Heparin-induced thrombocytopenia type II: a serious hazard in preemptive renal transplantation: a case report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.

Hypercalcemia Due to Resistant Hyperparathyroidism in Renal Transplant Patients Treated With the Calcimimetic Agent Cinacalcet

INTRODUCTION AND AIMS

Calcimimetic agents increase the sensitivity of calcium-sensing receptors of parathyroid glands and suppress both serum calcium levels and parathyroid hormone (PTH). The use of these drugs in patients with a functioning graft suffering from resistant hyperparathyroidism and hypercalcemia is still under investigation. We report seven patients who were treated with the calcimimetic agent cinacalcet.

METHODS

The four male and three female patients of 38 to 72 years of age received a renal transplant from 4 to 35 months before cinacalcet treatment. Serum creatinine was 1.2 to 1.8 mg/dL (estimated glomerular filtration rate between 40 and 75 mL/min). Immunosuppressive treatment consisted of interleukin-2 antibody induction therapy, calcineurin inhibitors (cyclosporine or tacrolimus), prednisolone, and mycophenolate mofetil. Mild to severe hyperparathyroidism resistant to vitamin D analog treatment (intact parathyroid hormone molecule [iPTH] 174 to 519 pg/mL) was accompanied by severe hypercalcemia (Ca >11 mg%). To date the patients have completed 3 to 18 months of therapy. Cinacalcet 30 mg/d was initially administered.

RESULTS

This treatment resulted in a rapid decrease in total serum calcium (8.6 to 9.2 mg/dL) while PTH showed a milder, progressive decrease. Having controlled calcium levels, 1alpha OH vitamin D (0.25 microg/d per os) was added to the treatment, which resulted in a further decline of iPTH without producing an increase in serum calcium concentrations (median initial iPTH value 401 pg/mL, median value after treatment 176 pg/mL). Therapy was well tolerated without hypocalcemic events.

CONCLUSION

Cinacalcet offered a better holistic treatment approach to such patients.