Metastatic Renal Cell Carcinoma With Hepatic Dysfibrinogenemia—A Case Report

Abstract

Background and Aim: Anaemia and edema have been shown to be poor prognostic factors in advanced malignancy. Thrombocytopenia, functional factor deficiency and accelerated fibrinolysis are possible hepatic causes of abnormal bleeding. Secondary dysfibrinogenemia due to increased fibrinogen sialylation which impairs the ability to form fibrin polymers is seen in advanced liver disease and renal cell carcinoma. Intravenous albumin infusion has been used to prevent paracentesis induced circulatory dysfunction (post LVP) and provide nephroprotection by improving microcirculation. Intravenous albumin and terlipressin have been used in hepatorenal syndrome due to malignant infiltration, which is often considered the functional equivalent of cirrhosis. Case Summary: 27-year-old male, a known case of metastatic renal cell carcinoma with distant spread to the liver and spleen with history of malignant ascites (post therapeutic paracentesis) presented with complaints of haematuria (multiple episodes). Examination findings revealed anasarca, hepatosplenomegaly and inferior vena caval obstruction. Coagulation profile was suggestive of an elevated PT and INR. Component transfusion with fresh frozen plasma (FFP) or cryoprecipitate and intravenous albumin infusion was considered. He showed clinical improvement after receiving tranexamic acid and three units of FFP. Conclusion: Management of bleeding and preservation of hepatic function form an important component of supportive management. Presence of active bleeding and need for interventional procedures are indications for component transfusion. Eight to ten units of cryoprecipitate may be required in severe liver disease. Intravesical installation of tranexamic acid, endoscopic ligation of the bleeding vessel, application of local haemostyptic agents and application of adrenaline soaked gauze have been to control bleeding. Role of intravenous albumin infusion in advanced cancer need to be evaluated further. Management of hepatic encephalopathy (in the absence of well defined cirrhosis) also needs to be discussed. The author has none to declare.