Search

Heparin-induced thrombocytopenia type II (HIT) is a clinicopathologic syndrome in which one or more clinical events are temporally related to heparin administration and caused by HIT antibodies. There are at least five different types of clinical events that are associated with HIT: thrombocytopenia; thrombosis; skin necrosis at heparin injection site, venous limb gangrene; and an acute systemic reaction that occurs 5-30 min after intravenous bolus of heparin. HIT typically presents 5-14 days after initiation of heparin therapy, later onset is unusual. Heparin is a routine anticoagulant in hemodialysis but administration is different than in surgical and other medical population. Doses are lower and administered every other day, yet hemodialysis patients receive heparin for years. Relationship between dialysis vintage and HIT-antibody positivity has been analyzed in two studies. In national survey of HIT in hemodialysis population of the United Kingdom mean time between starting hemodialysis and development of HIT was 61 days (5-390 days). Japanese authors also found greatest incidence of HIT antibody positivity in patients who were on hemodialysis for less than 1 year, none of patients on hemodialysis for more than 10 years was HIT-antibody positive. We present a case of 70-years old female who developed HIT after 24 years of hemodialysis and exposure to heparin. First 22 years she was receiving unfractionated heparin for anticoagulation during hemodialysis sessions. Afterwards her therapy was changed to low molecular weight heparin. Last 12 years she has tunneled cuffed catheter which was also filled with unfractionated heparin. She had a history of severe renal osteodistrophy and severe aortal valve stenosis, hypothyreosis, thrombosis of both subclavian veins and partial colon resection due to mesenterial artery thrombosis. Her thrombocyte count was low, but despite extensive work-up which included HIT antibody detection, no cause could be identified. She started complaining of flushing, dyspnea and chest pain that developed several minutes after start of hemodialysis and stopped spontaneously during or after hemodialysis. Symptoms were attributed to her heart disease and she was hospitalized for cardiac reevaluation. Thrombosis of right superficial and commune femoral vein was diagnosed as well as further worsening of thrombocytopenia. HIT antibodies were assessed again and they were positive. Anticoagulation during hemodialysis was changed to fondaparinux and catheter filling to citrate. Afterwards symptoms during hemodialysis disappeared and thrombocyte count recovered. HIT type II is a rare but potentially fatal syndrome that can develop years after start of heparin therapy. To our knowledge, this is the patient with longest hemodialysis vintage and newly diagnosed HIT. This is also the first case of patient on hemodialysis that developed HIT in Croatia published to date.

The balance and quality of different renal replacement treatment modalities used in the elderly with end-stage renal disease vary between countries depending on economic resources, distribution of renal units, number of specialists, and patterns of reimbursement of both hospitals and physicians. Elderly patients with end-stage renal disease need detailed assessment of medical, psychological, motor, and social factors in order to choose an appropriate renal replacement treatment option. Presence or absence of significant comorbidity is much more important than the chronological age. The choice between hemodialysis and continuous ambulatory peritoneal dialysis is largely dependant on preferences of the local team and the patient. Patients with adequate cardiovascular systems are generally considered to be more suitable for hemodialysis. Hemoglobin should be optimized (Hb between 100 and 120 g/L) in all patients. Poor cardiac status and/or angina will require assessment, medical treatment, and, if necessary, surgical treatment or angioplasty. Transplantation should be considered in all reasonably fit and carefully selected patients older than 65 or even 70 years. Only the permanent shortage of suitable kidneys limits our ability to treat all those who could benefit from this type of treatment. Renal transplant recipients may benefit in terms of both survival and quality of life even if older than 70 years and beyond. Immunosuppressive therapy in elderly patients should be moderate.

The presence of human leukocyte antigen (HLA) poses a significant therapeutic challenge in solid organ transplantation. Sensitized patients (panel reactive antibody, PRA > 10%) receiving a heart transplant are at an increased risk of developing several clinical syndromes that influence short-term, and possibly also long-term patient survival. We present a case of immune system modulation in a highly sensitized patient awaiting heart transplantation. To our knowledge, this is the first case of desensitization therapy in solid organ transplantation done in Croatia. The patient with decompensated primary dilated cardiomyopathy received left ventricular assist device as a bridge to heart transplantation. Pre-transplantation evaluation revealed the presence of fungal pneumonia and high sensitization to HLA antibodies (PRA 97%). Desensitization protocol consisted of mycophenolate mofetil, tacrolimus, intravenous immune globulin and preoperative plasmapheresis along with previously initiated antifungal therapy. We withheld the application of rituximab until after resolution of pneumonia, but our protocol lowered PRA to 6% even without it. Unfortunately, during the next several weeks, a suitable donor was not found and our patient died form multiorgan failure. Avoidance of allosensitization by early referral to transplantation center, early transplantation, and avoidance of transfusions are very important when treating a potential transplant recipient. In this way, waiting time to transplantation, development of posttransplantation complications and mortality are reduced.