|Year : 2014 | Volume
| Issue : 2 | Page : 76-78
Successful Hemodialysis Initiation in a Patient with Chronic Disseminated Intravascular Coagulation
Akihito Tanaka1, Yuichi Ito2
1 Department of Nephrology, Nakatsugawa City Hospital, Nakatsugawa City, Gifu Prefecture, Nagoya, Japan
2 Department of Emergency Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan
|Date of Web Publication||27-Oct-2014|
Department of Nephrology, Nakatsugawa City Hospital, 1522-1 Komaba, Nakatsugawa City, Gifu Prefecture - 5088502
Source of Support: None, Conflict of Interest: None
We report a 72-year-old man with end-stage renal disease due to chronic glomerulonephritis and chronic disseminated intravascular coagulation (DIC) caused by aortic aneurysm. He had had graft replacement for abdominal aortic aneurysm in 2012 at another hospital. He indicated development of thoracic aortic aneurysm, which developed chronic DIC with much subcutaneous hemorrhage. His renal function gradually decreased and we planned hemodialysis initiation. We administered camostat mesilate and platelet concentrate transfusion to treat hemorrhagic tendency before the arteriovenus fistula in May 2014. After the operation, we added tranexamic acid because of difficulty in hemostasis. About 1 month later, the patient reported with hemorrhage from the nose and his renal function was exacerbated. He was initiated into hemodialysis with transfusion of red blood cells and fresh frozen plasma. We raised the dose of camostat mesilate and adjusted the dose of anticoagulant with reference to activated clotting time. He was successfully initiated into dialysis without major trouble.
Keywords: Chronic disseminated intravascular coagulation, hemodialysis, renal failure
|How to cite this article:|
Tanaka A, Ito Y. Successful Hemodialysis Initiation in a Patient with Chronic Disseminated Intravascular Coagulation. J Integr Nephrol Androl 2014;1:76-8
|How to cite this URL:|
Tanaka A, Ito Y. Successful Hemodialysis Initiation in a Patient with Chronic Disseminated Intravascular Coagulation. J Integr Nephrol Androl [serial online] 2014 [cited 2021 Jul 24];1:76-8. Available from: http://www.journal-ina.com/text.asp?2014/1/2/76/143388
| Introduction|| |
Aortic aneurysm is known to cause chronic disseminated intravascular coagulation (DIC). In such a state of chronic DIC, hemorrhagic tendency is caused by consumption of coagulation factor.
On the other hand, an end-stage renal disease (ESRD) patient who requires hemodialysis therapy sometimes faces hemorrhagic problems such as vascular access operation, needle-insertion into vascular access at every hemodialysis session and choice of anticoagulant for extracorporeal circulation.
This time, we experienced a successful case of vascular access operation and hemodialysis initiation with careful control of medicine and transfusion. Because the number of patients initiated into hemodialysis with complications such as DIC is expected to increase, we herein report this case for future reference.
| Case report|| |
In May 2014, a 72-year-old man was admitted to our hospital to make an arteriovenus fistula (AVF) because his renal function was exacerbated. He had a past history of abdominal aortic aneurysm and graft replacement was performed in 2012 at another hospital. After operation, he indicated gradual development of thoracic aortic aneurysm without necessity of surgical treatment.
In 2013, he was first referred to our hospital because of chronic renal failure. We diagnosed the cause of renal failure was chronic glomerulonephritis and he started to come to our hospital regularly. Thereafter, we also diagnosed chronic DIC due to aortic aneurysm in May 2014. His renal function was exacerbated in due course of time. We planned to initiate hemodialysis. However, he had a problem of hemorrhagic tendency, such as much subcutaneous hemorrhage. We administered camostat mesilate 300 mg/day. He was admitted to our hospital the day before the AVF operation.
On admission, his height was 163.0 cm and weight was 61.0 kg. His physical examination revealed clear respiratory sounds and no cardiac murmur. His abdomen was soft and flat with operative scar. His body temperature was 36.2°C, blood pressure was 156/77 mmHg and heart rate was 65 beats/min with sinus rhythm. Clinical laboratory data of the blood and serum were as follows: White blood cell count, 4.2 × 10 3 /μL; red blood cell count, 203 × 10 4 /μL; hemoglobin, 6.7 g/dL; hematocrit, 19.4%; platelet count, 4.6 × 10 4 /μL; C-reactive protein, 0.76 mg/dL; total protein, 7.0 g/dL; albumin, 3.9 g/dL; glutamic oxaloacetic transaminase, 17 IU/L; glutamic pyruvic transaminase, 14 IU/L; total bilirubin, 0.3 mg/dL; lactate dehydrogenase, 364 IU/L; creatinine kinase, 153 IU/L; blood urea nitrogen, 95.4 mg/dL; creatinine, 6.34 mg/dL; sodium, 138 mEq/L; potassium 5.2 mEq/L; uric acid 6.9 mg/dL; corrected calcium, 8.4 mg/dL; phosphate, 5.3 mg/dL; activated partial thromboplastin time, 36.3 s (normal range 23.0-35.0); and prothrombin time international normalized ratio (PT-INR), 1.14; fibrinogen, 113 mg/dL; fibrinogen degradation product, 113.5 μg/mL; antithrombin 3, 88%; and D-dimer, 53.84 μg/mL.
On the day of admission, platelet concentrate transfusion (10 units) with dripping infusion of nafamostat mesilate (100 mg/day) was performed. The operation was stereotypically performed on his left forearm and we closed the wound after confirmation of hemostasis. However, on the next day, his left forearm swelled severely and oozing from the wound did not stop completely. We judged that more tight control of DIC was necessary and administered tranexamic acid (150 mg × 3 times/week). After 1 week, although swelling of his left forearm was persisting [Figure 1], he was discharged from the hospital because oozing from the wound stopped.
|Figure 1: The image of swelling on the forearm 1 week after the operation. A massive subcutaneous hemorrhage was seen. A scale bar = 5 cm|
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Although he was stable for about 1 month without hemorrhagic events, he was re-admitted to our hospital because of exacerbation of renal failure and hemorrhage from nose with uremic symptoms in June 2014. He was initiated into hemodialysis with transfusion of red blood cells and fresh frozen plasma. First, nafamostat mesilate was used as an anticoagulant for extracorporeal circulation and switched to low-molecular weight heparin. The dose of anticoagulant was adjusted within the range of activated clotting time (ACT) from 140 to 180 s (normal range 90-140 s). Finally, the dose of low-molecular weight heparin was fixed to 300 units/one-shot and 150 units/h. We also adjusted the dose of camostat mesilate up to 900 mg/day. His clinical course was shown in [Figure 2]. He became stable without hemorrhagic event and was discharged from our hospital.
|Figure 2: Clinical course around the hemodialysis initiation. Left vertical axis shows the level of fibrinogen degradation product (FDP). Right vertical axis shows the level of platelet count (Plt). A black arrowhead shows platelet concentrate (PC) transfusion (10 units). A gray arrowhead shows red blood cell (RCC) transfusion (2 units). A white arrowhead shows fresh frozen plasma (FFP) transfusion (4 units). A white arrow shows the timing of operation when arteriovenous fistula (AVF) was made|
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| Discussion|| |
About 3 to 4% of patients with chronic DIC reportedly show aortic aneurysm. , On the other hand, from 0.5 to 1.0% of patients with aortic aneurysm are reported to show clinically apparent symptoms of DIC.  Chronic DIC with aortic aneurysm is caused by local vascular wall abnormality and following consumption of coagulation factors in the aneurysm.  It is characterized by a chronic course and fibrinolytic dominant coagulation abnormality. 
First, he showed only subcutaneous hemorrhage without involvement of any organ. However, hemorrhagic tendency is considered to be a problem when we initiate dialysis therapy. We predict massive bleeding on vascular access operation and difficulty in hemostasis after removing needles for dialysis sessions. Although there is no proven therapy for chronic DIC, we administered camostat mesilate  and tranexamic acid,  which were reported to be efficacious. With these medications, we were able to control hemorrhagic tendency. Generally, subcutaneous or venous injection of heparin is a choice for treatment. However, in case of chronic DIC with aortic aneurysm, heparin seems to be controversial because of the risk of development of aneurysm or dissection. 
In hemodialysis induction, we need an anticoagulant, such as heparin, for extracorporeal circulation. However, low-molecular weight heparin or nafamostat mesilate is recommended when the patients show hemorrhagic tendency.  Furthermore, adjustment of the dose of anticoagulant is also important with monitoring ACT.  In our case, we used low-molecular weight heparin with measuring ACT on dialysis sessions finally. Although another report showed a successful case without anticoagulant,  we consider that adjusting the dose of anticoagulant individually by ACT is important.
When initiating patients with chronic DIC into hemodialysis, there are many problems, such as treatment of DIC itself, vascular access operation, anticoagulant for extracorporeal circulation and so on. Furthermore, a proven treatment of chronic DIC does not exist. Hence, we should take care of patients with chronic DIC individually. However, there are few reports about dialysis initiation in patients with chronic DIC. Hereafter, the number of hemodialysis initiations in patients with complications such as chronic DIC is expected to increase. We herein report our case for future reference.
| References|| |
Fine NL, Applebaum J, Elguezabal A, Castleman L. Multiple coagulation defects in association with dissecting aneurysms. Arch Intern Med 1967;119:522-6.
Fisher DF Jr, Yawn DH, Crawford ES. Preoperative disseminated intravascular coagulation associated with aortic aneurysm. A prospective study of 76 cases. Arch Surg 1983;118:1252-5.
Aboulafia DM, Aboulafia ED. Aortic aneurysm-induced disseminated intravascular coagulation. Ann Vasc Surg 1996;10:396-405.
ten Cate JW, Timmers H, Becker AE. Coagulopathy in ruptured or dissecting aortic aneurysms. Am J Med 1975;59:171-6.
Asakura H, Jokaji H, Saito M, Uotani C, Kumabashiri I, Morishita E, et al
. Study of the balance between coagulation and fibrinolysis in disseminated intravascular coagulation using molecular markers. Blood Coagul Fibrinolysis 1994;5:829-32.
Miyahara S, Yasu T, Yamada Y, Kobayashi N, Saito M, Momomura S. Subcutaneous Injection of Heparin Calcium Controls Chronic Disseminated Intravascular Coagulation Associated with Inoperable Dissecting Aortic Aneurysm in an Outpatient Clinic. Intern Med 2007;46:727-32.
Ontachi Y, Asakura H, Arahata M, Kadohira Y, Maekawa M, Hayashi T, et al
. Effect of combined therapy of danaparoid sodium and tranexamic acid on chronic disseminated intravascular coagulation associated with abdominal aortic aneurysm. Circ J 2005;69:1150-3.
Yamanouchi M, Ubara Y, Mise K, Hayami N, Hiramatsu R, Sumida K, et al
. Hemodialysis without anticoagulation for a patient with chronic disseminated intravascular coagulation. Case Rep Nephrol Urol 2014;4:25-30.
Nissenson AR, Fine RN. Anticoagulation in patients on hemodialysis. Clinical Dialysis, 4 th
ed. New York: McGraw-Hill; 2005. p. 127-52.
Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: Regional versus low-dose heparin. Kidney Int 1979;16:513-8.
[Figure 1], [Figure 2]