Sulodexide for hemodialysis anticoagulation in heparin-induced thrombocytopenia type II

Heparin-induced thrombocytopenia type II (HIT II) is an immune-mediated prothrombotic state. It requires cessation of all forms of heparin exposure. In maintenance hemodialysis (HD) patients, alternative anticoagulants (i.e. bivalirudin, danaparoid, fondaparinux) may be tried for HD procedure anticoagulation. Sulodexide (SLX) - a purified glycosaminoglycan preparation (80% heparan sulfate and 20% dermatan sulfate) - is not neutralized by platelet factor 4 and may be useful in HIT II. A 32-year-old man on continuous ambulatory peritoneal dilaysis (CAPD) and with protracted atrial fibrillation was given enoxaparin prophylaxis. On day 4, his platelets dropped from 119,000/micronL to 27,000/micronL and HIT II was diagnosed by positive heparin-induced platelet aggregation. While enoxaparin was withdrawn, the platelet count increased and remained stable. In the meantime, atrial fibrillation subsided but the patient developed pseudomonal peritonitis; the catheter was removed and the patient was switched to HD with SLX as an anticoagulant (bolus of 30 mg at HD onset). He was uneventfully treated with HD for 6 weeks and then reverted to CAPD. The widely available and inexpensive SLX may be a new, effective and potentially promising alternative anticoagulant in HD patients with HIT II.