Lepirudin for anticoagulation in patients with heparin‐induced thrombocytopenia treated with continuous renal replacement therapy

Abstract

Lepirudin is a potent, direct thrombin inhibitor used for anticoagulation in patients with heparin-induced thrombocytopenia type II (HIT). The half-life of lepirudin is prolonged in patients with renal insufficiency. Preliminary studies suggest that it is safe to use lepirudin in patients being treated with intermittent hemodialysis but information regarding its use with continuous renal replacement therapy (CRRT) is scarce. CRRT is used in acute care settings to remove fluid and uremic toxins in patients with renal failure with hemodynamic instability. Patients with HIT, renal failure, and hemodynamic instability pose a complex situation for clinical management. These patients require anticoagulation with nonheparin agents with simultaneous CRRT. There are no guidelines in the literature regarding the management of this patient group. We report our experience with lepirudin at managing four such patients with HIT, being treated with CRRT. Am. J. Hematol. 82:391-393, 2007. V V C 2006 Wiley-Liss, Inc.

Renal Replacement Therapy in the Critical Care Setting

“…It is a prothrombotic condition and usually requires systemic anticoagulation on CRRT. Management options include non-heparin-based anticoagulants such as argatroban, lepirudin, and danaparoid [82–86]. Argatroban has hepatic metabolism and may be preferred in AKI.…”

Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy

“…Heparin is the conventional and probably the most widely used anticoagulant in CRRT [2]; however, it carries significant limitations such as increased risk of bleeding and the occurrence of heparin-induced thrombocytopenia. Alternative strategies have been introduced by using low molecular heparin, serine proteinase inhibitors, prostaglandins, recombinant direct thrombin inhibitors, saline flushing and citrate [3][4][5][6]. Among them, anticoagulation with citrate is of great interest to clinicians.…”

Anticoagulation during continuous renal replacement therapy: An update

“…Hirudin and it analogs, lepirudin (recombinant hirudin) and bivalirudin, act independently of PF4 and cofactors; thus has been used as an alternative in patients with HIT [60][61][62][63][64][65][66] . For CRRT, lepirudin is administered either as a continuous infusion (0.005-0.01 mg⁄kg⁄h) or delivered in bolus doses (0.2 mg⁄kg); while bivalirudin is administered prefilter in 0.009-0.023 mg/kg/h (1-2.5mg/h) [62][63][64][65][66] . Although, APPT can be used as monitoring tool (aiming at 1.5-2.5 times baseline), there is no linear correlation with anticoagulation activity.…”