title: Recurring extracorporeal circuit clotting during continuous renal replacement therapy in fungal sepsis:  successful treatment with argatroban.
abstract: The relative effectiveness of anticoagulation strategies during continuous renal replacement therapy (CRRT) may vary according to the clinical circumstances. In this study, the case of a 46-year-old man who developed fungal mediastinitis with the pathogen Scedosporium prolificans after coronary bypass surgery is reported. Numerous debridements and multiple antifungal agents were not effective in this patient. Miltefosine, a non-Food and Drug Administration-approved agent, was started after institutional review board request and approval. CRRT was initiated with regional citrate anticoagulation (RCA) for clinical sepsis with acute kidney injury. Subsequently, crescendo clotting of the extracorporeal circuit (ECC) occurred. Multiple interventions, including escalating RCA, adding increasing heparin to RCA and exchanging the dialysis catheter, were not effective. Argatroban anticoagulation was started without further ECC clotting, and the patient recovered from both acute kidney injury and septic shock, despite continued miltefosine administration. Sepsis may contribute to recurrent ECC clotting. Argatroban, a direct thrombin inhibitor, had a disproportionate effectiveness to maintain ECC patency in this patient.
authors.affiliation: Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA. lmferguson@umc.edu
authors.forename: Lee M
authors.initials: LM
authors.lastname: Ferguson
authors.forename: Albert W
authors.initials: AW
authors.lastname: Dreisbach
authors.forename: Eva
authors.initials: E
authors.lastname: Csongrádi
authors.forename: Luis A
authors.initials: LA
authors.lastname: Juncos
authors.forename: Tibor
authors.initials: T
authors.lastname: Fulop
mesh_terms: D000935:Antifungal Agents / Q000008:administration & dosage; D000991:Antithrombins / Q000008:administration & dosage*; D001120:Arginine / Q000031:analogs & derivatives; D001777:Blood Coagulation / Q000187:drug effects*; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000209:etiology / Q000382:microbiology / Q000628:therapy; D008875:Middle Aged; D009181:Mycoses / Q000209:etiology / Q000382:microbiology / Q000628:therapy; D010767:Phosphorylcholine / Q000008:administration & dosage / Q000031:analogs & derivatives; D010875:Pipecolic Acids / Q000008:administration & dosage*; D011183:Postoperative Complications; D017582:Renal Replacement Therapy; D021681:Scedosporium; D018805:Sepsis / Q000209:etiology / Q000382:microbiology / Q000628:therapy; D013449:Sulfonamides
chemical_list: D000935:Antifungal Agents; D000991:Antithrombins; D010875:Pipecolic Acids; D013449:Sulfonamides; D010767:Phosphorylcholine; C039128:miltefosine; D001120:Arginine; C031942:argatroban