Use of argatroban for hemodialysis and continuous veno-veno hemodialysis in a patient with heparin-induced thrombocytopenia

Objective: To describe the use of argatroban in a post-cardiac operation patient with heparin-induced thrombocytopenia requiring hemodialysis and continuous veno-veno hemodialysis (CVVH). Case Summary:A 23-year-old Caucasian female with heparin-induced thrombocytopenia developed acute renal failure after cardiovascular surgery. Argatroban was used as a substitute for heparin during hemodialysis and CVVH. Both activated partial thromboplastin time (aPTT) and activated clotting time (ACT) were used to guide the dosage of argatroban. The patient was successfully dialyzed without clotting of the circuit. The dosage required in our patient was much lower than the manufacturer's recommendation. Discussion:Argatroban is a thrombin inhibitor that does not cross react with heparin. It is metabolized by the liver, and dosage adjustment is recommended in patients with severe hepatic impairment. The correct dosage for patient with unstable hemodynamics is not known. Our patient had apparently normal hepatic function at the initiation of dialysis, but the dosage of argatroban recommended by the manufacturer resulted in prolonged elevation of the aPTT and ACT with associated gastrointestinal bleeding. This may be related to hepatic congestion secondary to poor cardiac function and/or severe anasarca. And the dosage of argatroban required during dialysis was much lower than the recommendation. Conclusions:Argatroban is an effective alternative of heparin for CVVH. The correct initial dosage in patients with mild hepatic impairment and unstable hemodynamics is still unclear.