Management of Brachiocephalic Vein Thrombosis in a Lupus Nephritis Patient on Hemodialysis
Remove the hemodialysis catheter immediately and transition to therapeutic anticoagulation with a parenteral agent, as the current apixaban dose is inadequate for treating established central venous thrombosis in this dialysis-dependent patient. 1
Immediate Catheter Management
The triple lumen HD catheter must be removed urgently as it is the likely source of the brachiocephalic vein thrombosis after 10 days of placement, and continued presence increases risk of thrombus propagation and infection. 2, 3
Transition to an alternative dialysis access immediately—either create an arteriovenous fistula if vessels are adequate, or place a temporary catheter in the contralateral internal jugular vein or femoral vein to avoid the thrombosed territory. 2, 3
The right-sided central venous system should be completely avoided for future access given the brachiocephalic thrombosis. 3, 4
Anticoagulation Strategy
Escalate from prophylactic to therapeutic anticoagulation immediately. The current apixaban 2.5 mg twice daily is a prophylactic dose, not therapeutic, and is insufficient for treating established central venous thrombosis. 5
Specific Anticoagulation Approach:
Switch to unfractionated heparin or low-molecular-weight heparin initially given the dialysis dependence and need for procedural interventions (catheter removal, potential new access placement). This allows for rapid reversal if bleeding occurs. 1
Once stable without need for procedures, transition to therapeutic-dose anticoagulation. For this patient with lupus and improving renal function (creatinine now 2), options include:
- Warfarin with INR goal 2-3 (preferred in dialysis patients with established thrombosis)
- Apixaban 5 mg twice daily (therapeutic dose) if renal function continues to improve and patient is no longer dialysis-dependent 5
Test for antiphospholipid antibodies urgently as lupus patients with antiphospholipid syndrome require indefinite anticoagulation and may need higher intensity therapy. 1
Lupus-Specific Considerations
Evaluate for antiphospholipid syndrome immediately as this fundamentally changes anticoagulation management. 1
Send antiphospholipid antibody panel (anticardiolipin antibodies, anti-β2-glycoprotein I antibodies, lupus anticoagulant) before any further anticoagulation changes. 1
If antiphospholipid antibodies are positive, this patient has antiphospholipid syndrome nephropathy risk and will require prophylactic anticoagulation indefinitely to prevent dialysis access clotting and future thrombotic events. 1
Continue current immunosuppression for class 3 lupus nephritis as prescribed—the thrombosis is catheter-related, not a lupus flare requiring treatment modification. 1
Monitoring and Duration
Anticoagulate for minimum 3-6 months for catheter-related central venous thrombosis in the absence of antiphospholipid syndrome. 1
If antiphospholipid antibodies are positive, continue anticoagulation indefinitely given the high risk of recurrent thrombosis and dialysis access complications. 1
Repeat imaging (venogram or CT venography) at 3 months to assess thrombus resolution before considering discontinuation of anticoagulation. 3, 4
Monitor closely for bleeding complications given the combination of uremia-related platelet dysfunction, lupus, and anticoagulation. 1
Critical Pitfalls to Avoid
Do not continue the current apixaban 2.5 mg twice daily dose—this is prophylactic dosing and will not treat established thrombosis. 5
Do not leave the catheter in place—catheter-related thrombosis will not resolve with anticoagulation alone while the catheter remains as a nidus. 2, 3
Do not place future catheters on the right side—the thrombosed brachiocephalic vein territory must be avoided to prevent complications like superior vena cava syndrome or pseudotumor cerebri. 6, 4
Do not assume this is lupus-related thrombosis without testing for antiphospholipid antibodies—the management differs significantly if antiphospholipid syndrome is present. 1