Abstract
BackgroundDisseminated intravascular coagulation (DIC) is a relatively rare but important cause of bleeding diathesis in patients on maintenance dialysis. When the control of underlying disorders causing DIC is not achieved and anticoagulant therapy could not ameliorate the symptoms, other therapeutic options might be considered. While the use of antifibrinolytic agents, such as tranexamic acid, is generally not recommended in patients with DIC, the combined use of these agents with anticoagulants has produced good results in some cases with enhanced fibrinolytic-type DIC. Although the dose of tranexamic acid should be adjusted for patients with renal impairment to avoid neurotoxic complications, there are no widely accepted recommendations for dosage adjustment in dialysis patients. Therefore, the optimal indication and dosage of tranexamic acid in dialysis patients with hyper fibrinolytic type DIC remain unestablished.Case presentationWe herein report a 94-year-old male patient on maintenance hemodialysis with hyperfibrinolytic DIC induced by chronic aortic aneurysm and aortic dissection. He suffered from hemorrhagic diathesis and was successfully treated with oral administration of 750 mg tranexamic acid per day combined with intravenous infusion of low molecular weight heparin (LMWH) every dialysis session. There were no apparent adverse events. Unintended dose reduction of tranexamic acid resulted in exacerbation of DIC along with alarming recurrence of blood flow in the previously thrombosed aortic false lumen, which was ameliorated soon after surely performing medication.ConclusionsCombined use of oral tranexamic acid and minimum anticoagulant only during dialysis sessions successfully controlled aneurysm-induced DIC in a dialysis patient. Although the exact dosage and indication require further investigation, the treatment may be worth considering, even in dialysis patients, when other treatment options have failed to obtain good results.
Highlights
Disseminated intravascular coagulation (DIC) is a relatively rare but important cause of bleeding diathesis in patients on maintenance dialysis
We report a dialysis patient with hyperfibrinolytic DIC induced by chronic aortic aneurysm and aortic dissection. He was successfully treated with oral administration of 750 mg tranexamic acid per day combined with intravenous infusion of low molecular weight heparin (LMWH) at 1250 anti-factor Xa units every dialysis session without clinical adverse events
This trial resulted in a recurrence of extended time to hemostasis (40–50 min) and an exacerbation of laboratory data (platelets, 84,000/μL; Fibrin and fibrinogen degradation product (FDP), 148 μg/mL; D-dimer, 73.6 μg/mL; thrombin-antithrombin complex (TAT), 30.7 ng/mL; plasmin inhibitor complex (PIC), 9.3 μg/mL; α2 plasmin inhibitor (α2-PI), 69%; fibrinogen, 175 mg/dl; AT, 69%), which met the diagnostic criteria for overt DIC proposed by the Japanese Society on Thrombosis and Hemostasis [6]
Summary
Disorientation, upper Tranexamic acid extremity myoclonus, discontinuation and visual disturbance. Generalized tonic-clonic Tranexamic acid 1 day convulsion discontinuation, intravenous diazepam 5 mg for the acute treatment of second seizure. Literature review There are only few reported cases requiring hemodialysis with DIC induced by aortic aneurysm or aortic dissection, in which tranexamic acid was administered [2, 12, 23] (Table 2). Tranexamic acid was started because of difficulties in controlling the hemorrhagic diathesis by other treatment options such as anticoagulants and synthetic proteinase inhibitors. Other cases already received maintenance dialysis at the start of tranexamic acid. An improvement of hemorrhagic diathesis was achieved after the administration of tranexamic acid. The hemorrhagic diathesis gradually ameliorated over 1 month after the start of hemodialysis using LMWH and the increment of camostat mesylate, off-label use, with the same regimen of tranexamic acid.
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