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Use of Bivalirudin to Prevent Thrombosis Following Orthotopic Liver Transplantation in a Patient with Budd-Chiari Syndrome and a History of Heparin-Induced Thrombocytopenia

Address correspondence to John Lazarchick, M.D., Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 165 Ashley Ave., Charleston, SC 29425, USA; tel 843 792 0217; fax 843 792 4811; e-mail lazarj{at}musc.edu.

Type II heparin-induced thrombocytopenia (HIT) is an immune-mediated syndrome that may arise in a time-dependent manner following heparin therapy, placing patients at significant risk for thromboembolic events. Therapy includes anticoagulation with a direct thrombin inhibitor and avoidance of heparin. We report a patient with Budd-Chiari syndrome and a history of heparin-induced thrombocytopenia who presented for orthotopic liver transplant and required postoperative anticoagulation with bivalirudin. During the post-transplant graft function improvement, we observed a significant dose-effect alteration manifested by an increased bivalirudin dose requirement as factor V activity increased. This observation is an important consideration in the attempt to maintain an optimal balance between effective anticoagulation and a reduced risk of postoperative bleeding.

Keywords: liver transplant, Budd-Chiari syndrome, thrombocytopenia, heparin, bivalirudin, thrombosis