18_4_1
The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia
By Rose Faratro, RN, BHScN, CNeph(C), Celine D’Gama, RN, BHScN, CNeph(C), and Christopher Chan, MD, FRCP(C)
Abstract
Heparin-induced thrombocytopenia (HIT) is a potentially catastrophic hyercoagulable state. The prevalence of HIT in individuals doing nocturnal home hemodialysis (NHD) is unknown and the appropriate treatment protocol has yet to be determined. The objective is to describe the clinical course and treatment plan of a patient who developed HIT while undergoing NHD. A 49-year-old man with a past history of end stage renal disease (ESRD) of unknown etiology was initiated on NHD in February 2005. His clinical and biochemical parameters improved after conversion to NHD. However, excessive bleeding at the vascular access sites complicated his treatments. Clinical investigations revealed development of HIT. Alternative therapeutic strategies were attempted to enable our patient to continue NHD: unfractionated heparin, citrated regional anticoagulation, Danaparoid, and Argatroban. In conclusion, NHD patients with HIT pose a specific clinical challenge.We speculate that the augmented exposure of heparin coupled with a primed autoimmune response may be responsible for the development of HIT in our patient. Further research is required to elucidate the appropriate clinical monitoring and treatment strategy for this patient.
Author Affiliation(s):
Rose Faratro, RN, BHScN, CNeph(C), Staff Nurse, Home Hemodialysis Program, Toronto General Hospital, University Health Network.
Celine D’Gama, RN, BHScN, CNeph(C), Staff Nurse, Home Hemodialysis Program, Toronto General Hospital, University Health Network.
Christopher Chan, MD, FRCP(C), Staff Nephrologist, R. Fraser Elliott Chair in Home Dialysis, Medical Director— Home Hemodialysis, Toronto General Hospital, University Health Network.