Use of argatroban: experiences in continuous renal replacement therapy in critically ill patients after cardiac surgery.
OBJECTIVE
Acute kidney injury requiring renal replacement therapy (RRT) is a common complication after cardiac surgery, complicated by suspected or proven heparin-induced thrombocytopenia (type II). The present study evaluated the use of argatroban as an anticoagulant during continuous RRT in the early period after cardiac surgery. Argatroban was compared with unfractionated heparin (UH) with respect to bleeding complications and the effectiveness of anticoagulation.


METHODS
Patients requiring RRT after cardiac surgery from March 2007 to June 2009 were identified. The effectiveness of anticoagulation was measured indirectly by the duration of dialysis filter use. Bleeding was defined as clinical signs of blood loss or the need for transfusion.


RESULTS
Of 94 patients, 41 received argatroban, 27 UH, and 26 required conversion from UH to argatroban. In all 3 subgroups, RRT was begun within a median postoperative period of 2.0 days. Similar levels of anticoagulation were achieved with the duration of the circuit and filter changed an average of 1.1 times daily during RRT. Liver function was comparable in all patients. Neither clinically relevant signs of bleeding nor significant differences in the hemoglobin levels or a requirement for transfusion were noted. However, the Simplified Acute Physiology Score II values during dialysis and mortality were significantly greater in the patients initially receiving argatroban compared with those who received UH alone (54 ± 2 vs 43 ± 3, P < .001; 71% vs 44%, P = .04).


CONCLUSIONS
Argatroban can provide effective anticoagulation in postoperative cardiac patients receiving continuous RRT. Close monitoring and dose titration resulted in a comparable risk of bleeding for anticoagulation with both argatroban and heparin, regardless of the disease severity or impaired hepatic function.
Department of Internal Medicine, Nephrology, and Hypertension, Saarland University Hospital, Homburg/Saar, Germany. Electronic address: Matthias.Klingele@uks.eu.
Matthias
M
Klingele
Department of Thoracic and Cardiovascular Surgery, Saarland University Hospital, Homburg/Saar, Germany; Department of Anaesthesiology, Intensive Care, and Pain Therapy, Saarland University Hospital, Homburg/Saar, Germany.
Hagen
H
Bomberg
Department of Internal Medicine, Nephrology, and Hypertension, Saarland University Hospital, Homburg/Saar, Germany.
Anne
A
Lerner-Gräber
Department of Internal Medicine, Nephrology, and Hypertension, Saarland University Hospital, Homburg/Saar, Germany.
Danilo
D
Fliser
Department of Internal Medicine, Nephrology, and Hypertension, Saarland University Hospital, Homburg/Saar, Germany.
Aaron
A
Poppleton
Department of Thoracic and Cardiovascular Surgery, Saarland University Hospital, Homburg/Saar, Germany.
Hans J
HJ
Schäfers
Department of Thoracic and Cardiovascular Surgery, Saarland University Hospital, Homburg/Saar, Germany; Department of Anaesthesiology, Intensive Care, and Pain Therapy, Saarland University Hospital, Homburg/Saar, Germany.
Heinrich V
HV
Groesdonk
D018806:APACHE; D058186:Acute Kidney Injury / Q000097:blood / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001120:Arginine / Q000031:analogs & derivatives; D015415:Biomarkers / Q000097:blood; D001803:Blood Transfusion; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D016638:Critical Illness; D057915:Drug Substitution; D005260:Female; D006454:Hemoglobins / Q000378:metabolism; D006493:Heparin / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010875:Pipecolic Acids / Q000009:adverse effects / Q000627:therapeutic use*; D019106:Postoperative Hemorrhage / Q000097:blood / Q000139:chemically induced / Q000628:therapy; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012307:Risk Factors; D013449:Sulfonamides; D013997:Time Factors; D016896:Treatment Outcome
D000925:Anticoagulants; D015415:Biomarkers; D006454:Hemoglobins; D010875:Pipecolic Acids; D013449:Sulfonamides; D006493:Heparin; D001120:Arginine; C031942:argatroban