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CORRESPONDENCE Chronically intermittent hemodialysis for end-stage renal
failure requires anticoagulation to prevent clotting in the
extracorporeal circuit. Anticoagulation usually is performed by
continuous infusion of unfractionated heparin or by bolus
administration of low-molecular-weight heparin.1 At our
hemodialysis unit, we use an intravenous bolus injection of an average
of 80 IU dalteparin (Fragmin; Pharmacia, Stockholm, Sweden) per
kilogram of body weight. In 1998, regional citrate anticoagulation was
introduced for patients at high risk for hemorrhage, for patients
suffering from heparin-induced thrombocytopenia type II, or for
patients in which the extracorporeal circuit clotted despite an
extremely high dalteparin dose.2,3 During the last 3 years, 5 of our female patients on long-term
anticoagulation with dalteparin complained about excessive hair
loss (Table 1). In patient 1, poor
growth of hair, but no pathologic hair loss or even alopecia, was
noticed. In the other 4 patients, hair was coming out in handfuls,
leaving large areas of mutilating patchy alopecia. Those 4 patients
reported that hair loss had begun approximately 6 weeks to 3 months
after initiation of hemodialysis. We suspected that repeated
anticoagulation with dalteparin, which shares many side effects with
heparin,4 was responsible for the unexplained hair loss in
our patients. To test this hypothesis, regional citrate
anticoagulation2,3 was initiated, thus avoiding further
exposure to dalteparin. Six weeks to 3 months after the anticoagulation
regimen had been changed, all 5 patients reported cessation of the
excessive hair loss. In patients 2 to 5, normal hair growth allowing
fashionable hairstyling was observed. Citrate anticoagulation was
stopped in patient 2, and excessive effluvium reoccurred some weeks
after readministration of dalteparin. In patient 1, objective changes
in hair growth were not observed.
In summary, in 4 of 5 chronic hemodialysis patients, a clear temporal association of excessive hair loss with the start of dalteparin anticoagulation was observed. The resolution of the excessive effluvium in these 4 patients and the restoration of normal hair growth after the anticoagulation had been switched to citrate suggest that dalteparin was responsible for the mutilating alopecia. The recurrence of the hair loss in patient 2 soon after reexposure to dalteparin is a further hint in favor of this hypothesis. Our case series supports the observation of Barnes et al, who reported a potential association of alopecia with the administration of dalteparin in a child treated for sinus venous thrombosis.5 We conclude that long-term anticoagulation with dalteparin causes alopecia in some chronic hemodialysis patients. Regular hair growth can be restored by replacing low-molecular-weight heparin by regional citrate anticoagulation.
Robert Apsner, Walter H. Hörl, and Gere Sunder-Plassmann
References 1. Schrader J, Stibbe W, Armstrong VW, et al. Comparison of low molecular weight heparin to standard heparin in hemodialysis/hemofiltration. Kidney Int. 1988;33:890-896[Medline] [Order article via Infotrieve]. 2. Pinnik RV, Wiegmann TB, Diederich DA. Regional citrate anticoagulation for hemodialysis in the patient at high risk for bleeding. N Engl J Med. 1983;308:258-261[Medline] [Order article via Infotrieve]. 3. Apsner R, Buchmayer H, Sunder-Plassmann G, Hörl WH. A simple method for citrate anticoagulation (CA) during high-flux dialysis: experience with 670 dialyses in 34 patients [abstract]. J Am Soc Nephrol. 1999;10:188A. 4. Tosti A, Misciali C, Piraccini B, Peluso A, Bardazzi F. Drug-induced hair loss and hair growth: incidence, management, and avoidance. Drug Safety. 1994;10:310-317[Medline] [Order article via Infotrieve].
5.
Barnes C, Deidun D, Hynes K, Monagle P.
Alopecia and dalteparin: a previously unreported association [letter].
Blood.
2000;96:1618-1619   CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati What's this?
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