Recurring Extracorporeal Circuit Clotting During Continuous Renal Replacement Therapy in Fungal Sepsis: Successful Treatment With Argatroban

Abstract The relative effectiveness of anticoagulation strategies during continuous renal replacement therapy (CRRT) may vary according to the clinical circumstances. In this study, the case of a 46-year-old man who developed fungal mediastinitis with the pathogen Scedosporium prolificans after coro...

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Bibliographic Details
Published in:The American journal of the medical sciences 2013-03, Vol.345 (3), p.256-258
Main Authors: Ferguson, Lee M., MD, Dreisbach, Albert W., MD, Fulop, Tibor, MD, Csongrádi, Éva, MD, Juncos, Luis A., MD
Format: Article
Language:English
Subjects:
Antifungal agents
Antifungal Agents - administration & dosage
Antithrombins - administration & dosage
Argatroban
Blood Coagulation - drug effects
Continuous renal replacement therapy
Coronary Artery Bypass - adverse effects
Humans
Internal Medicine
Male
Mediastinitis - etiology
Mediastinitis - microbiology
Mediastinitis - therapy
Middle Aged
Miltefosine
Mycoses - etiology
Mycoses - microbiology
Mycoses - therapy
Phosphorylcholine - administration & dosage
Phosphorylcholine - analogs & derivatives
Pipecolic Acids - administration & dosage
Postoperative Complications
Regional citrate anticoagulation
Renal Replacement Therapy
Scedosporium
Scedosporium prolificans
Sepsis
Sepsis - etiology
Sepsis - microbiology
Sepsis - therapy
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Summary:Abstract The relative effectiveness of anticoagulation strategies during continuous renal replacement therapy (CRRT) may vary according to the clinical circumstances. In this study, the case of a 46-year-old man who developed fungal mediastinitis with the pathogen Scedosporium prolificans after coronary bypass surgery is reported. Numerous debridements and multiple antifungal agents were not effective in this patient. Miltefosine, a non-Food and Drug Administration-approved agent, was started after institutional review board request and approval. CRRT was initiated with regional citrate anticoagulation (RCA) for clinical sepsis with acute kidney injury. Subsequently, crescendo clotting of the extracorporeal circuit (ECC) occurred. Multiple interventions, including escalating RCA, adding increasing heparin to RCA and exchanging the dialysis catheter, were not effective. Argatroban anticoagulation was started without further ECC clotting, and the patient recovered from both acute kidney injury and septic shock, despite continued miltefosine administration. Sepsis may contribute to recurrent ECC clotting. Argatroban, a direct thrombin inhibitor, had a disproportionate effectiveness to maintain ECC patency in this patient.
ISSN:0002-9629
1538-2990
DOI:10.1097/MAJ.0b013e3182711e59