Multiple Hemodialysis Access Failures Due to Recurrent Thrombosis in a Patient with Antiphospholipid Antibody Syndrome

Abstract

Introduction: The most common complication of permanent hemodialysis (HD) vascular access is thrombosis, with some cases being related to a hypercoagulable state. Antiphospholipid antibody syndrome (APAS) is a cause of increased thrombotic tendency, and this may complicate the management of such patients on HD.
Case report: We describe a 48-year-old man with end stage renal disease (ESRD) of undetermined cause who was referred to our tertiary care center for urgent renal transplantation. He was maintained on regular HD, but his dialysis care was complicated by recurrent vascular access thrombosis to the extent that no further access site was available for his routine renal replacement treatment. A thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies. A diagnosis of APAS was made and he was anticoagulated with warfarin. A transhepatic dialysis catheter was inserted and HD was resumed, but this was complicated by a large intra-abdominal hematoma. His anticoagulation was reversed and he improved, but his transhepatic catheter got clotted. This catheter was removed and a translumbar dialysis catheter was inserted as a last resort. Within a week of his arrival to our hospital, he recieved a kidney transplant. Graft function was delayed, but eventually improved, though he has never regained normal renal function.
Conclusion: The presence of APAS can complicate HD management by causing recurrent vascular access thrombosis and failure, and nephrologists must remain alert to this possibility. Anticoagulation management of these patients must be handled with extra care to avoid bleeding complications.