I have a young ESRD Pt on PD who was admitted for migraines. She was receiving IP heparin at 1000 units per exchange for fibrin clots in her PD fluid. Also receiving SQ heparin for DVT prophylaxis. She developed progressive thrombocytopenia and HIT Ab was positive. Hematology has started angiomax (argatroban not on hospital formulary). I want to know if anyone has experience with an alternative agent for fibrin clots in PD fluid. Has anyone used fibrinolytics in PD fluid ? and what dose to use in 2 liter PD exchanges. I have done literature search and there are case reports of Pt’s developing HIT from heparin in PD fluid

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I have a young ESRD Pt on PD who was admitted for migraines. She was receiving IP heparin at 1000 units per exchange for fibrin clots in her PD fluid. Also receiving SQ heparin for DVT prophylaxis. She developed progressive thrombocytopenia and HIT Ab was positive. Hematology has started angiomax (argatroban not on hospital formulary). I want to know if anyone has experience with an alternative agent for fibrin clots in PD fluid. Has anyone used fibrinolytics in PD fluid ? and what dose to use in 2 liter PD exchanges. I have done literature search and there are case reports of Pt’s developing HIT from heparin in PD fluid

2 answers

Doc (Belgium) September 5, 2018

First of all, in the presence of fibrin clots in the peritoneal effluent and/or in the catheter, peritoneal infection/inflammation (e.g., peritonitis, EPS, tuberculosis) should be systematically ruled out.

Next, as heparin is formally contraindicated in this case because of heparin-induced thrombocytopenia with the documentation of circulating antibodies, a reasonable alternative should considered. The choice of non-heparin anticoagulation is based on the availability of molecules and i.e. on the residual renal function of a considered patient. In patients with ESRD, potential alternatives include argatroban, warfarin, rivaroxaban and apixaban. Urokinase has been suggested for relapsing/refractory peritonitis induced by coagulase negative staph epidermidis – on top of adequate antibiotherapy (Demoulin et al, Perit Dial Int 2009) – and for catheter obstruction; however, to my knowledge, it has not been used for fibrin clots.

Lastly, due to the presence of HIT and headache (which led to the patient’s admission), one may consider performing brain MRI to rule out cerebral venous thrombosis.

#1
Doctor (Canada) September 28, 2018

HIT can rarely occur from heparin added to PD fluid. As per the other expert response, I am not aware of any literature on good alternative agents. Most patients do not routinely have fibrin in their dialysate, and therefore would only use heparin at the time of peritonitis when formation of fibrin would be more likely. In the context of HIT, one may have to not use any agent for the fibrin and hope for the best. If the catheter becomes blocked, a fibrinolytic could be tried.

#2

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