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Hematology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Fever, confusion and headache; purpura; platelets 12×10⁹/L, Hb 72 g/L; schistocytes; normal PT/aPTT. Bloody diarrhoea before kidney failure points to HUS
Red flags Confusion, headache, seizure, focal deficit Chest pain or troponin rise Platelets <10×10⁹/L Oliguria Differential diagnosis DIC (abnormal coagulation) Evans syndrome (DAT positive) Malignant hypertension HELLP Sepsis-associated TMA Severe B12 deficiency (pseudo-TMA) When to admit, call ICU or discharge Admit: Every suspected TMAICU: Neurological or cardiac involvement, plasma exchange, dialysis or instabilityDialysis: HUS with oliguria, K⁺ >6.5, overload or uraemiaTransfuse: Red cells as needed; platelets only for life-threatening bleedingKey points Untreated TTP is ~90% fatal; with plasma exchange survival is >80–90% — it is a same-day emergency. ADAMTS13 <10% confirms TTP; the sample must precede plasma. Caplacizumab speeds platelet recovery and prevents exacerbations — start early, not as rescue (ISTH 2025). Do not delay PLEX if it is unavailable. B12 deficiency can mimic TTP (very high LDH, low reticulocytes) — check B12. Never Transfuse platelets in TTP unless bleeding is life-threatening Wait for the ADAMTS13 result before plasma exchange Give antibiotics or antimotility drugs in STEC-HUS Start antiplatelets while platelets are <50×10⁹/L Common mistakes Platelet transfusion Delaying PLEX for ADAMTS13 Missing B12 pseudo-TMA Antibiotics in STEC-HUS Disposition and follow-up HDU/ICU in a centre that can do plasma exchange; transfer early and give FFP meanwhile if PLEX is not available locally.
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