Hemodialysis with a Permcath Kept Open with Streptokinase and Later Citrate in a Heparin-Sensitive Patient

M.H. Gault, Division of Nephrology, The General Hospital, Health Sciences Centre, St. John’s, Nfld. A1B 3 V6 (Canada) Dear Sir, A 74-year-old 56 kg blind woman developed dialysis-depended acute on chronic renal failure following coronary angiography in February 1989. She had gross lymphe-dema of the left arm following radical mastectomy 5 years before and multiple-thrombosed vessels in the right arm. She was considered unsuitable for standard arteri-ovenous graft or fistula, or for continuous ambulatory peritoneal dialysis. Soon after dialysis was started with a subclavian catheter using heparin in the catheter between dialyses and for anticoagulation during dialysis, her platelet count fell to 20,000 and she developed deep-vein thrombosis in her left leg. Platelets returned quickly to normal when all heparin was discontinued. Warfarin therapy was commenced and prothrombin time was kept on average 15% of control. A test for platelet heparin sensitivity was positive [1]. A Permcath (Quinton Instrument Co., Seattle, Wash.) was introduced through the right internal jugular vein into the superior vena cava. Starting March 15, patency was maintained between dialyses with 20,000 units streptokinase (Hoechst, Montreal, Que.) in a volume of 1.5 iVsaline in both arterial and venous compartments. For 9 months, dialysis for 4 h was performed twice weekly with saline flushes as needed, but without an anticoagulant other than warfarin. There was no clotting of the catheter and rarely clotting of the dialyzers. Blood flow was estimated at 275–400 ml/min during dialysis. The dialyzer was a Filtral 16 and the delivery system a Monitrol S, both from Hospal Ltd., Montreal, Que. Dialyzer reuse averaged 3.5 times. Activated clotting times (HemoTek Inc., Englewood, Colo.) remained at 100–110 s at the start of dialysis. Hemoglobin was maintained > 80 g/l by transfusion when needed. On November 6th, treatment of a bacteremia due to infection related to the Permcath with Staphylococcus epidermidis was commenced with vancomycin and later with rifampin 600 mg daily. The latter drug induced a fall in the prothrombin time and then there was recurrent clotting of the Permcath and dialyzers. Predialysis values for activated clotting times fell to 60–70 s and prothrombin time to 110% of control. On January 4, 1990, the old catheter was removed and a new Permcath was inserted on the right into the atrium over a guide wire, but in a new tunnel, and an arteriovenous fistula was fashioned in the right arm. It was not considered possible to insert a graft without heparin. Then rifampin was discontinued. The large amount of streptokinase infused around that time (1 million units) probably led to the worsening anaphylactoid reactions which were associated with hypotension, erythema, edema and a hot sensation