A case of heparin-induced thrombocytopenia precipitated by heparin flushes in a chronic kidney disease patient with cirrhosis

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  • 透析導入期にヘパリンフラッシュを誘因としてヘパリン起因性血小板減少症を発症した肝硬変合併慢性腎臓病患者の1例
  • 症例報告 透析導入期にヘパリンフラッシュを誘因としてヘパリン起因性血小板減少症を発症した肝硬変合併慢性腎臓病患者の1例
  • ショウレイ ホウコク トウセキ ドウニュウキ ニ ヘパリンフラッシュ オ ユウイン ト シテ ヘパリン キインセイ ケッショウバン ゲンショウショウ オ ハッショウ シタ カンコウヘン ガッペイ マンセイ ジンゾウビョウ カンジャ ノ 1レイ

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Abstract

<p>Heparin-induced thrombocytopenia (HIT) is a transient immunological abnormality characterized by thrombocytopenia and paradoxical thrombosis. A 67-year-old male with decompensated cirrhosis caused by alcoholic hepatitis (Child-Pugh class B, MELD score=23) and chronic kidney disease was admitted due to streptococcal bacteremia. During antibiotic treatment, his kidney damage progressed, and so it was necessary to start hemodialysis. Before the initiation of hemodialysis, 100 IU of unfractionated heparin were administered daily for four weeks as an intravenous flush to maintain the patency of the peripheral venous catheter. In addition, a 2000-IU bolus was administered intravenously around the time of the creation of the arteriovenous fistula (two weeks prior to the initiation of hemodialysis). During the first hemodialysis session, clotting was noted in the extracorporeal circuit, and it worsened over time despite increased doses of heparin being administered. Moreover, rapidly progressive thrombocytopenia was observed. Based on these findings, a clinical diagnosis of rapid-onset HIT was made, which led to the cessation of the heparin therapy and the intermittent use of a direct thrombin inhibitor, argatroban, during hemodialysis. After that, an elevated IgG-HIT antibody titer was detected, and a functional assay for detecting HIT produced a positive result. During the first month of hemodialysis, HIT should be considered as a possible diagnosis in cases involving concurrent clotting in the hemodialysis circuit and thrombocytopenia because many patients are exposed to heparin for the first time during hemodialysis. Although the HIT antibody is usually detected when a substantial amount of heparin is administered over the course of a week, heparin catheter flushing can contribute to the development of HIT. Rapid-onset HIT has atypical manifestations, which can delay its diagnosis. As it is necessary to markedly reduce the dose of argatroban administered to patients with severe liver disease, appropriate monitoring of the activated partial thromboplastin time is recommended in such cases. The present patient underwent hemodialysis with a 7.5-mg bolus (approximately 0.1 mg/kg) without suffering circuit clot formation or bleeding complications.</p>

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