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Abstract: SA-PO044

Combined Bivalirudin and Citrate Anticoagulation for Recurrent Continuous Kidney Replacement Therapy Clotting in COVID-19-Associated AKI

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical‚ Outcomes‚ and Trials

Authors

  • Pal, Chaitanya A., University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
  • Milano, Victoria, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
  • Shieh, Michelle, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
  • Sarangarm, Preeyaporn, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
  • Teixeira, J. Pedro, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
Introduction

Extracorporeal circuit (EC) thrombosis commonly complicates continuous kidney replacement therapy (CKRT), especially in prothrombotic COVID-19 patients in which refractory EC clotting is well described. We present a case of recurrent EC clotting in acute kidney injury (AKI) requiring CKRT in COVID-19 managed with regional citrate anticoagulation (RCA) and bivalirudin.

Case Description

A 70-year-old man presents with weakness and is diagnosed with COVID-19, pulmonary tuberculosis, left internal jugular (IJ) deep vein thrombosis treated with IV unfractionated heparin (UFH), and cerebellar stroke. He develops respiratory failure requiring mechanical ventilation, septic shock, rectal bleeding causing interruptions in anticoagulation (AC), oliguric AKI, and hyperkalemia for which CKRT is initiated with a PrisMax device and a 15-cm-long 13-French Power-Trialysis catheter placed in the right IJ. Despite good access function and a mean filtration fraction of 15.3%, recurrent EC thrombosis develops, for which various AC strategies are trialed [Table]. Only the combination of systemic bivalirudin and RCA proves effective. However, he ultimately dies after the family opts to transition to comfort measures.

Discussion

The use of direct thrombin inhibitors (DTIs) as AC for CKRT had only been reported pre- pandemic in small studies or case series, with only one case report describing argatroban combined with RCA. Though RCA has repeatedly been shown in non-COVID-19 patients to be superior to UFH as AC for CKRT, both therapies in COVID-19 often fail to prevent EC thrombosis, leading many to try other strategies such as DTIs or RCA combined with UFH. In our patient, UFH with RCA allowed one EC to last >24h, but multiple subsequent ECs clotted in <12h. However, by combining bivalirudin and RCA we prevented premature thrombosis of the subsequent two ECs. This is the first report of using bivalirudin with RCA for CKRT AC and suggests the combination may be useful in COVID-19 patients with recurrent CKRT circuit clotting.