PB0311 - Anticoagulation in a Hypercoagulable Infant with End-Stage Renal Disease on Renal Replacement Therapies

Background: Although renal failure (RF) has been associated with bleeding tendency, thrombotic events are common among certain subgroups particularly with nephrotic syndrome. While there is recent adult data supporting safety of direct oral anticoagulants (DOAC), pediatric data for anticoagulation in end-stage renal disease (ESRD) is lacking.

Aims: We aim to evaluate safety of anticoagulant therapy in a pediatric RF patient.

Methods: We review a case of complex anticoagulation in a nephrotic infant with ESRD.

Results: A term female infant was born with RF secondary to Pierson syndrome, a rare cause of congenital nephrotic syndrome with ocular and neurological manifestations. At 2 weeks of age, a tunneled central line was placed in the right internal jugular vein for frequent albumin infusions and electrolyte monitoring. Given high thrombosis risk, low dose bivalirudin anticoagulation was initiated. Heparin was not chosen due to low antithrombin. Furthermore, our institution has been using bivalirudin for continuous renal replacement therapy (CRRT) for 2 years, conveying experience in RF patients. No bleeding or thrombosis occurred over 1 week of use. She was then transitioned to rivaroxaban, with monitoring of levels given lack of data with DOACs in pediatric ESRD. At 2 months of age, she required peritoneal dialysis (PD) catheter placement. Anticoagulation was discontinued pre-operatively. Post-operatively, significant fibrin deposition in the catheter resulted in lack of drainage, requiring catheter revision on post-op day 5. Catheter dysfunction recurred due to fibrin, requiring placement of a 7 Fr dialysis catheter for CRRT. Bivalirudin anticoagulation was restarted for 15 days. PD was then restarted with excellent drainage. Bivalirudin transitioned back to rivaroxaban without bleeding or thrombosis.

Conclusion(s): Multidisciplinary collaboration is vital to evaluate thrombosis and bleeding risk in pediatric ESRD and prevent loss of vascular and other device access through thrombotic complications. Further study is necessary to evaluate safety of anticoagulants in this complex population.