Severe Skin Necrosis Associated with Heparin in Hemodialysis

Abstract

Skin necrosis is a well-recognized although rare complication of continuous heparin therapy. We report the case of a 66-year-old diabetic woman with end-stage renal failure who received intermittent intravenous heparin during hemodialysis. She developed severe necrotic cutaneous ulcers over both legs, with typical histological findings. Thrombocytopenia never occurred but platelet studies demonstrated enhanced aggregation when heparin was added in vitro. Platelet-aggregating immunoglobulins produced in response to heparin can lead to thrombotic events. Thrombocytopenia usually develops prior to the onset of cutaneous lesions, but as in this case, may be absent. Heparin should be discontinued when the condition is recognized. Unfortunately, a poor outcome is frequently observed.

Heparin-Induced Skin Necrosis in a Patient with End-Stage Renal Failure and Functional Protein S Deficiency

“…Given that the majority of hemodialysis patients regularly receive heparin, it is somewhat surprising that only a handful of cases of heparin-induced skin ulceration have been reported in this patient population [7][8][9]. We speculate that this is because many cases of heparin-induced skin necrosis are misdiagnosed as calciphylaxis.…”

“…Highmolecular weight heparins and those of bovine lung sources may cause these complications more frequently than lower molecular weight heparins and those of porcine gut sources [1,5]. Skin necrosis may be seen at sites of heparin injection [2] or occur at distant sites such as thighs, abdomen and buttocks particularly in obese dia- betic women [6][7][8][9]. Onset of skin necrosis usually occurs 5-10 days after initiating heparin but lesion formation may be delayed several months as reported in 1 hemodialysis patient [8].…”

Heparin‐induced skin necrosis associated with thrombocytopenia and acquired protein C and protein S deficiency

“…Skin necrosis may be seen at sites of heparin injection [4], or occur at distant sites such as thighs, abdomen, and buttocks especially in obese diabetic women [6].…”

Low-molecular-weight heparin-induced skin necrosis

“…These include a more predictable pharmacokinetic behavior, which leads to a greater antithrombotic efficacy at a lower risk of hemorrhage and a lower risk of heparin-induced thrombocytopenia [25] and osteoporosis after long-term treatment [14]. Skin necrosis is an extremly rare complication of treatment with UFH [4,6,8,11,20,22,24,27,28] but has also been observed in a small number of cases after treatment with LMWH [3,5,12,15,17,19].…”