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Leong R, Patel J, Samji N, Paes BA, Chan AKC, Petropoulos JA, Bhatt MD. Use of thrombolytic agents to treat neonatal thrombosis in clinical practice. Blood Coagul Fibrinolysis 2022; 33:193-200. [PMID: 35285449 DOI: 10.1097/mbc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among children, neonates have the highest incidence of thrombosis. Thrombolytic agents are used for the management of life and/or organ-threatening thrombosis. Literature on the efficacy and safety of thrombolytic agents in neonates is limited. We reviewed the evidence on dosing, administration, monitoring and treatment duration of tissue plasminogen activator (tPA), streptokinase and urokinase (URK) in neonates (≤ 28days). A systematic literature search was conducted of current databases from inception until 31 March 2021. The initial search yielded 6881 articles and 18 were retained for review. tPA, streptokinase and URK was utilized in 12, seven and four studies on 115, 51 and 16 patients, respectively. The dose range for tPA, streptokinase and URK was 0.01 -0.6 mg/kg/h, 50-2000 and 1000-0 000 units/kg/h, respectively, and treatment duration ranged from 30 min to 30 days. This is the first study to objectively summarize the efficacy and safety of thrombolytic agents in neonates. Overall, thrombolysis was associated with 87.9% complete or partial thrombus resolution and 7.4% recurrence risk. The bleeding risk associated with thrombolytic agents was 23.1% on pooled analysis, which is higher than other anticoagulants. Larger prospective studies are required to determine effective dosing regimens of these therapeutic drugs and further clarify their efficacy and safety. Blood Coagul Fibrinolysis 33:000-000 Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
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Affiliation(s)
| | | | | | - Bosco A Paes
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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2
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Lawson EN, Seckeler MD. Successful Percutaneous Recanalization of a Chronically Occluded Inferior Vena Cava in a Young Child. World J Pediatr Congenit Heart Surg 2018; 11:NP186-NP189. [PMID: 30296929 DOI: 10.1177/2150135118771316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Young children with congenital heart disease are undergoing an increasing number of catheter-based interventions. These procedures can lead to obstruction of large central veins, making future interventions more challenging or even impossible. We present a young child with a chronically occluded inferior vena cava (IVC) secondary to prior catheterization-based interventions for congenital heart disease. The IVC was recanalized with serial angioplasty and stent placement with continued patency for over two years. Despite the long duration of obstruction, the IVC was successfully recanalized, eliminating the potential consequences of long-term IVC obstruction and making it easier for future catheter-based interventions, if needed.
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Affiliation(s)
- Emily N Lawson
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
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3
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Aluloska N, Janchevska S, Tasic V. Non Catether Induced Renal and Inferior Vena Cava Trombosis in a Neonate: A Case Report. Open Access Maced J Med Sci 2018; 6:1678-1681. [PMID: 30337987 PMCID: PMC6182507 DOI: 10.3889/oamjms.2018.306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/23/2018] [Accepted: 07/27/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Neonatal renal vein thrombosis is the most common vascular condition in the newborn kidney, which could lead to serious complication in infants. CASE REPORT: We report a case of the unilateral renal vein and inferior vena cava thrombosis, presented with gross hematuria and thrombocytopenia in a neonate. The neonate was a macrosomic male born to a mother with hyperglycemia in pregnancy. The baby was born with perinatal asphyxia and early neonatal infection and massive hematuria. Clinical and laboratory examination showed enlarged kidney having corticomedullary differentiation diminished and azotemia. Diagnosis of renal vein thrombosis was suspected by renal ultrasound and confirmed by magnetic urography. Prothrombotic risk factors were evaluated. The child is being managed conservatively. Measures aimed at the prevention of end-stage renal disease because of its poor outcome were highlighted. Despite anticoagulant therapy, the right kidney developed areas of scarring and then atrophy. CONCLUSION: In this work, we present a patient with multiple entities in the aetiology of non-catheter induced renal and vena cava thrombosis in a neonate. Clinicians should suspect renal vein thrombosis in neonates when presented with early postnatal gross hematuria, palpable abdominal mass and thrombopenia.
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Affiliation(s)
- Natasha Aluloska
- Neonatology Department, University Children Hospital, Skopje, Republic of Macedonia
| | - Snezana Janchevska
- NICU, University Clinic for Gynecology and Obstetrics, Skopje, Republic of Macedonia
| | - Velibor Tasic
- Nephrology Department, University Children Hospital, Skopje, Republic of Macedonia
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4
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Khan Z, Sciveres M, Salis P, Minervini M, Maggiore G, Cintorino D, Riva S, Gridelli B, Emma F, Spada M. Combined split liver and kidney transplantation in a three-year-old child with primary hyperoxaluria type 1 and complete thrombosis of the inferior vena cava. Pediatr Transplant 2011; 15:E64-70. [PMID: 19793227 DOI: 10.1111/j.1399-3046.2009.01241.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PH1 is an inborn error of the metabolism in which a functional deficiency of the liver-specific peroxisomal enzyme, AGT, causes hyperoxaluria and hyperglycolic aciduria. Infantile PH1 is the most aggressive form of this disease, leading to early nephrocalcinosis, systemic oxalosis, and end-stage renal failure. Infantile PH1 is rapidly fatal in children unless timely liver-kidney transplantation is performed to correct both the hepatic enzyme defect and the renal end-organ damage. The surgical procedure can be further complicated in infants and young children, who are at higher risk for vascular anomalies, such as IVC thrombosis. Although recently a limited number of children with IVC thrombosis have underwent successful kidney transplantation, successful multi-organ transplantation in a child with complete IVC thrombosis is quite rare. We report here the interesting and technically difficult case of a three-yr-old girl with a complete thrombosis of the IVC, who was the recipient of combined split liver and kidney transplantation for infantile PH1. Although initial delayed renal graft function with mild-to-moderate acute rejection was observed, the patient rapidly regained renal function after steroid boluses, and was soon hemodialysis-independent, with good diuresis. Serum and plasma oxalate levels progressively decreased; although, to date they are still above normal. Hepatic and renal function indices were at, or approaching, normal values when the patient was discharged 15-wk post-transplant, and the patient continues to do well, with close and frequent follow-up. This is the first report of a successful double-organ transplant in a pediatric patient presenting with infantile PH1 complicated by complete IVC thrombosis.
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Affiliation(s)
- Zahida Khan
- University of Pittsburgh School of Medicine, Medical Scientist Training Program, Pittsburgh, PA, USA
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5
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Abstract
Renal vein thrombosis RVT is the most common non-catheter related venous thromboembolic events VTE in newborns and is responsible for approximately 10% of all VTE in newborns. Almost 80% of all RVT present within the first month and usually within the first week of life. Currently ultrasound is the radiographic test of choice because of its practicality, sensitivity and lack of adverse effects. The sonographic features vary according to the severity, the extent of the thrombus, the development of collateral circulation and the stage of renal vein thrombosis. Initial diagnostic features include, renal enlargement, echogenic medullary streaks that have a vascular or perivascular distribution, thrombus in the vein prominent echopoor medullary pyramids, subsequently loss of corticomedullary differentiation, reduced echogenicity around the affected pyramids and echogenic band at the extreme apex of the pyramid. Higher resistance index and absent, steady, or less pulsatile venous flow on the affected side compared with flow in the contralateral kidney are helpful Doppler signs. While sonography may be useful in revealing the venous and renal morphology, it is insufficiently reliable for assessment of the functional impact of these morphologic findings. There are no characteristic grey-scale or Doppler ultrasound prognostic features to predict outcome of neonatal RVT and long-term follow up of those children is required.
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6
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Frazer JR, Ing FF. Stenting of stenotic or occluded iliofemoral veins, superior and inferior vena cavae in children with congenital heart disease: Acute results and intermediate follow up. Catheter Cardiovasc Interv 2009; 73:181-8. [DOI: 10.1002/ccd.21790] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Khan JU, Takemoto CM, Casella JF, Streiff MB, Nwankwo IJ, Kim HS. Catheter-directed thrombolysis of inferior vena cava thrombosis in a 13-day-old neonate and review of literature. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S153-60. [PMID: 18004620 DOI: 10.1007/s00270-007-9229-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 09/28/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
Abstract
Complete inferior vena cava thrombosis (IVC) in neonates is uncommon, but may cause significant morbidity. A 13-day-old neonate suffered IVC thrombosis secondary to antithrombin III deficiency, possibly contributed to by a mutation in the methyl tetrahydrofolate reductase gene. Catheter-directed thrombolysis (CDT) with recombinant tissue plasminogen activator (rt-PA, Alteplase) was used successfully to treat extensive venous thrombosis in this neonate without complications. We also review the literature on CDT for treatment of IVC thrombosis in critically ill neonates and infants.
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Affiliation(s)
- Jawad U Khan
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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8
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Eneriz-Wiemer M, Sarwal M, Donovan D, Costaglio C, Concepción W, Salvatierra O. Successful Renal Transplantation in High-Risk Small Children with a Completely Thrombosed Inferior Vena Cava. Transplantation 2006; 82:1148-52. [PMID: 17102765 DOI: 10.1097/01.tp.0000236644.76359.47] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis is generally a contraindication to renal transplantation in small children because of the technical difficulty and limitations in allograft venous outflow drainage that risk graft thrombosis. METHODS The records of six consecutive children (9.9-27.4 kg) with end-stage renal disease and thrombosed IVCs were reviewed. Small deceased donor renal allografts were utilized in all cases where immediate posttransplant venous renal outflow would theoretically not exceed the drainage capacity of the iliac or adjacent pelvic collateral veins. RESULTS There is 100% patient survival with two patients returning to dialysis at seven and three years posttransplantation. There were no surgical complications or delayed graft function. Postoperatively, progressive renal vein and simultaneous iliac venous enlargement was observed in five of six recipients concomitant with renal allograft enlargement. In these patients, maximum renal volume achieved was between 152 and 275 ml and last recorded Schwartz glomerular filtration rates ranged from 67 to 118 ml/min. The sixth allograft had an early, severe rejection episode that limited renal growth and attainment of good renal function. All patients demonstrated resumption of growth rates commensurate with age but without significant catch-up growth. CONCLUSION A small deceased donor kidney can provide freedom from dialysis and better quality of life for small children with IVC thrombosis during an age when dialysis treatment is difficult and the complications of the thrombosed IVC may compromise life. Good renal function was attained in patients without rejection episodes. In those with rejection, our approach allowed for patient growth during allograft function, providing a bridge for a repeat transplant.
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Affiliation(s)
- Monica Eneriz-Wiemer
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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9
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Albisetti M. Thrombolytic therapy in children. Thromb Res 2006; 118:95-105. [PMID: 16709478 DOI: 10.1016/j.thromres.2004.12.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Revised: 12/22/2004] [Accepted: 12/23/2004] [Indexed: 10/25/2022]
Abstract
Thrombolysis is increasingly considered a treatment option in newborns and children with arterial and venous thromboembolic events, or occluded central venous lines. However, no uniform recommendations are available with regard to indications, drug of choice, route of administration, and dosing regimen. Thus, several protocols are used for the different thrombolytic agents, leading to differing outcome with respect to the effectiveness of therapy and bleeding complications. This article will summarize the available information on the use of thrombolytic agents in newborns and children, focussing on the potential indications, efficacy and safety profiles, and evidence supporting dosing schedules.
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Affiliation(s)
- Manuela Albisetti
- Division of Hematology, University Children's Hospital, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland.
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10
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Kobayashi T, Kobayashi T, Mayuzumi H, Morikawa A. Percutaneous hydrodynamic thrombectomy for congenital deep vein thrombosis in a neonate. Pediatr Cardiol 2006; 27:170-174. [PMID: 16391982 DOI: 10.1007/s00246-005-1185-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 1-day-old boy with a complete occlusive inferior vena cava and bilateral renal vein thrombus removed successfully using a hydrodynamic thrombectomy catheter is reported. Although blood flow to the inferior vena cava and bilateral renal veins was restored with no distal embolism or vascular injury, he died of bleeding complications due to fibrinolytic therapy after hydrodynamic thrombectomy. To the best of our knowledge, this is the first report of hydrodynamic thrombectomy of a neonate.
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Affiliation(s)
- T Kobayashi
- Department of Cardiology, Gunma Children's Medical Center, 779 Shimohakoda, Hokkitsu, Seta-gun, Gunma, 377-8577, Japan.
| | - T Kobayashi
- Department of Cardiology, Gunma Children's Medical Center, 779 Shimohakoda, Hokkitsu, Seta-gun, Gunma, 377-8577, Japan
| | - H Mayuzumi
- Department of Neonatology, Gunma Children's Medical Center, 779 Shimohakoda, Hokkitsu, Seta-gun, Gunma, 377-8577, Japan
| | - A Morikawa
- Department of Pediatrics and Developmental Medicine, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 377-8511, Japan
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11
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Dunn SP, Tsai A, Griffin G, Toth S, Casas-Melley AT, Falkenstein KP, Marando CA, Krueger LJ. Liver transplantation as definitive treatment for a factor V Leiden mutation. J Pediatr 2005; 146:418-22. [PMID: 15756233 DOI: 10.1016/j.jpeds.2004.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Liver transplantation (LT) was achieved for factor V Leiden-induced thrombophilia in a neonate with hepatic veno-occlusive disease. Initial LT was performed with a liver segment removed from a child with primary oxalosis. Four months later, a second, definitive LT was performed. The child remains well without recurrent thrombosis.
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Affiliation(s)
- Stephen P Dunn
- Division of Solid Organ Transplantation, Nemours Biomedical Research, Nemours Children's Clinic-Wilmington, Alfred I. duPont Hospital for Children, Delaware, USA
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12
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Abstract
This article about antithrombotic therapy in children is part of the 7th American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh the risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this article are the following. In neonates with venous thromboembolism (VTE), we suggest treatment with either unfractionated heparin or low-molecular-weight heparin (LMWH), or radiographic monitoring and anticoagulation therapy if extension occurs (Grade 2C). We suggest that clinicians not use thrombolytic therapy for treating VTE in neonates, unless there is major vessel occlusion that is causing the critical compromise of organs or limbs (Grade 2C). For children (ie, > 2 months of age) with an initial VTE, we recommend treatment with i.v. heparin or LMWH (Grade 1C+). We suggest continuing anticoagulant therapy for idiopathic thromboembolic events (TEs) for at least 6 months using vitamin K antagonists (target international normalized ratio [INR], 2.5; INR range, 2.0 to 3.0) or alternatively LMWH (Grade 2C). We suggest that clinicians not use thrombolytic therapy routinely for VTE in children (Grade 2C). For neonates and children requiring cardiac catheterization (CC) via an artery, we recommend i.v. heparin prophylaxis (Grade 1A). We suggest the use of heparin doses of 100 to 150 U/kg as a bolus and that further doses may be required in prolonged procedures (both Grade 2 B). For prophylaxis for CC, we recommend against aspirin therapy (Grade 1B). For neonates and children with peripheral arterial catheters in situ, we recommend the administration of low-dose heparin through a catheter, preferably by continuous infusion to prolong the catheter patency (Grade 1A). For children with a peripheral arterial catheter-related TE, we suggest the immediate removal of the catheter (Grade 2C). For prevention of aortic thrombosis secondary to the use of umbilical artery catheters in neonates, we suggest low-dose heparin infusion (1 to 5 U/h) (Grade 2A). In children with Kawasaki disease, we recommend therapy with aspirin in high doses initially (80 to 100 mg/kg/d during the acute phase, for up to 14 days) and then in lower doses (3 to 5 mg/kg/d for > or = 7 weeks) [Grade 1C+], as well as therapy with i.v. gammaglobulin within 10 days of the onset of symptoms (Grade 1A).
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Affiliation(s)
- Paul Monagle
- Division of Laboratory Services, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Flemington Rd, Parkville, Melbourne, VIC, Australia 3052.
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13
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Affiliation(s)
- Laila Obaid
- Department of Neonatology, Royal Alexandria Hospital, Edmonton, Alberta T5H 3V9, Canada
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14
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Abstract
In neonates and infants, numerous clinical and environmental conditions lead to elevated thrombin generation and subsequent thrombus formation. Genetic prothrombotic defects (protein C, protein S and antithrombin deficiency, mutations of coagulation factor V and factor II, elevated lipoprotein (a)) have been established as risk factors of thromboembolic events in neonates and infants. The interpretation of the laboratory evaluation relies on age-dependent normal reference values. Because appropriate clinical trials are missing in these age groups, treatment recommendations are adapted from small-scale studies in neonates and infants and from guidelines relating to adult patient protocols. Secondary long-term anticoagulation should be administered on an individual basis.
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Affiliation(s)
- Christine Heller
- Paediatric Haematology/Oncology, University Hospital of Frankfurt, Germany
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15
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Abstract
Acquired and inherited prothrombotic risk factors increase the risk of thrombosis in children. This review is based on "milestone" pediatric reports and new literature data (January 2001-February 2002) on the presence of acquired and inherited prothrombotic risk factors, imaging methods, and treatment modalities in pediatric thromboembolism. After confirming clinically suspected thromboembolism with suitable imaging methods, pediatric patients should be screened for common gene mutations (factor V G1691A, prothrombin G20210A and MTHFR C677T genotypes), rare genetic deficiencies (protein C, protein S, antithrombin, and plasminogen), and new candidates for genetic thrombophilia causing elevated levels of lipoprotein(a), and homocysteine, and probable genetic risk factors (elevations in fibrinogen, factor IX, and factor VIIIC, and decreases in factor XII). Data interpretation is based on age-dependent reference ranges or the identification of causative gene mutations/polymorphisms with respect to individual ethnic backgrounds. Pediatric treatment protocols for acute thromboembolism, including thrombolytic and anticoagulant therapy, are mainly adapted from adult patient protocols.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Department of Pediatric Hematology/Oncology, University of Münster, Germany.
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16
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Rimensberger PC, Humbert JR, Beghetti M. Management of preterm infants with intracardiac thrombi: use of thrombolytic agents. Paediatr Drugs 2002; 3:883-98. [PMID: 11772150 DOI: 10.2165/00128072-200103120-00002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Improvement in neonatal care has led to improvements in survival and patient outcome in preterm infants; however, this improved survival has been associated with the development of secondary complications, such as catheter-associated intravascular and intracardiac thrombus formation with a non-negligible morbidity and mortality. The sick preterm infant is at high risk of catheter-related thrombus formation because of the combination of a high prothrombotic activity, low levels of natural anticoagulants, and various imbalances in the fibrinolytic systems. Based on clinical experience in adults and children, and several neonatal case reports demonstrating the efficacy and tolerability of specific thrombolytic treatment, this approach should be recommended as a first choice treatment in the premature infant with intracardiac or intravascular thrombosis. The thrombolytic agents of choice are urokinase or tissue plasminogen activator (tPA); however, none of them have proven to be superior to the other in terms of efficacy or tolerability, either in adult patients or premature infants. In the past, it has been suggested that newborn infants may require higher doses of thrombolytic agents than adults for effective systemic thrombolysis; however, based on more recent in vitro studies, it seems unlikely that this is true. Nevertheless, systemic (high dose) fibrinolysis is of concern as premature neonates present an increased risk of cerebral haemorrhage during the first weeks of life; therefore, low dose treatment has been proposed with, if possible, direct infusion of the fibrinolytic agent into, or close to, the thrombus. This approach has proven to be efficient and well tolerated in several small case series of newborn and preterm infants. Recommended doses are 1000 to 3000 U/kg/h for urokinase or 0.01 to 0.05 mg/kg/h for tPA. A systemic proteolytic state will not be induced by this low dose; however, specific monitoring of fibrinogen plasma levels has to be recommended. Fibrinogen levels should remain above 100 mg/dL during low dose treatment. Lower levels of fibrinogen will indicate the presence of an unwanted systemic fibrinolytic state. After successful thrombolysis, a follow-up treatment, preferentially with low-molecular-weight heparin for neonates at adjusted doses, should be instituted for at least 6 weeks in the absence of any persisting thrombophilic factor. A longer course (3 to 6 months) of anticoagulation therapy is recommended when thrombophilic factors (i.e. hereditary thrombophilia or central venous catheter still in place) are present. Furthermore, it is recommended that any neonate with thrombosis should be evaluated for hereditary thrombophilia later in life.
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Affiliation(s)
- P C Rimensberger
- Unit of Neonatal Intensive Care, Hematology-Oncology and Cardiology, Department of Pediatrics, Children's Hospital, University of Geneva, Rue Willy-Donzé, Geneva, 6, CH-1211, 14, Switzerland.
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17
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Abstract
Thrombotic problems are rare during childhood but are increasingly recognized, particularly in tertiary care paediatric populations, and represent a different spectrum of disorders to those seen in adults. An understanding of the aetiological factors involved in the pathogenesis of these events is important both for prevention and management. A number of inherited prothrombotic defects have been shown to be independent risk factors for thromboembolism in adult studies, and may also contribute to thrombotic events in childhood. Homozygous deficiencies of naturally occurring inhibitors of coagulation are clearly associated with major prothrombotic disorders, often presenting in the perinatal period. The association of other inherited prothrombotic disorders with thrombosis in childhood is less well defined. The prevalence of heritable thrombophilia varies in different clinical settings and the risks associated with individual defects has only been addressed in a small number of studies to date. Additional acquired risk factors are also present in a high percentage of cases and again differ from those seen in adult thrombosis. Further studies are required to assess the risks associated with heritable thrombophilia during infancy and childhood, and to define the place of thrombophilia screening in paediatric practice.
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Affiliation(s)
- E A Chalmers
- Department of Haematology, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow, UK.
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18
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van Ommen CH, Heijboer H, Büller HR, Hirasing RA, Heijmans HS, Peters M. Venous thromboembolism in childhood: a prospective two-year registry in The Netherlands. J Pediatr 2001; 139:676-81. [PMID: 11713446 DOI: 10.1067/mpd.2001.118192] [Citation(s) in RCA: 453] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To study the incidence, signs and symptoms, diagnostic tests, risk factors, therapy, and complications of pediatric venous thromboembolism (VTE) in The Netherlands. METHODS A prospective 2-year registry of VTE in children aged < or = 18 years. RESULTS Ninety-nine patients were registered. The annual incidence of VTE was 0.14/10,000 children, 35% of whom were symptom free. Almost half of the patients were newborns. Neonatal VTE was almost exclusively catheter related, located in the upper venous system, and asymptomatic. In older children VTE was catheter related in approximately one third and more often was located in the lower venous system. In 85% of all patients, thrombosis developed while the patient was in the hospital. Diagnosis was usually made by ultrasonography. In 98% of all patients, at least 1 risk factor was present. Congenital prothrombotic disorders were more often present in older children (21%) than in neonates (6%). A variety of treatment modalities were used. Morbidity consisted of bleeding (7%) and recurrent thrombosis (7%). Two children died as result of VTE. CONCLUSION VTE is mostly diagnosed in hospitalized children, especially sick newborns with central venous catheters and older children with a combination of risk factors. Primary prevention, optimal treatment, and long-term outcome of pediatric symptomatic and asymptomatic VTE need to be studied.
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Affiliation(s)
- C H van Ommen
- Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, The Netherlands
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19
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Abstract
AIM To evaluate the long term outcome after paediatric inferior vena cava (IVC) thrombosis. METHODS A combined retrospective and prospective study on infants and children with IVC thrombosis treated at Aachen and Maastricht University Hospitals between 1980 and 1999. RESULTS Forty patients were enrolled, including four with preceding cardiac catheterisation, 18 with central venous saphenous lines, and an additional eight with umbilical venous catheters. Six patients died within three months of diagnosis; one patient was lost to follow up. Twelve of the remaining 33 patients had suffered from limited IVC thrombosis; during follow up (for up to nine years) none showed persisting caval obstruction (successful thrombolysis, n = 2; spontaneous recanalisation, n = 10). The remaining 21 patients presented with extensive IVC thrombosis. During follow up (for up to 18 years) complete restitution was found in only four cases (one thrombolysis, two surgery, one spontaneous recanalisation). Persisting iliac and/or caval venous obstruction occurred in 17 patients, including six with thrombolysis. Varicose veins were found in 12, and post-thrombotic syndrome in seven of these cases. According to Kaplan-Meier analysis, 30% of patients with persisting venous disease will develop post-thrombotic syndrome within 10 years of the thrombotic event. CONCLUSIONS Infants and children with extensive IVC thrombosis are at high risk for persisting venous disease and serious long term complications. Prospective trials are urgently needed to establish effective treatment strategies and to improve long term prognosis. Central venous catheters, contributing to IVC thrombosis in the majority of cases reported here, should be inserted only if essential.
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Affiliation(s)
- M Häusler
- Department of Paediatrics, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany.
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Hartmann J, Hussein A, Trowitzsch E, Becker J, Hennecke KH. Treatment of neonatal thrombus formation with recombinant tissue plasminogen activator: six years experience and review of the literature. Arch Dis Child Fetal Neonatal Ed 2001; 85:F18-22. [PMID: 11420316 PMCID: PMC1721267 DOI: 10.1136/fn.85.1.f18] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Thrombosis is a relatively rare event in children. However, many conditions in the neonatal period result in an increased risk of thrombus formation. The major risk factor is the indwelling intravascular catheter. Numerous small studies have reported experience of thrombolytic treatment for neonatal thrombotic disease with a wide range of different thrombolytic agents in various forms of administration, dosage, and duration, but no conclusions on the most effective treatment for neonates has been reached. OBJECTIVE To assess the efficacy and safety of thrombolytic treatment of neonatal catheter related thrombus (CRT) formation with recombinant tissue plasminogen activator (rt-PA). METHOD Over a six year period, 14 neonates with CRT were treated with the same rt-PA protocol (an initial bolus of 0.7 mg/kg over 30-60 minutes followed by infusion of 0.2 mg/kg/h). RESULTS Complete clot dissolution was documented in 11 patients, and partial clot lysis in two patients, leading to a patency rate of 94%. In two cases, local bleeding occurred, resulting in treatment failure in one case. Finally, antithrombin III substitution was required in one case. No other complications such as severe bleeding were recognised. CONCLUSION With the use of close clinical and haematological monitoring on a neonatal intensive care unit combined with serial two dimensional colour echocardiography, the present rt-PA protocol was shown to be a safe and effective method of clot dissolution in neonates.
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Affiliation(s)
- J Hartmann
- Department of Pediatric Cardiology, Vestische Kinderklinik, University of Witten-Herdecke, Dr-Friedrich-Steiner-Str 5, 45711-Datteln, NRW, Germany.
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Affiliation(s)
- G Hausdorf
- Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Str. 1, D-30625 Hannover, Germany.
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Häusler M, Hübner D, Hörnchen H, Mühler EG, Merz U. Successful thrombolysis of inferior vena cava thrombolysis in a preterm neonate. Clin Pediatr (Phila) 2001; 40:105-8. [PMID: 11261446 DOI: 10.1177/000992280104000208] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M Häusler
- Department of Pediatrics, University Hospital RWTH Aachen, Germany
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