The Uncertainty of Bleeding Risk Monitoring for ESKD Patient on Continuous Anticoagulation Infusion
- 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
- Siu, Man Kit Michael, University of California Irvine, Irvine, California, United States
- Tantisattamo, Ekamol, University of California Irvine, Irvine, California, United States
- Patel, Samir Dinesh, University of California Irvine, Irvine, California, United States
Patients with end-stage kidney disease (ESKD) are at increased risk of bleeding due to: chronic anemia, uremic platelet dysfunction, vascular calcification, and dialysis-related complications. Additionally, the risk of venous thromboembolism is also heightened, making anticoagulation management challenging. This case report presents the unfortunate outcome of an ESKD patient who experienced acute intracranial bleeding after initiation of heparin infusion for ischemic digits, leading to death.
Patient is a 38-year-old female with ESKD secondary to diabetes mellitus (DM) on peritoneal dialysis (PD) and a history of scleroderma. She presented with progressive digit pain and discoloration. During hospital stay, she developed worsening respiratory status due to ESBL pneumonia, requiring intubation. She was started on epoprostenol given concern for Raynaud’s crisis, as well as heparin infusion for severe atherosclerotic vascular disease with stenosis. Unfortunately, hospital course was further complicated by a non-operable intraparenchymal bleed with cerebral edema and herniation, leading to eventual extubation and transition to comfort care.
Bleeding events in ESKD patients, ranging from bruises and bleeding at venipuncture sites to intracranial hemorrhage, significantly contribute to mortality and morbidity. Furthermore, blood transfusions can lead to alloimmunization and limit future transplantation options. In this case, several factors contributed to the adverse events. Team factors, including limited communication between the medical teams involved, may have hindered comprehensive management given patient's ongoing anticoagulation need. Patient factors, such as multiple comorbidities (ESKD, cardiovascular disease on aspirin) and the initiation of epoprostenol (a potent platelet aggregation inhibitor), further increased bleeding risk. Lastly, hospital policies, such as specific protocol tailored to ESKD patient that minimizes bolusing and allow for slower infusion rates could have potentially prevented these adverse events and improve patient outcomes.