Hydroxocobalamin-Triggered Blood Leak Detection During Hemodialysis in a Liver Transplant Patient
- Hemodialysis: Case Reports, Series, QI Projects
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 801 Dialysis: Hemodialysis and Frequent Dialysis
- Ostrosky-Frid, Mauricio, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
- Owens, Charles T., The University of Texas Southwestern Medical Center, Dallas, Texas, United States
- Lakhani, Laila S., The University of Texas Southwestern Medical Center, Dallas, Texas, United States
High-dose intravenous hydroxocobalamin, known as Cyanokit, is routinely administered for vasoplegic shock, a life-threatening complication from cardiac surgery when conventional vasopressors are insufficient to maintain an appropriate mean arterial blood pressure goal. In liver transplant patients, hydroxocobalamin use has become more common for vasoplegia and to decrease time on pressor dependence post-transplant.
After liver transplant, some patients with acute kidney injury require continuous renal replacement therapy (CRRT) followed by transition to intermittent hemodialysis (iHD).
Hydroxocobalamin is mostly excreted in the urine and has a half-life of 26-31 hours. It also has a deep red color, causing discoloration of body fluids, including urine and dialysis effluent. iHD machines have a light sensor to detect small blood leaks into the effluent as a safety feature to prevent unwitnessed hemolysis or bleeding into the filter. Interestingly, hydroxocobalamin is detected as a blood leak, which halts the hemodialysis procedure. Hydroxocobalamin does not affect CRRT, so patients remain on CRRT for approximately 5 days and then transition to iHD.
A 67 year-old male with decompensated NASH cirrhosis and acute kidney injury from hepatorenal syndrome requiring dialysis underwent a liver transplant. He received hydroxocobalamin and was transferred to the SICU where he was started on CRRT briefly, and, given no pressor requirement, iHD was initiated. However, the iHD machine detected hydroxocobalamin as a small blood leak and stopped the procedure. CRRT was restarted. iHD was restarted after another 72 hours and no complications were noted.
Hydroxocobalamin-triggered blood leak detection is common and causes increased time on CRRT. Fresenius iHD machine has a photometric sensor consisting of a green and red light transmitter and a photodetector. An alarm is triggered when green light is absorbed by blood and hydroxocobalamin is capable of triggering this alarm. Alternatives to allow for earlier transition to hemodialysis are other iHD machines that have different sensors that do not detect hydroxocobalamin, empirical adjustment of dialysate and blood flow to decrease detection of hydroxocobalamin, and treating intraoperative vasoplegic syndrome with methylene blue instead of hydroxocobalamin, which does not impair iHD.