Use of lepirudin in patients with heparin-induced thrombocytopenia and renal failure requiring hemodialysis

OBJECTIVE: To report two cases of successful lepirudin use in two patients with heparin-induced thrombocytopenia (HIT) and renal failure. CASE SUMMARY: Two patients with renal failure requiring hemodialysis develo ped HIT syndrome during intravenous heparin therapy. Anticoagulation was ne cessary to prevent recurrent, acute venous thrombosis in one patient and to prevent arterial thrombosis associated with the use of an intraaortic ball oon pump in the second. Intravenous lepirudin was initiated at doses of 0.0 1 mg/kg/h and 0.005 mg/kg/h, respectively, and titrated based on the activa ted partial thromboplastin time (aPTT). Steady-state doses were 0.015 mg/kg /h to maintain aPTT values of approximately 60 seconds in one patient, and 0.005-0.008 mg/kg/h to achieve an aPTT of approximately 45 seconds in the o ther patient. DISCUSSION: Lepirudin is one of few anticoagulants that can be safely used in patients with HIT Because it is eliminated through the kidneys, great ca re must be taken when administering lepirudin to patients with renal failur e; in fact, its use is currently not recommended in patients requiring hemo dialysis. Lepirudin effectively prevented acute thrombosis in both of our p atients with documented HIT, with no bleeding complications. We describe ho w we selected the initial doses and report results of aPTT monitoring. CONCLUSIONS: In patients with renal failure who develop HIT lepirudin is on e available alternative to heparin despite its poor renal elimination patte rn and subsequently prolonged half-life.