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we did not realise that the catheter manufacturing information specified sterilisation with ethylene oxide and its impregnation with heparin&#46;</p><p class="elsevierStylePara">We decided to discontinue heparin due to a suspicion of HIT II&#44; with the following sessions experiencing many catheter flow and resistance problems aside from repeated circuit coagulations&#46; While awaiting treatment with argatroban&#44; the jugular tunnelled catheter was replaced by another with similar characteristics&#44; without improved performance&#44; and as such&#44; a cervical computerised axial tomography scan was taken&#44; and we observed partial thrombosis of the left jugular vein &#40;Figures 2 and 3&#41;&#46; Two days later&#44; the patient presented at the unit without symptoms&#44; but 10 minutes after being connected&#44; they experienced a new episode of sudden dyspnoea with p0<span class="elsevierStyleInf">2</span>&#160;of 78&#37;&#44; from which they recovered in 1 hour with the normal support measures and did not require hospital admission&#46; The platelet count was 101x10<span class="elsevierStyleSup">9</span>&#47;l&#44; which was below that of the previous days&#46; Forty-eight hours later the platelets were 162x10<span class="elsevierStyleSup">9</span>&#47;l&#46; Finally&#44; argatroban became available and was administered at the previously reported bolus dose of 2590mic&#47;kg at the start of the session and at the subsequent perfusion dose of 2mic&#47;kg&#47;min&#44; which finished 1 hour before disconnection&#46; The activated partial thromboplastin time &#40;APTT&#41; controls were maintained within the recommended range of 1&#46;5 to 2&#46;5 over the baseline value&#46; After that&#44; circuit coagulations disappeared and the performance of the same catheter was excellent&#46; During the waiting period before starting treatment with the thrombin inhibitor&#44; and afterwards&#44; until the patient finally started peritoneal dialysis&#44; antiaggregant treatment was prescribed in the form of clopidogrel&#46; This was due to the threat of new central vessel punctures and two pending surgical interventions&#58; peritoneal catheter and transurethral resection of a small bladder tumour&#44; although the latter was carried out when peritoneal dialysis had already begun&#46; At no time before the patient was transferred to the reference hospital for a change of renal replacement therapy were argatroban and dicoumarins administered together&#46; We must also mention the absence of acute venous thrombosis data and that the heart rate was controlled&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical and laboratory data</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">HIT II is defined as a 50&#37; decrease in the number of platelets&#44; with a count below 100x10<span class="elsevierStyleSup">9</span>&#47;l&#44; which occurs within between 5 and 15 days of the first exposure&#46; In our setting&#44; this condition has not gone unnoticed <span class="elsevierStyleSup">6-8</span>&#46; The considerable risk of thrombosis means that we must act quickly&#46; The diagnosis is carried out by functional and antigen tests&#46; The first&#44; more specifically STRA &#40;14C&#160;serotonin release assay&#41;&#44; HIPA &#40;heparin-induced platelet activation assay&#41; and PAT &#40;platelet aggregation test&#41;<span class="elsevierStyleSup">9&#44;10</span>&#44; have the disadvantage of not being available in all hospitals&#44; with STRA being the main functional test due to its specificity &#40;99&#37;&#41;&#46; The antigen tests using ELISA and the PaGIA &#40;particle gel immuno assay&#41; do not achieve this degree of specificity<span class="elsevierStyleSup">11</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Diagnosis</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The clinical process permits other assumptions&#58; an allergic reaction to ethylene oxide<span class="elsevierStyleSup">12</span>&#160;usually manifests with a skin reaction and does not explain thrombocytopenia or the rapid recovery without anti-histamines&#46; Ethylene oxide antibodies were not determined&#46; Another condition with a similar clinical presentation is the anaphylactoid reaction upon using negatively charged filters in patients treated with renin-angiotensin system blockers due to bradykinin activation<span class="elsevierStyleSup">13&#44;14</span>&#44; and the patient was not taking these drugs&#46; Other contaminants or sterilisers in the circuit seem very unlikely in haemodialysis with the current control systems&#46; The scheduled determination of endotoxins in the dialysate was always normal&#46;</p><p class="elsevierStylePara">In extracorporeal treatment&#44; it is necessary to rule out air embolisms&#44; haemolysis and acute anaemia&#46; The visible area of the catheter was intact and no leaks were detected in the circuit&#46; There were no haemolysis data&#44; with LDH of 501U&#47;l&#46;</p><p class="elsevierStylePara">Situations inherent to patient pathology&#44; such as pulmonary oedema&#44; heart attack&#44; embolism or pericardial tamponade&#44; can be excluded in the clinical&#44; biological and radiological context&#46; It is true that there was a certain amount of myocardial suffering in view of the increased cTnI figure&#44; but there were no electrocardiographic changes&#46; The possibility of sepsis seems unlikely without a fever or leukocytes&#44; and as such&#44; procalcitonin was not determined&#46;</p><p class="elsevierStylePara">Thrombocytopenia was not explained by the patient&#8217;s normal pharmacology&#44; or by pulmonary sequestration with biocompatible filters&#44; sepsis or disseminated intravascular coagulation &#40;DIC&#41;&#44; with it being confirmed by the Haematology department that it was not a spurious form&#46;</p><p class="elsevierStylePara">Bearing in mind the chronopathology of the event and following the parameters of the test mentioned &#40;Table 1&#41; with a subjective score of 7&#44; we decided to adjust to a presumptive diagnosis of HIT II&#44; later supported by a positive ELISA test &#40;Table 2&#41;&#44; weighing up the risks and benefits&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">We should not wait for diagnostic confirmation from laboratory tests when there is strong clinical suspicion&#46; The first step is to discontinue heparin&#46; The drugs indicated are thrombin inhibitors&#58; lepirudin&#44; bivalirudin and argatroban&#46; The first has the disadvantage of causing anaphylaxis and it is excreted by the kidneys&#46; Although it is not currently available&#44; it has been successfully used in our setting<span class="elsevierStyleSup">6</span>&#46; Bivalirudin use is generalised in catheterisation laboratories due to its short half-life&#44; however&#44; it is also excreted by the kidneys<span class="elsevierStyleSup">15</span>&#46; Argatroban is not excreted by the kidneys and it therefore seems more suitable in Nephrology&#59; it is acquired as foreign drug&#46;</p><p class="elsevierStylePara">Argatroban<span class="elsevierStyleSup">16</span>&#160;is a synthetic thrombin inhibitor&#44; to which it binds selectively and reversibly&#46; It has a short half-life&#44; and as such&#44; its effect disappears soon after it is discontinued&#46; It is not immunogenic and does not require dose modification in renal failure&#46; It is capable of inhibiting both free thrombin and clot-bound thrombin&#46; It is metabolised in the liver and eliminated in bile and finally in faeces&#46; Equilibrium concentrations are achieved within between 1 and 3 hours and its effect disappears 1-2 after it is discontinued&#46; Liver and multiorgan failure require a dose reduction &#40;0&#46;5mic&#47;kg&#47;min&#41;&#58; a quarter of the normal dose of 2mic&#47;kg&#47;min&#46; Two prospective studies tested its efficacy and safety<span class="elsevierStyleSup">3&#44;17</span> in terms of its anti-thrombotic power&#44; without an increase in bleeding&#46; Trials carried out in haemodialysis<span class="elsevierStyleSup">18-20</span> and haemofiltration<span class="elsevierStyleSup">21</span> demonstrated elimination of up to 20&#37;&#44; which should be borne in mind&#44; since there is no antidote to the drug&#46;</p><p class="elsevierStylePara">The often necessary transition from argatroban to dicoumarins must be carried out carefully&#44; due to the risk of necrosis&#44; gangrene and leg amputation brought on by the effect of dicoumarins in reducing protein S and C levels<span class="elsevierStyleSup">22&#44;23</span>&#46; Thrombin inhibitors change the international normalized ratio &#40;INR&#41; values due to their high osmotic concentration&#46; In practice&#44; once platelet count is normal&#44; argatroban can be administered alongside acenocoumarol over a minimum of 4-5 days until an INR&#62;4 Is achieved&#46; Then argatroban is discontinued and a new INR test is carried out after 6 hours&#46; It was found that during the joint administration of both drugs with an INR&#62;4&#44; the relationship between the INR and the risk of bleeding changed&#44; with the risk of thrombosis being higher&#46; If a patient is taking a dicoumarin anticoagulant and HIT II is observed&#44; vitamin K should be administered in order to reverse a greater risk of thrombosis in this context&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">This case warns us about HIT II&#44; which can often only be detected by thrombocytopenia in the time interval mentioned&#44; after the first administration of heparin&#46; In our case&#44; the discontinuation of heparin and the administration of argatroban were safe and effective&#44; and we achieved adequate dialysis as we waited for the patient to be transferred to the reference hospital for peritoneal dialysis&#44; where they are continuing this treatment without any incidents&#46; In the differential diagnosis&#44; we must consider all the details&#44; which we did not do in our case because we forgot to check the manufacture information on methods of sterilisation and impregnation of the catheter with heparin&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59923&#95;en&#95;t1&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59923_en_t1.12317_3.jpg" alt="4T scoring systems for suspected heparin-induced thrombocytopenia "></img></a></p><p class="elsevierStylePara">Table 1&#46; 4T scoring systems for suspected heparin-induced thrombocytopenia </p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59924&#95;en&#95;t2&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59924_en_t2.12317_3.jpg" alt="Diagnostic probability of heparin-induced thrombocytopenia in haemodialysis &#40;three clinical factors and ELISA&#41;7"></img></a></p><p class="elsevierStylePara">Table 2&#46; Diagnostic probability of heparin-induced thrombocytopenia in haemodialysis &#40;three clinical factors and ELISA&#41;7</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59925&#95;en&#95;f1&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59925_en_f1.12317_3.jpg" alt="Platelet count in relation to time and anticoagulant treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Platelet count in relation to time and anticoagulant treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59926&#95;en&#95;f2&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59926_en_f2.12317_3.jpg" alt="Jugular vein thrombosis &#40;cross-sectional view&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Jugular vein thrombosis &#40;cross-sectional view&#41;&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59927&#95;en&#95;f3&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59927_en_f3.12317_3.jpg" alt="Jugular vein thrombosis &#40;front view&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Jugular vein thrombosis &#40;front view&#41;&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Se presenta el caso de un paciente con un diagn&#243;stico de probabilidad de trombocitopenia inmune inducida por heparina &#40;TIH II&#41; con base en criterios cl&#237;nicos y test de ELISA positivo&#44; en que la urgencia terap&#233;utica fue determinante ante la gravedad del proceso&#46; La suspensi&#243;n de heparina y la administraci&#243;n de argatroban solventaron la ineficacia de la di&#225;lisis debida a coagulaci&#243;n repetida del circuito y cat&#233;ter&#44; permitiendo el paso a di&#225;lisis peritoneal sin mayores contratiempos&#46; Consideramos prioritaria la toma de decisiones antes de certificar la seguridad diagn&#243;stica&#46;</p>"
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Heparin-induced thrombocytopenia in haemodialysis treated with argatroban
Trombocitopenia inducida por heparina en hemodiálisis tratada con argatroban
Luis Quiñones-Ortiza, Ana Suárez-Laurésa, Montserrat Pablos-de Pabloa, Verónica Roblesb, Cristina Calzón-Blancoc, Sara Quiñones-Pérezc, Aitor Ayausty-Ruizc
a Servicio de Nefrología, Hospital de Cabueñes, Gijón, Asturias,
b Servicio de Hematología, Hospital de Cabueñes, Gijón, Asturias,
c Servicio de Farmacia Hospitalaria, Hospital de Cabueñes, Gijón, Asturias,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Heparin-induced thrombocytopenia &#40;HIT&#41; in haemodialysis may be of two types&#58; type I &#40;HIT I&#41;&#44; which is mild&#44; self-limiting&#44; it appears 1-4 days after administration and has an incidence of 10&#37;-20&#37;&#59; the second type &#40;HIT II&#41; is severe&#44; it appears between 5 and 15 days after the first exposure to heparin and it results in a decrease in the number of platelets greater than 30&#37;-50&#37; on the baseline value&#44; with a platelet count that is generally lower than 100x10&#47;l<span class="elsevierStyleSup">1</span>&#46; It is immune and may be fatal&#44; due to often being accompanied by thromboembolic events&#44; such as heart attacks&#44; skin necrosis&#44; pulmonary embolism and gangrene&#46; Its incidence is around 1&#37;-2&#37;&#46;</p><p class="elsevierStylePara">The pathogeny consists of antibody formation&#44; generally IgG&#44; against the antigen complex consisting of the heparin platelet factor 4 complex with platelet activation and uncontrolled thrombin activation&#46; Its firm diagnosis requires functional tests to detect antibodies against the aforementioned antigen<span class="elsevierStyleSup">2</span>&#46; The treatment must be immediate&#44; since mortality of up to 30&#37; has been reported<span class="elsevierStyleSup">3</span>&#46;</p><p class="elsevierStylePara">We treated a case with characteristics typical of the process as appearing in the event probability scale &#40;4T&#41;<span class="elsevierStyleSup">4</span>&#160;&#40;Table 1&#41;&#44; and we decided to carry out empirical treatment before receiving the results of the ELISA &#40;<span class="elsevierStyleItalic">enzyme-linked immunosorbent assay</span>&#41;&#44; since functional tests were not available&#46; At that time&#44; we reviewed all forms of heparinisation and sterilisation of the circuit&#44; without realising that the catheter manufacture report included ethylene oxide use for its sterilisation&#44; as well as its impregnation with heparin&#46; The choice of argatroban was based on its suitable pharmacokinetic profile in renal failure and in haemodialysis<span class="elsevierStyleSup">5</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">71-year-old patient diagnosed with advanced chronic renal failure secondary to nephroangiosclerosis&#59; it was advisable to start haemodialysis due to progressive asthenia and a glomerular filtration rate &#60;10ml&#47;min&#46; The patient received treatment with acenocoumarol&#44; due to a history of atrial fibrillation and ischaemic stroke&#46; It was not possible to create an arteriovenous fistula due to poor arterial and venous development in the arms&#46;</p><p class="elsevierStylePara">Three days before the first dialysis session&#44; low-molecular-weight heparin administration was initiated to replace the patient&#8217;s regular anticoagulant&#46; A left jugular tunnelled catheter was inserted&#44; with regular doses of heparin administered to prevent coagulation of the circuit&#44; as well as unfractionated heparin for catheter sealing&#46; The platelet count was 210x10<span class="elsevierStyleSup">9</span>&#47;l&#46; The first sessions were unsatisfactory due to poor catheter performance&#46; Nine days after the first administration of heparin&#44; in the fourth dialysis session&#44; we treated the first acute event&#58; sudden dyspnoea and chest pain at the start of the session without low blood pressure&#44; haemoptysis or fever&#46; Blood pressure&#58; 180&#47;100mmHg&#44; tachypnoea&#44; no fever&#44; jugular vein engorgement or cyanosis&#44; with a heart rate of 90 beats per minute&#44; with systolic ejection murmur II&#47;VI&#44; without ectopic beats or pericardial rubs&#44; bronchospasms without crepitant rales&#44; no oedema or signs of deep venous thrombosis&#44; with normal foot temperature and colouring&#46; No skin rash&#46; Haemoglobin&#58; 9&#46;6g&#47;dl&#44; leukocytes&#58; 7200&#46; Platelets&#58; 44x10<span class="elsevierStyleSup">9</span>&#47;l &#40;Figure 1&#41;&#44; lactate dehydrogenase &#40;LDH&#41;&#58; 510U&#47;l&#44; cardiac troponin 1 &#40;cTnI&#41;&#58; 2&#46;6ng&#47;ml&#46; No signs of ischaemia or lesions in the electrocardiogram&#46; The patient was observed for 24 hours with normalisation of clinical profile &#40;over the course of the session&#41; and with a significant decrease in the cTnI figure to 1&#46;2ng&#47;ml&#46; The x-ray did not provide relevant data&#46;</p><p class="elsevierStylePara">The filter used was made of steam-sterilised polysulfone&#46; Haemodialysis was conventional with volume control&#46; The patient did not receive therapy with renin-angiotensin system blockers&#44; but rather with beta-blockers and calcium channel blockers&#46; At that time&#44; we did not realise that the catheter manufacturing information specified sterilisation with ethylene oxide and its impregnation with heparin&#46;</p><p class="elsevierStylePara">We decided to discontinue heparin due to a suspicion of HIT II&#44; with the following sessions experiencing many catheter flow and resistance problems aside from repeated circuit coagulations&#46; While awaiting treatment with argatroban&#44; the jugular tunnelled catheter was replaced by another with similar characteristics&#44; without improved performance&#44; and as such&#44; a cervical computerised axial tomography scan was taken&#44; and we observed partial thrombosis of the left jugular vein &#40;Figures 2 and 3&#41;&#46; Two days later&#44; the patient presented at the unit without symptoms&#44; but 10 minutes after being connected&#44; they experienced a new episode of sudden dyspnoea with p0<span class="elsevierStyleInf">2</span>&#160;of 78&#37;&#44; from which they recovered in 1 hour with the normal support measures and did not require hospital admission&#46; The platelet count was 101x10<span class="elsevierStyleSup">9</span>&#47;l&#44; which was below that of the previous days&#46; Forty-eight hours later the platelets were 162x10<span class="elsevierStyleSup">9</span>&#47;l&#46; Finally&#44; argatroban became available and was administered at the previously reported bolus dose of 2590mic&#47;kg at the start of the session and at the subsequent perfusion dose of 2mic&#47;kg&#47;min&#44; which finished 1 hour before disconnection&#46; The activated partial thromboplastin time &#40;APTT&#41; controls were maintained within the recommended range of 1&#46;5 to 2&#46;5 over the baseline value&#46; After that&#44; circuit coagulations disappeared and the performance of the same catheter was excellent&#46; During the waiting period before starting treatment with the thrombin inhibitor&#44; and afterwards&#44; until the patient finally started peritoneal dialysis&#44; antiaggregant treatment was prescribed in the form of clopidogrel&#46; This was due to the threat of new central vessel punctures and two pending surgical interventions&#58; peritoneal catheter and transurethral resection of a small bladder tumour&#44; although the latter was carried out when peritoneal dialysis had already begun&#46; At no time before the patient was transferred to the reference hospital for a change of renal replacement therapy were argatroban and dicoumarins administered together&#46; We must also mention the absence of acute venous thrombosis data and that the heart rate was controlled&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical and laboratory data</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">HIT II is defined as a 50&#37; decrease in the number of platelets&#44; with a count below 100x10<span class="elsevierStyleSup">9</span>&#47;l&#44; which occurs within between 5 and 15 days of the first exposure&#46; In our setting&#44; this condition has not gone unnoticed <span class="elsevierStyleSup">6-8</span>&#46; The considerable risk of thrombosis means that we must act quickly&#46; The diagnosis is carried out by functional and antigen tests&#46; The first&#44; more specifically STRA &#40;14C&#160;serotonin release assay&#41;&#44; HIPA &#40;heparin-induced platelet activation assay&#41; and PAT &#40;platelet aggregation test&#41;<span class="elsevierStyleSup">9&#44;10</span>&#44; have the disadvantage of not being available in all hospitals&#44; with STRA being the main functional test due to its specificity &#40;99&#37;&#41;&#46; The antigen tests using ELISA and the PaGIA &#40;particle gel immuno assay&#41; do not achieve this degree of specificity<span class="elsevierStyleSup">11</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Diagnosis</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The clinical process permits other assumptions&#58; an allergic reaction to ethylene oxide<span class="elsevierStyleSup">12</span>&#160;usually manifests with a skin reaction and does not explain thrombocytopenia or the rapid recovery without anti-histamines&#46; Ethylene oxide antibodies were not determined&#46; Another condition with a similar clinical presentation is the anaphylactoid reaction upon using negatively charged filters in patients treated with renin-angiotensin system blockers due to bradykinin activation<span class="elsevierStyleSup">13&#44;14</span>&#44; and the patient was not taking these drugs&#46; Other contaminants or sterilisers in the circuit seem very unlikely in haemodialysis with the current control systems&#46; The scheduled determination of endotoxins in the dialysate was always normal&#46;</p><p class="elsevierStylePara">In extracorporeal treatment&#44; it is necessary to rule out air embolisms&#44; haemolysis and acute anaemia&#46; The visible area of the catheter was intact and no leaks were detected in the circuit&#46; There were no haemolysis data&#44; with LDH of 501U&#47;l&#46;</p><p class="elsevierStylePara">Situations inherent to patient pathology&#44; such as pulmonary oedema&#44; heart attack&#44; embolism or pericardial tamponade&#44; can be excluded in the clinical&#44; biological and radiological context&#46; It is true that there was a certain amount of myocardial suffering in view of the increased cTnI figure&#44; but there were no electrocardiographic changes&#46; The possibility of sepsis seems unlikely without a fever or leukocytes&#44; and as such&#44; procalcitonin was not determined&#46;</p><p class="elsevierStylePara">Thrombocytopenia was not explained by the patient&#8217;s normal pharmacology&#44; or by pulmonary sequestration with biocompatible filters&#44; sepsis or disseminated intravascular coagulation &#40;DIC&#41;&#44; with it being confirmed by the Haematology department that it was not a spurious form&#46;</p><p class="elsevierStylePara">Bearing in mind the chronopathology of the event and following the parameters of the test mentioned &#40;Table 1&#41; with a subjective score of 7&#44; we decided to adjust to a presumptive diagnosis of HIT II&#44; later supported by a positive ELISA test &#40;Table 2&#41;&#44; weighing up the risks and benefits&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">We should not wait for diagnostic confirmation from laboratory tests when there is strong clinical suspicion&#46; The first step is to discontinue heparin&#46; The drugs indicated are thrombin inhibitors&#58; lepirudin&#44; bivalirudin and argatroban&#46; The first has the disadvantage of causing anaphylaxis and it is excreted by the kidneys&#46; Although it is not currently available&#44; it has been successfully used in our setting<span class="elsevierStyleSup">6</span>&#46; Bivalirudin use is generalised in catheterisation laboratories due to its short half-life&#44; however&#44; it is also excreted by the kidneys<span class="elsevierStyleSup">15</span>&#46; Argatroban is not excreted by the kidneys and it therefore seems more suitable in Nephrology&#59; it is acquired as foreign drug&#46;</p><p class="elsevierStylePara">Argatroban<span class="elsevierStyleSup">16</span>&#160;is a synthetic thrombin inhibitor&#44; to which it binds selectively and reversibly&#46; It has a short half-life&#44; and as such&#44; its effect disappears soon after it is discontinued&#46; It is not immunogenic and does not require dose modification in renal failure&#46; It is capable of inhibiting both free thrombin and clot-bound thrombin&#46; It is metabolised in the liver and eliminated in bile and finally in faeces&#46; Equilibrium concentrations are achieved within between 1 and 3 hours and its effect disappears 1-2 after it is discontinued&#46; Liver and multiorgan failure require a dose reduction &#40;0&#46;5mic&#47;kg&#47;min&#41;&#58; a quarter of the normal dose of 2mic&#47;kg&#47;min&#46; Two prospective studies tested its efficacy and safety<span class="elsevierStyleSup">3&#44;17</span> in terms of its anti-thrombotic power&#44; without an increase in bleeding&#46; Trials carried out in haemodialysis<span class="elsevierStyleSup">18-20</span> and haemofiltration<span class="elsevierStyleSup">21</span> demonstrated elimination of up to 20&#37;&#44; which should be borne in mind&#44; since there is no antidote to the drug&#46;</p><p class="elsevierStylePara">The often necessary transition from argatroban to dicoumarins must be carried out carefully&#44; due to the risk of necrosis&#44; gangrene and leg amputation brought on by the effect of dicoumarins in reducing protein S and C levels<span class="elsevierStyleSup">22&#44;23</span>&#46; Thrombin inhibitors change the international normalized ratio &#40;INR&#41; values due to their high osmotic concentration&#46; In practice&#44; once platelet count is normal&#44; argatroban can be administered alongside acenocoumarol over a minimum of 4-5 days until an INR&#62;4 Is achieved&#46; Then argatroban is discontinued and a new INR test is carried out after 6 hours&#46; It was found that during the joint administration of both drugs with an INR&#62;4&#44; the relationship between the INR and the risk of bleeding changed&#44; with the risk of thrombosis being higher&#46; If a patient is taking a dicoumarin anticoagulant and HIT II is observed&#44; vitamin K should be administered in order to reverse a greater risk of thrombosis in this context&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">This case warns us about HIT II&#44; which can often only be detected by thrombocytopenia in the time interval mentioned&#44; after the first administration of heparin&#46; In our case&#44; the discontinuation of heparin and the administration of argatroban were safe and effective&#44; and we achieved adequate dialysis as we waited for the patient to be transferred to the reference hospital for peritoneal dialysis&#44; where they are continuing this treatment without any incidents&#46; In the differential diagnosis&#44; we must consider all the details&#44; which we did not do in our case because we forgot to check the manufacture information on methods of sterilisation and impregnation of the catheter with heparin&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59923&#95;en&#95;t1&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59923_en_t1.12317_3.jpg" alt="4T scoring systems for suspected heparin-induced thrombocytopenia "></img></a></p><p class="elsevierStylePara">Table 1&#46; 4T scoring systems for suspected heparin-induced thrombocytopenia </p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59924&#95;en&#95;t2&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59924_en_t2.12317_3.jpg" alt="Diagnostic probability of heparin-induced thrombocytopenia in haemodialysis &#40;three clinical factors and ELISA&#41;7"></img></a></p><p class="elsevierStylePara">Table 2&#46; Diagnostic probability of heparin-induced thrombocytopenia in haemodialysis &#40;three clinical factors and ELISA&#41;7</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59925&#95;en&#95;f1&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59925_en_f1.12317_3.jpg" alt="Platelet count in relation to time and anticoagulant treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Platelet count in relation to time and anticoagulant treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59926&#95;en&#95;f2&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59926_en_f2.12317_3.jpg" alt="Jugular vein thrombosis &#40;cross-sectional view&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Jugular vein thrombosis &#40;cross-sectional view&#41;&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12317&#95;16025&#95;59927&#95;en&#95;f3&#46;12317&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12317_16025_59927_en_f3.12317_3.jpg" alt="Jugular vein thrombosis &#40;front view&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Jugular vein thrombosis &#40;front view&#41;&#46;</p>"
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