The dose of lepirudin (Refludan, Berlex) needs to be reduced for a patient with heparin-induced thrombocytopenia and renal insufficiency. The adjustment is based on the level of residual renal function.
NOTE: The maximum dose is not listed. For a patient with normal renal function, the maximum dose is achieved at a body weight of 110 kilograms. I will use this in the implementation, but this needs to be confirmed.
The aPTT ratio (see previous section) is performed on a patient prior to therapy. Therapy is not started if the ratio is >= 2.5.
For the patient with renal insufficiency but not being dialyzed:
Estimated Creatinine Clearance in mL per minute
IV Bolus Dose to Administer in mg per kg body weight
IV Infusion Rate in mg per kg per hour
45 - 60
0.2
0.075
30 - 44
0.2
0.045
15 - 29
0.2
0.0225
< 15
not given
not given
If the patient is being hemodialyzed, then a bolus dose is given every other day ONLY if the aPTT ratio is < 1.5.
IV Bolus Dose to Administer in mg per kg body weight
IV Infusion Rate in mg per kg per hour
0.05 - 0.10
not given
If the patient is critically ill and undergoing continuous venovenous hemodialysis, then:
IV Bolus Dose to Administer in mg per kg body weight
IV Infusion Rate in mg per kg per hour
0.007 - 0.025
0.006 - 0.009
The aPTT ratio is determined at 4 hours after initiating therapy. The target ratio is 2. If the ratio is < 1.5 or > 2.5, then the testing is repeated before the infusion is adjusted..
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