoglobin	Remained stable
			Mortality	Patient survived
			Thromboembolism	No incidence of thromboembolism

Comment(s)

The evidence for the use of tranexamic acid in life-threatening haematuria is weak and predominantly in patients with autosomal-dominant polycystic kidney disease. The case reports do suggest a benefit, but larger studies are needed to prove this benefit and exclude the increased risk of thromboembolic complications.

Clinical Bottom Line

The evidence is limited, but there may be a role for tranexamic acid in life-threatening haematuria, particularly in patients with autosomal-dominant polycystic kidney disease.

References

1. Vujkovac B.,Sabovic M. A successful treatment of life-threatening bleeding from polycystic kidneys with antifibrinolytic agent tranexamic acid. Blood Coagul Fibrinolysis 2006;17:589–91.
2. Peces R, Aguilar A, Vega C, et al. Medical therapy with tranexamic acid in autosomal dominant polycystic kidney disease patients with severe haematuria. Nefrologia 2012;32:160–5.
3. AlAmeel T, West M. Tranexamic Acid Treatment of Life-Threatening Hematuria in Polycystic Kidney Disease. Int J Nephrol. 2011;2011:203579.
4. Davies NF, McGuire BB, Lawlor L, et al. Oral tranexamic acid as a novel treatment option for persistent haematuria in patients with sickle cell disease. Ann Hematol 2010;89:1179–80.