Is anyone aware of an alternative to IP heparin to reduce the production of fibrin? I have a pt that has a severe allergy to heparin and a lot of fibrin. Thank you for your time.

Questions About PD

Lisa M, Nurse from Tempe, AZ asked
Is anyone aware of an alternative to IP heparin to reduce the production of fibrin? I have a pt that has a severe allergy to heparin and a lot of fibrin. Thank you for your time.

1 answer

Nurse Canada with members of the ISPD Nursing Committee March 19, 2024

We thank you for your question. We surveyed members of our ISPD nursing committee, and, unfortunately, none of us have had the experience you describe: managing a patient on PD with excessive fibrin in the PD effluent, but, a severe allergy to heparin. Moreover, we were unable to find any article in the published literature addressing your concern, with the understanding that fibrin in the PD effluent can lead to PD catheter blockage and is usually treated with heparin IP. While all of us had protocols for use of the thrombolytic drug tissue plasminogen activator (tPA) (alteplase, Cathflo® Activase®) in blocked catheters, it is expensive, and since the protocols are for tPA to be administered according to the internal volume of the specific type of PD catheter, this procedure would not necessarily be helpful to prevent the formation of fibrin in the peritoneal cavity.
 
However, we would like to make a few comments. First and foremost, it is important to be absolutely certain that a patient with fibrin in the PD effluent does not have an underlying peritonitis. We presume you have ruled out peritonitis as a cause for the fibrin, but, if you have not, we would strongly recommend you review with the patient’s nephrologist and send off a sample of PD effluent after a minimum 2-hour dwell with 1 L of PD fluid, following aseptic technique, for Gram stain, WBC count with differential, culture and sensitivity and consider including for fungal and mycobacterial culture, following the latest ISPD peritonitis guidelines (1). We note here that an uncommon, non-infectious, usually benign, cause of fibrin in the PD effluent could be eosinophilic peritonitis, whereby an eosinophil count >10% is observed in the differential of the WBC count from the PD effluent, more common in patients newly started on PD (2).
 
In the meantime, we suggest you review with the patient’s primary nephrologist for other causes of excessive fibrin in the PD effluent e.g. adhesions. If the patient is new to PD, some of our members have observed that the fibrin in the PD effluent may decrease over time, but there is limited information on this topic.
 
Another suggestion to help prevent the fibrin blocking the PD catheter for your patient, is to have the patient add daily PD flushes using a 2 L PD solution bag, in and out exchange, zero dwell time, 1 L x 2, then to continue with the usual PD prescription. Using a higher volume, such as 2 L, could help to access more isolated areas of the peritoneum and flush out more fibrin.
 
We trust this information is helpful to you!
 
1.Li PK, Chow KM, Cho Y, Fan S, Figueiredo AE, Harris T, Kanjanabuch T, Kim YL, Madero M, Malyszko J, Mehrotra R. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal dialysis international. 2022 Mar;42(2):110-53. Available at: https://journals.sagepub.com/doi/10.1177/08968608221080586
 
2.Kenan BU, Büyükkaragöz B, Leventoğlu E, Bakkaloğlu SA. Eosinophilic peritonitis in children undergoing maintenance peritoneal dialysis: A case report and literature review. In Seminars in Dialysis. 2022 Nov (Vol. 35, No. 6, pp. 548-555).

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