Heparin leak from a hemodialysis catheter causing major bleeding, ultimately leading to transplant rejection and death Gavin DREYER, 1 Paul LAWTON, 2 Matthew JOSE 3 1 Department of Nephrology, Royal London Hospital, London, UK; 2 Renal Unit, Royal Darwin Hospital, Darwin, Northern Territory, Australia; 3 Renal Unit, Royal Hobart Hospital, Hobart, Tasmania, Australia Abstract Leakage of hemodialysis catheter-locking solutions into the circulation has been reported in in vitro and in vivo studies, although there have been few reports of serious clinical adverse events. We describe a case of heparin leak from a hemodialysis catheter, which caused significant clinical bleed- ing requiring multiple transfusions and may have ultimately been responsible for the patient’s death after transplantation. Key words: Bleeding, catheter, death, hemodialysis, heparin, transplant INTRODUCTION Leakage of hemodialysis catheter-locking solutions into the circulation has been reported in in vitro and in vivo studies, 1–6 although there have been few reports of seri- ous clinical adverse events. We describe a case of heparin leak from a hemodialysis catheter, which caused signifi- cant clinical bleeding requiring multiple transfusions and may have ultimately been responsible for the pa- tient’s death after transplantation. CASE REPORT A 49-year-old woman, originally from Papua New Guinea, was referred to the renal clinic for assessment of advanced chronic kidney disease. At presentation, her creatinine clear- ance was 17.9 mL/min/1.73 m 2 . She had a past history of hypertension, bronchiectasis, and excision of a prolactinoma in 1985. In preparation for dialysis, a native, left brachio- cephalic arteriovenous fistula (AVF) was formed but was slow to mature due to a venous stenosis. The patient re- mained clinically well with a creatinine clearance of 13 mL/ min/1.73 m 2 and, hence, the stenosis was not treated. Two years later, the patient presented with end-stage renal failure (creatinine 1979 mmol/L, urea 81.8 mmol/L) and in the absence of a viable AVF, emergency hemodialysis was com- menced using a right internal jugular temporary dialysis catheter (the patient was too unwell to receive a tunneled dialysis catheter at presentation). Dialysis was given on alternate days for 4 hours per session. The patient received a standard intradialytic dose of heparin, with a 2000 U bolus and maintenance dose of 1000 U/h. Between hemodialysis sessions and immediately after insertion, the catheter was locked with standard heparin and vancomycin solution ac- cording to local protocols (total dose heparin= 26,250 U based on lumen volumes supplied by the manufacturer). Ten days after starting hemodialysis, a cephalic vein patch to the AVF was undertaken to facilitate permanent native dialysis access. The procedure was successful and a drain was inserted for mild postoperative oozing. Two days after fistula repair, the drain contained 60 mL of blood and mild ooze was noted from the suture line. The following day, the patient spontaneously developed a hematoma on her right hand and left knee. The hemo- globin (Hb) had fallen to 51 g/dL from a preoperative value of 99 g/dL. Heparin-free dialysis was prescribed (13 days after the start of hemodialysis therapy) and no blood was transfused at this time. One day later, the patient suffered a collapse with hy- potension (blood pressure 75/45 mmHg), and became Correspondence to: G. Dreyer, Department of Nephrology, Royal London Hospital, London E1 1BB, UK. E-mail: gavin_dreyer@hotmail.com Hemodialysis International 2008; 12:431–433 r 2008 The Authors. Journal compilation r 2008 International Society for Hemodialysis 431