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Heparininduzierte Thrombozytopenie bei dialysepflichtiger Niereninsuffizienz

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Heparin-induced thrombocytopenia in hemodialysis-dependent kidney failure

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  • Arzneimitteltherapie
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Die Nephrologie Aims and scope

Zusammenfassung

Die heparininduzierte Thrombozytopenie (HIT) ist eine seltene, aber schwerwiegende Komplikation der Gabe von unfraktioniertem Heparin (UFH), kommt aber auch unter niedermolekularen Heparinen (NMH) vor. Die Immunisierung gegen den Heparin-Plättchenfaktor-4-Komplex verursacht eine starke Thrombozytenaktivierung mit Thrombozytenabfall um 50 % oder mehr und häufig venöse, aber auch arterielle Thromboembolien. Man kann 5 Phasen der HIT unterscheiden. Während die HIT bei orthopädisch-chirurgischen Patienten aufgrund von NMH und direkten oralen Antikoagulanzien (DOAK) keine Rolle mehr spielt, ist sie bei dialysepflichtigen Patienten weiterhin eine wichtige Differenzialdiagnose und betrifft 0,25–1 %, vorwiegend in der Anfangsphase der Dialysepflichtigkeit. Die Diagnose einer HIT hat bei Dialysepatienten mitunter über viele Jahre Auswirkungen auf die Therapie, da UFH und NMH dauerhaft gemieden werden müssen. Bei dringendem Verdacht sollten UFH und NMH sofort gestoppt, und es sollte eine therapeutische Antikoagulation primär mit Argatroban, alternativ mit Danaparoid oder Bivalirudin („off-label“) eingeleitet werden. Ein negativer HIT-IgG (Immunglobulin G)-ELISA (enzyme-linked immunosorbent assay) schließt die Diagnose aus, ein positiver HIPA (heparininduzierte Plättchenaktivierung)-Test bestätigt sie. Bei HIT mit Thromboembolie (HITT) wird für mindestens 3 Monate therapeutisch antikoaguliert. Vitamin-K-Antagonisten werden bei Dialysepatienten zunehmend kritisch gesehen. Die DOAK Apixaban und Rivaroxaban sind mittlerweile eine gute Option („off-label“). Bei isolierter HIT kann die therapeutische Antikoagulation nach spätestens 4 Wochen beendet werden. Für die Antikoagulation während der Dialyse sind dann die regionale Zitratantikoagulation, Argatroban und auch Fondaparinux („off-label“) geeignet.

Abstract

Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of the administration of unfractionated heparin (UFH). Low molecular weight heparins (LMWH) may also cause HIT. Immunization against the heparin-platelet factor 4 complex induces a strong platelet activation leading to a ≥50% decline of the platelet count frequently accompanied by venous and arterial thromboembolisms. The HIT can be divided into five phases. Whereas in orthopedic surgery HIT no longer plays a role, mostly due to LMWH and direct oral anticoagulants (DOAC), it remains an important diagnosis in patients with dialysis-dependent kidney failure affecting 0.25–1%, mostly during initiation of hemodialysis treatment. The diagnosis of HIT has a tremendous impact on dialysis patients, as UFH or LMWH may have to be avoided for many years. If HIT is clinically suspected, UFH and LMWH should immediately be stopped and an alternative therapeutic anticoagulation, primarily with argatroban, should be initiated. Danaparoid or bivalirudin (off label) may also be used. A negative HIT-immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) excludes HIT, a positive heparin-induced platelet activation (HIPA) test confirms it. If HIT is complicated by thromboembolisms (HITT), the therapeutic anticoagulation should be continued for at least 3 months. Vitamin K antagonists are no longer clearly preferred in dialysis patients. The DAOCs apixaban or rivaroxaban seem to be reasonable options (off label). In isolated HIT anticoagulation can be terminated after a maximum of 4 weeks. For anticoagulation during dialysis regional citrate anticoagulation, argatroban and fondaparinux (off label) are suitable choices.

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  1. Klinik für Innere Medizin, Sektion Nephrologie und Dialyse, St. Antonius-Hospital Eschweiler, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland

    Rolf Dario Frank

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Frank, R.D. Heparininduzierte Thrombozytopenie bei dialysepflichtiger Niereninsuffizienz. Nephrologie (2024). https://doi.org/10.1007/s11560-023-00711-0

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