Heparin-induced thrombocytopenia in a renal transplant recipient

Case Report: Heparin-Induced Thrombocytopenia Treated With Plasmapheresis Before Living-Donor Kidney Transplantation

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin. Additionally, although heparin can affect kidney transplantation, there only have been a few reports on this condition. Here, we report a case wherein surgery was safely performed with preoperative plasmapheresis in a patient with HIT.

CASE PRESENTATION

The patient was a 48-year-old woman who was on dialysis because of immunoglobulin A nephropathy. Immediately after the initiation of dialysis, the patient experienced repeated arteriovenous fistula occlusion and thrombocytopenia and had a positive HIT antibody test result. Subsequently, she received an ABO-incompatible living-donor kidney transplantation from her spouse. The surgery was performed without using anticoagulants because HIT antibodies disappeared with preoperative plasmapheresis. Eighteen months after surgery, her kidney function remained stable, and there was no recurrence of HIT.

CONCLUSION

Preoperative plasmapheresis is useful for patients with HIT.

Living kidney transplantation without perioperative anticoagulation therapy for a patient with heparin-induced thrombocytopenia

INTRODUCTION

Heparin-induced thrombocytopenia is an antibody-mediated acquired prothrombotic state induced by heparin exposure. The risk of thromboembolic diseases in kidney transplantation with heparin-induced thrombocytopenia without perioperative anticoagulation has not been determined.

CASE PRESENTATION

A 64-year-old male hemodialysis patient with heparin-induced thrombocytopenia was referred to our hospital for living kidney transplantation. Anti-heparin-induced thrombocytopenia antibody was positive at the time of referral; however, it turned negative 4 months after heparin cessation during hemodialysis sessions. Living kidney transplantation by donation from his wife was performed using the standard technical procedure. Both heparinization and application of medical equipment containing heparin were avoided; however, no anticoagulant was administered intra- and postoperatively. The graft kidney functioned immediately, and no thromboembolic event related to heparin-induced thrombocytopenia occurred.

CONCLUSION

Kidney transplantation without perioperative anticoagulation therapy after disappearance of anti-heparin-induced thrombocytopenia antibody is a well-tolerated treatment option for patients with end-stage kidney disease.

Heparin-induced thrombocytopenia in solid organ transplant recipients: The current scientific knowledge

Exposure to heparin is associated with a high incidence of immunization against platelet factor 4 (PF4)/heparin complexes. A subgroup of immunized patients is at risk of developing heparin-induced thrombocytopenia (HIT), an immune mediated prothrombotic adverse drug effect. Transplant recipients are frequently exposed to heparin either due to the underlying end-stage disease, which leads to listing and transplantation or during the transplant procedure and the perioperative period. To review the current scientific knowledge on anti-heparin/PF4 antibodies and HIT in transplant recipients a systematic PubMed literature search on articles in English language was performed. The definition of HIT is inconsistent amongst the publications. Overall, six studies and 15 case reports have been published on HIT before or after heart, liver, kidney, and lung transplantation, respectively. The frequency of seroconversion for anti-PF4/heparin antibodies ranged between 1.9% and 57.9%. However, different methods to detect anti-PF4/heparin antibodies were applied. In none of the studies HIT-associated thromboembolic events or fatalities were observed. More importantly, in patients with a history of HIT, reexposure to heparin during transplantation was not associated with thrombotic complications. Taken together, the overall incidence of HIT after solid organ transplantation seems to be very low. However, according to the current knowledge, cardiac transplant recipients may have the highest risk to develop HIT. Different alternative suggestions for heparin-free anticoagulation have been reported for recipients with suspected HIT albeit no official recommendations on management have been published for this special collective so far.

Successful preemptive renal retransplantation in a patient with previous acute graft loss secondary to HIT type II: a case report and review of literature

Type II heparin-induced thrombocytopenia (HIT II) is an immune-mediated reaction to heparin administration associated with thrombocytopenia and thrombotic complication with potentially serious outcome. We report a case of a 50-year-old man with history of autosomal dominant polycystic kidney disease (ADPKD), homocystinemia, and history of deep vein thrombosis (DVT), who was switched to intravenous heparin from oral coumadin preoperatively in preparation for preemptive living related renal transplant. Following the operation heparin-induced thrombocytopenia type II lead to graft renal artery thrombosis and subsequent graft loss. One year after first transplant patient underwent successful second living unrelated kidney transplantation with no complications with continued anticoagulation with coumadin and with no reexposure to heparin. Two years after the second transplant and 1 year after stopping anticoagulation, patient was readmitted with bilateral lower extremity DVT and high probability of pulmonary embolism. He was given argatroban on admission as a bridge to anticoagulation with lifelong coumadin therapy and is doing well with excellent graft function. To our knowledge, this is the third reported case of HIT in renal transplantation, second reported case associated with graft loss secondary to HIT and the first reported case of successful retransplantation after initial HIT with graft loss. Heparin-induced thrombocytopenia in transplantation can lead to catastrophic consequences in organ recipients. Successful management of this condition emphasizes promptness of diagnosis and treatment and complete cessation of heparin exposure.

Immediate posttransplantation cotrimoxazole-induced immune thrombocytopenia

Drug-induced immune thrombocytopenia (DITP) can be caused by numerous drugs. When this condition develops, platelet destruction results from binding of antibodies to normal platelets only in the presence of a sensitizing drug. A recently proposed model suggests that these drug-dependent antibodies are derived from a pool of naturally occurring antibodies with weak affinity for specific epitopes on certain platelet membrane glycoproteins. We describe here a case of DITP secondary to cotrimoxazole exposure in the immediate posttransplantation phase in a renal transplant recipient. Apart from heparin-induced thrombocytopenia, DITP posttransplantation has to the best of our knowledge never been described, perhaps because of its immune-mediated origin. Our case demonstrates that DITP can occur posttransplantation, that cotrimoxazole due to its intensive use in the transplanted population is one of the most likely causative agents and that a timely recognition and treatment might have important consequences for both graft and patient.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Heparin-induced thrombocytopenia type II: a serious hazard in preemptive renal transplantation: a case report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.

Necessity of routine postoperative heparinization in non-risky live-donor renal transplantation: results of a prospective randomized trial

OBJECTIVES

To determine the exact value of postoperative heparinization in preventing thrombotic sequelae in non-risky renal transplants and to assess the possible hazards of this therapy through a prospective randomized trial.

METHODS

Of 120 consecutive live-donor renal transplants, 45 patients were excluded because of young age, multiple or atheromatous graft arteries, a history of thromboembolic disease, or intraoperative technical difficulties. The remaining patients were prospectively randomized into three groups, with 25 patients each. Group 1 did not undergo heparinization. Groups 2 and 3 received a prophylactic dose of low-molecular-weight heparin and conventional heparin, respectively, for 1 week.

RESULTS

None of our patients in any group developed graft vascular thrombosis, deep venous thrombosis, or pulmonary embolism, and the rate of spontaneous closure of arteriovenous fistulas was comparable among the three groups (P = 0.79). No statistically significant difference was found among the three groups in terms of the development of significant perirenal hematomas, rate of blood transfusions, or mean number of transfused units (P = 0.37, P = 0.56, and P = 0.69, respectively). In contrast, a significant decrease in the hemoglobin level occurred in group 3 compared with group 1 among nontransfused patients (1.6 +/- 0.8 g% and 0.7 +/- 0.9 g%, respectively; P = 0.01). Moreover, a significant shortening of lymph drainage time and a reduction of the total amount of lymphorrhea were found in group 1 compared with groups 2 and 3 (P = 0.01, P = 0.03, respectively).

CONCLUSIONS

Postoperative heparinization should not be routinely indicated in non-risky live-donor renal transplantation.