Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
Department of Trauma Surgery, University Hospital Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
BMC Geriatr. 2022 Feb 5;22(1):102. doi: 10.1186/s12877-022-02781-6.
The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed.
We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient's renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home.
Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications.
人口结构转变导致需要接受治疗性抗凝的老年患者数量不断增加，这是多种合并症所致。尽管治疗性抗凝可以降低这些患者栓塞并发症的发生风险，但在考虑此类治疗时，需要牢记大出血等主要并发症。然而，关于高龄慢性肾脏病患者选择抗凝药物的证据有限。在本报告中，讨论了一个基于指南的抗凝治疗方案，该方案导致了一例突发的创伤性出血并发症。
我们报告了一例 85 岁的女性慢性肾脏病 5 期患者，因接受低分子肝素（LMWH）治疗性抗凝而出现左下肢弥漫性动脉和皮下出血。抗凝治疗是根据房颤患者的一般建议开始的，剂量根据患者的肾功能进行调整。然而，还是发生了上述并发症，出血导致了失血性休克和慢性肾脏病的急性肾损伤。血肿需要在手术室进行手术清除和局部止血。在后续的病程中，由于皮肤感染坏死，患者又进行了另外 4 次手术干预，包括植皮。此外，患者还需要持续肾脏替代治疗和重症监护病房治疗，共 47 天，随后进行了 36 天的老年康复治疗。之后，患者出院回到之前的养老院。
尽管治疗性抗凝可以充分保护处于心血管风险的患者，但大出血等主要并发症可能随时发生。因此，医生需要定期重新评估治疗性抗凝的任何先前指征。通过本病例报告，我们希望引起人们对老年患者群体的关注，并需要更多且更具差异性的研究环境，以更好地预防任何潜在的可避免的并发症。
