Thrombocytopenia in a home hemodialysis patient with NxStage system
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NEPHROLOGY - LETTER TO THE EDITOR
Thrombocytopenia in a home hemodialysis patient with NxStage system Malvinder S. Parmar1 Received: 20 April 2020 / Accepted: 7 September 2020 © Springer Nature B.V. 2020
Keywords Hemodialysis · Thrombocytopenia · Heparin-induced thrombocytopenia · Dialyzer membrane-induced thrombocytopenia · NxStage Editor A 56-year-old man with progressive diabetic kidney disease who recently started conventional hemodialysis, was interested in home hemodialysis, started undergoing home hemodialysis training using NxStage System One, with heparin as an anticoagulant. After 3–4 weeks of training, blood work showed a significant drop in platelet count (from 172 to 107) that dropped further to 83. We wondered about converting the patient to conventional therapy, or using an alternate anticoagulant, or switching to peritoneal dialysis. However, though all these options were possible but had drawbacks—higher annual cost and not supporting patient choice with conventional hemodialysis, and the higher cost of an alternate anticoagulant if used [1]. After reviewing the clinical history and the significant drop in platelet count after switching to home hemodialysis, we initially felt that thrombocytopenia was either, though less likely, to be Heparininduced thrombocytopenia (HIT) [2] (had been receiving heparin at least for 4 months during conventional hemodialysis) or higher dose of heparin. He was receiving 4500 units of heparin during conventional hemodialysis, 3 times a week (total weekly dose of 13,500 units) versus 7000 units with NxStage System, 6 times a week (total weekly dose of 42,000 units), and we did initially reduce dose of heparin 3500 units per treatment, supplemented with hourly ‘saline flushes’ until the polyspecific ELISA HIT antibody test was negative [3], and then, we resumed standard dose of heparin. We also considered the possibility of thrombocytopenia * Malvinder S. Parmar [email protected] 1
Northern Ontario School of Medicine, Sudbury and Thunder Bay, Suite L‑536, 700 Ross Ave. East, Timmins, ON P4N 8P2, Canada
being secondary to the ‘daily exposure to dialysis membrane or the sterilisation procedure [4–6]’, and wondered if changing the dialyzer or flushing the dialyzer with saline would help as Yang and Lindsay [7] reported resolution of ‘dialyzer reaction’ in a new hemodialysis patient by giving a predialyzer infusion of saline, using ‘flush and dump’ technique [8], though, not specific for the management of thrombocytopenia. The NxStage ONE is a closed system—means the dialyzer and its associated tubing are ONE and is built within the system. We considered changing the dialyzer but NxStage System being a closed system, it was difficult and was going to be more expensive and more cumbersome, and possibly risky being an open system (as the patient need to connect tubing and dialyzer, increasing risk of air embolism and infection), and were not sure if that would help, as rest of the tubing would still be from the system, so we considered the later, being financiall
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