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Iwafuchi Y, Ito Y, Imai N, Oyama Y, Narita I. Dabigatran-related Nephropathy Complicated by Tubulointerstitial Nephritis in a Patient with a Normal Renal Function and Undiagnosed IgA Nephropathy. Intern Med 2024; 63:1615-1621. [PMID: 37866913 PMCID: PMC11189709 DOI: 10.2169/internalmedicine.2628-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023] Open
Abstract
A 69-year-old woman was referred to our hospital because of an acute kidney injury with macroscopic hematuria. She had been taking dabigatran for atrial flutter for six years. Based on the typical histological findings of her kidney biopsy and her history of dabigatran use with prolonged activated partial thromboplastin time, she was diagnosed with dabigatran-related nephropathy complicated by tubulointerstitial nephritis with IgA nephropathy. After prednisolone therapy, the renal function improved. Direct-acting oral anticoagulants, including dabigatran, may cause anticoagulant-related nephropathy similar to warfarin, even in patients with a normal renal function. Tubulointerstitial nephritis may coexist with dabigatran-related nephropathy, and prednisolone therapy should be considered in such cases. IgA nephropathy has been reported as a background disease, and caution should be exercised when encountering it.
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Affiliation(s)
- Yoichi Iwafuchi
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Japan
| | - Yumi Ito
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Naofumi Imai
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Yuko Oyama
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
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Vischini G, Speciale S, Przygocka A, Martano L, La Manna G, Baraldi O. Lessons for the clinical nephrologist: acute kidney injury during therapy with apixaban. J Nephrol 2024; 37:511-513. [PMID: 38055150 PMCID: PMC11043096 DOI: 10.1007/s40620-023-01781-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/03/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Gisella Vischini
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Serena Speciale
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Via Giuseppe Massarenti 9, Bologna, Italy
| | - Agnieszka Przygocka
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Via Giuseppe Massarenti 9, Bologna, Italy
| | - Laura Martano
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Via Giuseppe Massarenti 9, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Via Giuseppe Massarenti 9, Bologna, Italy.
| | - Olga Baraldi
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Xu Q, Chen G, Ai S, Zheng K, Zhao B, Li X. Acute Kidney Injury in Different Anticoagulation Strategies: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07558-0. [PMID: 38319470 DOI: 10.1007/s10557-024-07558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Acute kidney injury (AKI) following anticoagulant application has received growing attention as a significant emerging complication of anticoagulation. Nevertheless, there remains a lack of real-world studies to compare the incidence, clinical features, and prognosis of AKI across different anticoagulant regimens. METHODS Disproportionality analysis and Bayesian analysis were used to identify suspected AKI cases after different anticoagulant use within the Food and Drug Administration's Adverse Event Reporting System from January 2004 to March 2023. The time to onset, fatality, and hospitalization rates of anticoagulant-associated AKI were also investigated. RESULTS We identified 9313 anticoagulant-associated AKIs, which appeared to influence mostly patients over 65 years old (65.37%). Lepirudin displayed a stronger AKI association than others, based on the highest reporting odds ratio (ROR = 6.66, 95% CI = 3.97-11.18), proportional reporting ratio (PRR = 6.08, χ2 = 69.12), and empirical Bayes geometric mean (EBGM = 6.08, the lower 90% one-sided CI = 3.95). Warfarin showed the slightest association with AKI in oral anticoagulants, lower than any direct oral anticoagulants excluding apixaban. Edoxaban exhibited the highest potential renal risk among direct oral anticoagulants, with an ROR of 3.32 (95% CI = 2.95-3.72). The median time to AKI onset was 36 (IQR 7-205) days following the initiation of anticoagulation therapy, and most AKI cases occurred within the first month. CONCLUSION Particular attention should be directed toward monitoring renal function in individuals receiving anticoagulants, including warfarin and direct oral anticoagulants, as well as other anticoagulant agents. This diligence is particularly imperative within the first month after anticoagulant administration for individuals with a tendency for AKI.
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Affiliation(s)
- Qiuyu Xu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Sanxi Ai
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Bin Zhao
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
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Yang Z, Xu H, Gou S, Wu H, Hu Z. Pembrolizumab induced-C3 glomerulonephritis and RBC cast nephropathy: a case report. BMC Nephrol 2023; 24:145. [PMID: 37226096 DOI: 10.1186/s12882-023-03202-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are increasingly being used in the treatment of several cancers. Pembrolizumab is an anti-programmed cell death-1 (anti-PD-1) monoclonal antibody that is approved for the treatment of metastatic non-small cell lung cancer (NSCLC). Pembrolizumab-associated renal toxicity is relatively rare, even in pembrolizumab-associated glomerulonephritis. In this study, we report a rare case of pembrolizumab-induced C3 glomerulonephritis (C3GN) and RBC cast nephropathy. CASE PRESENTATION A 68-year-old man with NSCLC was receiving treatment with pembrolizumab. After 19 cycles of pembrolizumab therapy, he presented with gross hematuria, severe lower-limb edema and oliguria. Laboratory tests revealed hypoalbuminemia, increased serum creatinine and low serum C3 level. Renal biopsy revealed a typical membranoproliferative glomerulonephritis accompanied by remarkable RBC casts in tubular cavities and tubulointerstitial infiltration of CD8-positive lymphocytes. Based on C3-only immunofluorescence deposit on glomeruli, a diagnosis of C3GN was made. Pembrolizumab was considered the cause of C3GN. Pembrolizumab was discontinued immediately, and 60 mg/day of prednisone was initiated. One dose of cyclophosphamide (400 mg, IV) was also administered. Upon treatment, his symptoms improved rapidly and serum creatinine decreased a lot. However, the patient became dialysis dependent eventually. CONCLUSION This is the first case of C3GN with RBC cast nephropathy caused by ICIs. This rare case caused by the prolonged use of pembrolizumab further strengthens the relationship between ICIs and C3GN. Thus, periodic evaluation of urine and renal function is recommended in patients receiving pembrolizumab and other ICIs.
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Affiliation(s)
- Zhi Yang
- Department of Nephrology, West China Hospital, Sichuan University, 37# Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Huan Xu
- Department of Pathology, West China Hospital, Sichuan University, 37# Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Shenju Gou
- Department of Nephrology, West China Hospital, Sichuan University, 37# Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Hongyan Wu
- Department of Nephrology, West China Hospital, Sichuan University, 37# Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Zhangxue Hu
- Department of Nephrology, West China Hospital, Sichuan University, 37# Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan Province, China.
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Chen S, Liao D, Yang M, Wang S. Anticoagulant-related nephropathy induced by direct-acting oral anticoagulants: Clinical characteristics, treatments and outcomes. Thromb Res 2023; 222:20-23. [PMID: 36563521 DOI: 10.1016/j.thromres.2022.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION There is a scarcity of data on anticoagulation-related nephropathy (ARN) caused by direct-acting oral anticoagulants (DOACs) in recent years. MATERIALS AND METHODS We collected literatures on DOACs-induced ARN to October 1, 2022, without language restrictions for retrospective analysis. RESULTS Twenty events were included with a median onset time of 28 days among which fourteen were caused by dabigatran. Patients accompanied by chronic kidney disease (85 %) seemed more easily to have an ARN. Clinical symptoms associated with ARN were mostly presented as hematuria and acute decline of renal function (100 %), then abnormal coagulation function (75 %) but only one with an INR over 3. Renal biopsies were performed in 14 patients, with thirteen showing occlusive intratubular red blood cell casts and ten showing acute tubular injury of varying intensity or even tubular necrosis. Extensive changes in interstitial compartment like hemorrhage, fibrosis or inflammation were also presented in eight biopsies. IgA nephropathy as a latent or undiagnosed disease was demonstrated in eight biopsies. Treatments of ARN were mainly supportive with all patients discontinuing DOACs and 35 % initiating dialysis for acute deterioration of renal function. Steroids were used in 9 patients with a severe ARN verified by biopsy. 60 % of patients did not recover baseline renal function and some even deteriorated. CONCLUSIONS In conclusion, DOACs-induced ARN is a rare but serious adverse reaction. A prompt diagnosis of ARN and supportive treatments are necessary for patients receiving DOACs concurrent with an acute renal injury.
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Affiliation(s)
- Shanshan Chen
- Department of Pharmacy, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, China
| | - Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, China
| | - Minghua Yang
- Postdoctoral Research Station of Clinical Medicine and Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
| | - Shengfeng Wang
- Department of Pharmacy, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, China; Postdoctoral Research Station of Clinical Medicine and Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China; Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
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Acquah F, Ganta N, Alnabwani D, Alaan C, Anantharaman P, Cheriyath P. Warfarin-Related Nephropathy Manifested as Diffuse Mesangial Proliferative Glomerulonephritis. Cureus 2022; 14:e22284. [PMID: 35350506 PMCID: PMC8933143 DOI: 10.7759/cureus.22284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
Warfarin is associated with anticoagulant-related nephropathy (ARN), one of the potential side effects. This is evidenced by a progressively increasing number of detected cases of deterioration in the kidney function even in patients with normal baseline function (GFR {glomerular filtration rate}) in addition to the chronic kidney disease (CKD) patients who are already vulnerable to ARN. There has been a clinical correlation in a rapid decline of kidney function and international normalized ratio (INR) levels of greater than three. ARN is a significant but underdiagnosed complication of anticoagulation that is associated with increased renal morbidity and all-cause mortality. We want to emphasize the importance of monitoring kidney function regularly and adjusting the appropriate doses of warfarin. We present a case of a 57-year-old female who was on warfarin for the mechanical aortic valve, presented with acute kidney injury and supratherapeutic INR. Her renal biopsy showed diffuse mesangial proliferative glomerulonephritis.
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Trujillo H, Sandino J, Cavero T, Caravaca-Fontán F, Gutiérrez E, Sevillano ÁM, Shabaka A, Fernández-Juárez G, Doyágüez PR, Muñoz RG, García LC, Cabello V, Muñoz-Terol JM, Santiago AG, Toldos O, Moreno JA, Praga M. IgA nephropathy is the most common underlying disease in patients with anticoagulant-related nephropathy. Kidney Int Rep 2022; 7:831-840. [PMID: 35497792 PMCID: PMC9039479 DOI: 10.1016/j.ekir.2022.01.1048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Anticoagulant-related nephropathy (ARN) is a relatively novel recognized entity characterized by hematuria-associated acute kidney injury (AKI) in the context of overanticoagulation. Preexisting or underlying kidney disease seems to be a predisposing factor; however, few studies have described histologic findings in patients with ARN. We aimed to evaluate underlying kidney pathology in patients on oral anticoagulation who presented an episode of AKI with hematuria in whom a kidney biopsy was performed. Methods Retrospective observational multicenter case study in patients treated with oral anticoagulants who developed macroscopic or intense hematuria followed by AKI. Only patients with available kidney biopsy specimens were included. Histologic findings and clinical data throughout follow-up were analyzed. Results A total of 26 patients were included with a median age of 75 years (62–80) and a follow-up period of 10.1 months. Of the patients, 80% were male, and most cases (92%) were on anticoagulation with vitamin K antagonists (VKAs). At admission, median serum creatinine (SCr) level was 4.2 mg/dl (2.8–8.2), median international normalized ratio (INR) 2.4 (1.5–3.4), and 11 patients (42%) required acute dialysis during hospitalization. Kidney biopsy results revealed that all patients except 1 had an underlying nephropathy: IgA nephropathy (IgAN) in 19, probable IgAN in 1, diabetic nephropathy in 3, nephrosclerosis in 1, and idiopathic nodular glomerulosclerosis in 1. At 12 weeks after discharge, only 6 subjects (24%) attained complete kidney recovery whereas 7 (28%) remained on chronic dialysis. Conclusion IgAN was the most common underlying kidney disease in our biopsy-proven series of ARN, in which a significant percentage of patients did not achieve kidney function recovery.
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Gomez-Fernández P, Martín Santana A, Arjona Barrionuevo JDD. Oral anticoagulation in chronic kidney disease with atrial fibrillation. Nefrologia 2021; 41:137-153. [PMID: 36165375 DOI: 10.1016/j.nefroe.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/11/2020] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomizedtrials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.
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Affiliation(s)
- Pablo Gomez-Fernández
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain.
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Belčič Mikič T, Kojc N, Frelih M, Aleš-Rigler A, Večerić-Haler Ž. Management of Anticoagulant-Related Nephropathy: A Single Center Experience. J Clin Med 2021; 10:jcm10040796. [PMID: 33669373 PMCID: PMC7920283 DOI: 10.3390/jcm10040796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anticoagulant-related nephropathy (ARN) is a form of acute kidney injury that mainly occurs in patients with previously unrecognized glomerular disease in addition to excessive anticoagulation. Since a renal biopsy is not performed in most cases, the diagnosis is often presumptive. METHODS Here, we present the characteristics of a national Slovenian patient cohort with histologically verified ARN, from the first case in 2014 to December 2020, and a review of the current literature (Pubmed database). RESULTS In Slovenia, ARN has been detected in 13 patients, seven of whom were treated with coumarins, and others with direct oral anticoagulants. In seven patients, ARN appeared after excessive anticoagulation. As many as 11 patients had underlying IgA nephropathy. Similar to the global data presented here, the pathohistological impairment associated with pre-existing glomerulopathy was mild and disproportionate to the degree of functional renal impairment. The majority of our patients with ARN experienced severe deterioration of renal function associated with histological signs of accompanying acute tubular injury, interstitial edema, and occlusive red blood cell casts. These patients were treated with corticosteroids, which (in addition to supportive treatment and discontinuation of the anticoagulant drug) led to a further improvement in renal function. CONCLUSIONS Anticoagulant therapy combined with a pre-existing glomerular injury may lead to ARN. In addition to discontinuation of the anticoagulant and supportive care, corticosteroids, which are currently listed in only a few cases in the world literature, may have a positive influence on the course of treatment. However, the benefits of steroid treatment must be weighed against the risk of complications, especially life-threatening infections.
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Affiliation(s)
- Tanja Belčič Mikič
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
| | - Nika Kojc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (N.K.); (M.F.)
| | - Maja Frelih
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (N.K.); (M.F.)
| | - Andreja Aleš-Rigler
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
| | - Željka Večerić-Haler
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-1548
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10
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Acute Kidney Injury due to Anticoagulant-Related Nephropathy : A Suggestion for Therapy. Case Rep Nephrol 2020; 2020:8952670. [PMID: 32566333 PMCID: PMC7298278 DOI: 10.1155/2020/8952670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 02/02/2023] Open
Abstract
The relationship between kidneys and anticoagulation is complex, especially after introduction of the direct oral anticoagulants (DOAC). It is recently growing evidence of an anticoagulant-related nephropathy (ARN), a form of acute kidney injury caused by excessive anticoagulation. The pathogenesis of kidney damage in this setting is multifactorial, and nowadays, there is no established treatment. We describe a case of ARN, admitted to our Nephrology Unit with a strong suspicion of ANCA-associated vasculitis due to gross haematuria and haemoptysis; the patient was being given dabigatran. Renal biopsy excluded ANCA-associated vasculitis and diagnosed a red blood cell cast nephropathy superimposed to an underlying IgA nephropathy. Several mechanisms are possibly responsible for kidney injury in ARN: tubular obstruction, cytotoxicity of heme-containing molecules and free iron, and activation of proinflammatory/profibrotic cytokines. Therefore, the patient was given a multilevel strategy of treatment. A combination of reversal of coagulopathy (i.e., withdrawal of dabigatran and infusion of its specific antidote) along with administration of fluids, sodium bicarbonate, steroids, and mannitol resulted in conservative management of AKI and fast recovery of renal function. This observation could suggest a prospective study aiming to find the best therapy of ARN.
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Ravera M, Bussalino E, Fusaro M, Di Lullo L, Aucella F, Paoletti E. Systematic DOACs oral anticoagulation in patients with atrial fibrillation and chronic kidney disease: the nephrologist's perspective. J Nephrol 2020; 33:483-495. [PMID: 32200488 DOI: 10.1007/s40620-020-00720-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is highly prevalent among patients with chronic kidney disease (CKD), and also associated with unfavorable outcome. Anticoagulant therapy is the mainstep of management in such patients, aimed at reducing the high risk of systemic thromboembolism and especially of ischemic stroke, which is reportedly associated with increased mortality in CKD patients. Even though new direct oral anticoagulant agents (DOACs) proved to be effective in patients with non valvular chronic AF, and are therefore recommended by recent guidelines for their treatment, warfarin is currently used in more than one-half of subjects needing oral anticoagulation, and only 30% of them are converted from a vitamin K antagonist- to a DOAC-based regimen. The main reason for not prescribing DOACs is often a reduction in renal function, even if mild. Aim of this review was therefore to evaluate the impact of DOAC therapy in the setting of CKD, from a nephrological perspective, by comparing available evidence on the role of DOACs in patients with CKD and AF with that emerging from traditional warfarin-based therapy. Both the pathogenesis of AF in CKD, and available findings of renal, cardiovascular and bone effects of DOACs in CKD are discussed, leading to the conclusion that DOAC therapy should be considered as the first line therapy for non valvular AF in patients with mild and moderate reduction of renal function, and could also be adopted for patients with severe CKD not on hemodialysis treatment, whereas there is insufficient evidence for ESRD patients on dialysis.
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Affiliation(s)
- Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy.
| | - Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padua, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Rome, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS "Casa Sollievo della Sofferenza" Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
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12
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Ikeda M, Tanaka M, Shimoda S, Saita H, Nishikawa S, Shimada H, Taniguchi K, Hagihara K, Iwanari S, Takeoka H. Dabigatran-induced anticoagulant-related nephropathy with undiagnosed IgA nephropathy in a patient with normal baseline renal function. CEN Case Rep 2019; 8:292-296. [PMID: 31347098 PMCID: PMC6820621 DOI: 10.1007/s13730-019-00410-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/16/2019] [Indexed: 12/29/2022] Open
Abstract
Occasionally, over-anticoagulation with warfarin induces acute kidney injury (AKI) characterized by glomerular hemorrhage with tubular obstruction by red blood cell casts, which is widely acknowledged as warfarin-related nephropathy. Owing to extensive use of direct oral anticoagulants, similar AKI cases have been reported among patients treated with dabigatran. Dabigatran is primarily excreted by the kidneys; thus, renal impairment is one of the risk factors for dabigatran-induced bleeding complications. Nevertheless, risk factors for dabigatran-induced anticoagulant-related nephropathy (ARN) remain partially clarified. Here, we report a histologically established case of dabigatran-induced ARN with undiagnosed IgA nephropathy in a patient with normal baseline renal function. In addition, we summarize previously published cases of biopsy-proven, dabigatran-related ARN. A 67-year-old female with normal preexisting renal function developed macrohematuria and AKI. She had been treated with dabigatran for deep vein thrombosis. A renal biopsy diagnosed ARN with inactive IgA nephropathy. After dabigatran withdrawal, her macrohematuria and renal function improved. This report demonstrates that ARN could occur in patients with normal baseline renal function. Our case and prior reports suggest that IgA nephropathy could be a risk factor for dabigatran-induced ARN.
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Affiliation(s)
- Masaki Ikeda
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan.
| | - Mari Tanaka
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Saeko Shimoda
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Hirona Saita
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Seira Nishikawa
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Hiroki Shimada
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Keisuke Taniguchi
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Koichiro Hagihara
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Sachio Iwanari
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
| | - Hiroya Takeoka
- Department of Nephrology and Dialysis, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Hyogo, Amagasaki, 660-8550, Japan
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Li X, Cheung CY. Dabigatran causing severe acute kidney injury in a patient with liver cirrhosis. CEN Case Rep 2019; 8:125-127. [PMID: 30659506 DOI: 10.1007/s13730-019-00378-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/08/2019] [Indexed: 01/09/2023] Open
Abstract
Anticoagulant-related nephropathy (ARN), a significant but frequently undiagnosed problem in patients receiving anticoagulation, is found to be associated with increased renal morbidity and all-cause mortality. While ARN is mainly associated with warfarin use, recent case reports suggest that it may also occur in patients taking direct oral anticoagulants (DOAC). We report a patient who had a history of alcoholic liver cirrhosis and paroxysmal atrial fibrillation, and received dabigatran 110 mg twice daily for 1 year. He presented with gross hematuria and severe acute kidney injury with an international normalized ratio of 4.09. Dabigatran was stopped and he was put on temporary hemodialysis support. His renal function gradually improved when the hematuria subsided. Renal biopsy later confirmed the presence of red blood cell casts inside the renal tubules with features of IgA nephropathy. Finally, his renal function returned back to baseline level. As DOAC has been increasingly used nowadays for the treatment of various thromboembolic diatheses, regular monitoring of renal function is warranted, especially in patients with underlying glomerular diseases and coagulopathy such as chronic liver diseases.
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Affiliation(s)
- Xin Li
- Department of Microbiology, Queen Mary Hospital, Hong Kong, SAR, China
| | - Chi Yuen Cheung
- Renal Unit, Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong, SAR, China.
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14
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Anticoagulant Related Nephropathy Induced by Dabigatran. Case Rep Nephrol 2018; 2018:7381505. [PMID: 30631615 PMCID: PMC6304482 DOI: 10.1155/2018/7381505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/19/2018] [Indexed: 11/18/2022] Open
Abstract
We describe a case of biopsy-proven dabigatran related nephropathy in a patient without underlying IgA nephropathy. To date, dabigatran related nephropathy was only reported in patients with concurrent or undiagnosed IgA nephropathy, suggesting that it may predispose patients to dabigatran associated injury. The patient is an 81-year-old woman with multiple medical comorbidities, including nonvalvular atrial fibrillation, who was anticoagulated with dabigatran. She presented to hospital with acute kidney injury in the setting of volume overload. Her estimated glomerular filtration rate decreased from a baseline of 57 mL/min/1.73 m2 to 4 mL/min/1.73 m2, necessitating hemodialysis. Renal ultrasound findings, fractional excretion of sodium, and urinalysis suggested acute kidney injury. Renal biopsy showed acute tubular injury, tubular red blood cell casts, and an absence of active glomerulonephritis, similar to the pathological findings of warfarin related nephropathy. A diagnosis of anticoagulant related nephropathy secondary to dabigatran was therefore established. This case demonstrates that dabigatran, like warfarin, may increase tubular bleeding risk in patients, irrespective of underlying kidney or glomerular disease.
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15
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Zhang C, Gu ZC, Ding Z, Shen L, Pan MM, Zheng YL, Lin HW, Pu J. Decreased risk of renal impairment in atrial fibrillation patients receiving non-vitamin K antagonist oral anticoagulants: A pooled analysis of randomized controlled trials and real-world studies. Thromb Res 2018; 174:16-23. [PMID: 30551039 DOI: 10.1016/j.thromres.2018.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 10/30/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients with warfarin have a potential risk of warfarin-related nephropathy, which could result in the discontinuation of anticoagulation therapy. The question of whether non-vitamin K antagonist oral anticoagulants (NOACs) use is associated with increased risk of renal impairment in atrial fibrillation (AF) patients remains unanswered. METHODS Studies were systematically searched through Medline, Embase, Cochrane Library databases, and ClinicalTrials.gov Website. Randomized controlled trials (RCTs) reporting renal impairment events and observational nationwide database studies presenting adjusted hazard ratio (HR) in AF patients with NOACs were identified. The Primacy outcome was renal impairment, defined as a composite of any renal disorder. The secondary outcomes were narrow definition of renal failure (including renal failure, acute renal failure, chronic renal failure, acute prerenal failure and postrenal failure) and individual renal impairment reported in involved studies. HR and 95% confidence intervals (95%CI) were calculated using fixed- or random-effects models according to the extent of heterogeneity. Subgroup analyses were conducted according to individual NOACs, study types and different controls. RESULTS Totally, 189,483 patients from 11 RCTs and 3 observational database studies were included in the analysis (119,188 patients with NOACs and 70,295 patients with vitamin K Antagonists or acetylsalicylic acid). Overall results indicated a significantly lower risk of renal impairment in AF patients with NOACs versus VKAs/acetylsalicylic acid (HR: 0.67, 95%CI: 0.62-0.73). Results of narrow definition of renal impairment were accordant with the primacy outcome (HR: 0.65, 95%CI: 0.60-0.71). Compared with VKAs or acetylsalicylic acid, dabigatran (HR: 0.64, 95%CI: 0.56-0.72), rivaroxaban (HR: 0.66, 95%CI: 0.55-0.77) and apixaban (HR: 0.73, 95%CI: 0.59-0.87) were all associated with a significantly lower risk of renal impairment, with the exception of edoxaban (HR: 0.79, 95%CI: 0.30-1.27). CONCLUSIONS Patients with NOACs might bring about a lower risk of renal impairment compared to VKA or acetylsalicylic acid. Further specialized designs of RCTs and real-world studies on evaluation of renal function are warranted to obtain a robust result on this issue.
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Affiliation(s)
- Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China.
| | - Zheng Ding
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Mang-Mang Pan
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Ying-Li Zheng
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, China.
| | - Hou-Wen Lin
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
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16
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Abstract
Anticoagulant-related nephropathy (ARN) is a newly recognized form of AKI in which overanticoagulation causes profuse glomerular hemorrhage, which manifests on renal biopsy as numerous renal tubules filled with red cells and red cell casts. The glomeruli show changes, but they are not sufficient to account for the glomerular hemorrhage. We were the first to study ARN, and since then, our work has been confirmed by numerous other investigators. Oral anticoagulants have been in widespread use since the 1950s; today, >2 million patients with atrial fibrillation take an oral anticoagulant. Despite this history of widespread and prolonged exposure to oral anticoagulants, ARN was discovered only recently, suggesting that the condition may be a rare occurrence. This review chronicles the discovery of ARN, its confirmation by others, and our animal model of ARN. We also provide new data on analysis of "renal events" described in the post hoc analyses of three pivotal anticoagulation trials and three retrospective analyses of large clinical databases. Taken together, these analyses suggest that ARN is not a rare occurrence in the anticoagulated patient with atrial fibrillation. However, much work needs to be done to understand the condition, particularly prospective studies, to avoid the biases inherent in post hoc and retrospective analyses. Finally, we provide recommendations regarding the diagnosis and management of ARN on the basis of the best information available.
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Affiliation(s)
- Sergey Brodsky
- Renal and Transplant Pathology Laboratory, Department of Pathology and
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lee A Hebert
- Division of Nephrology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; and
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L'Imperio V, Guarnieri A, Pieruzzi F, Sinico RA, Pagni F. Anticoagulant-related nephropathy: a pathological note. J Thromb Thrombolysis 2018; 46:260-263. [PMID: 29679257 DOI: 10.1007/s11239-018-1669-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The wide employment of oral anticoagulants and the introduction of new anticoagulant agents highlight disparate kind of toxicities that can affect many different organ systems. Renal toxicity by oral anticoagulants is a well-known entity characterized by hematuria and the worsening of renal function associated with uncontrolled INR values. Although it is mainly a clinical diagnosis, renal biopsy may help especially in challenging cases when multiple comorbidities and underlying renal conditions exist. The mechanism of the anticoagulant-induced damage is still debated and special tissue stains (such as Perls') could help in detecting the direct tubular toxicity induced by chronic glomerular bleeding. The employment of a diagnostic clinic-pathological flow-chart can help in the prompt detection and full characterization of these cases, improving the management of the patient.
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Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Alessia Guarnieri
- Department of Medicine and Surgery, Pathology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Federico Pieruzzi
- Nephrology Unit, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Renato Alberto Sinico
- Nephrology Unit, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy. .,Research Center for Renal Immunopathology, University of Milan, Milan, Italy.
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18
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Abstract
Introduction Postmarketing pharmacovigilance reports have raised concerns about non-bleeding adverse events associated with direct oral anticoagulants (DOACs), but only limited results are available from large claims databases. Objective The aim of this study was to assess the potential association between DOAC initiation and the onset of four types of non-bleeding adverse events by sequence symmetry analysis (SSA). Methods SSA was performed using nationwide data from the French National Healthcare databases (Régime Général, 50 million beneficiaries) to assess a cohort of 386,081 DOAC new users for the first occurrence of four types of non-bleeding outcomes: renal, hepatic, skin outcomes identified by using hospitalization discharge diagnoses, and gastrointestinal outcomes by using medication reimbursement. Asymmetry in the distribution of each investigated outcome occurring before and after initiation of DOAC therapy was used to test the association between DOAC therapy and these outcomes. SSA inherently controls for time-constant confounders, and adjusted sequence ratios were computed after correcting for temporal trends. Negative (glaucoma) and positive (bleeding, depressive disorders) control outcomes were used and analyses were replicated on a cohort of 310,195 patients initiating a vitamin K antagonist (VKA). Results This study demonstrated the expected positive association between either DOAC or VKA therapy and hospitalised bleeding and initiation of antidepressant therapy, while no association was observed between either DOAC or VKA therapy and initiation of antiglaucoma medications. For DOAC therapy, signals were the associations with hepatic outcomes, including acute liver injury [for the 3-month time window, aSR3 = 2.71, 95% confidence interval (CI) 1.79–4.52]; gastrointestinal outcomes, including initiation of drugs for constipation and antiemetic drugs (aSR3 = 1.31, 95% CI 1.27–1.36; and 1.17, 95% CI 1.12–1.22, respectively); and kidney diseases (aSR3 = 1.33, 95% CI 1.29–1.37). Conclusion Results of this nationwide study suggest that DOACs are associated with rare but severe liver injury and more frequent gastrointestinal disorders. A low risk of kidney injury with DOAC therapy can also not be excluded. Electronic supplementary material The online version of this article (10.1007/s40264-018-0668-9) contains supplementary material, which is available to authorized users.
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Patel S, Hossain MA, Ajam F, Patel M, Nakrani M, Patel J, Alhillan A, Hammoda M, Alrefaee A, Levitt M, Asif A. Dabigatran-Induced Acute Interstitial Nephritis: An Important Complication of Newer Oral Anticoagulation Agents. J Clin Med Res 2018; 10:791-794. [PMID: 30214652 PMCID: PMC6134997 DOI: 10.14740/jocmr3569w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/21/2018] [Indexed: 11/16/2022] Open
Abstract
Acute kidney injury (AKI) due to an acute interstitial nephritis (AIN) is common and can lead to increased morbidity and mortality. Medications such as antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPI) and rifampin are common offending agents. Anticoagulant-associated AIN is more frequently reported with the use of warfarin; however, only few case reports have reported an association with the use of novel oral anticoagulants (NOACs). Herein, we report the case of a 59-year-old male who developed AKI after initiating dabigatran for the treatment of atrial fibrillation. Laboratory data demonstrated elevated blood urea nitrogen (BUN) of 115 mg/dL (baseline = 35 mg/dL) and serum creatinine (Cr) of 5.06 mg/dL (baseline = 1.3 mg/dL). Urinalysis revealed eosinophiluria. Renal biopsy disclosed diffuse tubulointerstitial nephritis and eosinophils and confirmed the diagnosis of AIN. At 1 week, renal function improved (BUN/Cr = 53/2.73 mg/dL) with steroid therapy and discontinuation of dabigatran. With an increasing use of NOACs, it is important to monitor renal function to diagnose AIN in a timely fashion. Early diagnosis and prompt treatment can mitigate serious renal damage induced by dabigatran.
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Affiliation(s)
- Swapnil Patel
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohammad A. Hossain
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Firas Ajam
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mayurkumar Patel
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mihir Nakrani
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Jasmine Patel
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Alsadiq Alhillan
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohamed Hammoda
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Anas Alrefaee
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Michael Levitt
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
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Elalamy I, Hanon O, Deray G, Launay-Vacher V. Anticoagulants in frail patients. Seven situations at risk. JOURNAL DE MEDECINE VASCULAIRE 2018; 43:302-309. [PMID: 30217344 DOI: 10.1016/j.jdmv.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 06/30/2018] [Indexed: 06/08/2023]
Abstract
In the case of venous thromboembolic disease (VTE), physicians are facing more and more difficulties in managing VTE and their treatment in frail patients. These patients could present several risk situations such as: chronic kidney disease (CKD), underweight or malnourished, falls, cognitive impairment, multi-medicated patients, cancer and pregnancy. Guidelines typically recommend anticoagulation. There are multiple challenges in the safe use of anticoagulation in frail patients, including bleeding risk, monitoring and adherence, and polypharmacy. The objective of this review is to explore these at-risk situations and to suggest adequate anticoagulation therapy, when possible, in each of these complex situations.
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Affiliation(s)
- I Elalamy
- Hematology department, Tenon Hospital, 75020 Paris, France
| | - O Hanon
- Geriatrics department, Broca Hospital, 75013 Paris, France
| | - G Deray
- Service ICAR, Pitié-Salpêtrière Hospital, 75013 Paris, France; Nephrology department, Pitié-Salpêtrière Hospital, 75013 Paris, France
| | - V Launay-Vacher
- Service ICAR, Pitié-Salpêtrière Hospital, 75013 Paris, France; Nephrology department, Pitié-Salpêtrière Hospital, 75013 Paris, France.
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21
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Awesat J, Sagy I, Haviv YS, Rabinovich A, Jotkowitz A, Shleyfer E, Barski L. Dabigatran-induced nephropathy and its successful treatment with Idarucizumab - case report and literature review. Thromb Res 2018; 169:120-122. [PMID: 30032039 DOI: 10.1016/j.thromres.2018.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/08/2018] [Accepted: 07/12/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs. CASE REPORT We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran. CONCLUSION The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.
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Affiliation(s)
- Jenan Awesat
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Iftach Sagy
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yosef S Haviv
- Department of Nephrology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis unit, Hematology institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Alan Jotkowitz
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Elena Shleyfer
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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22
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Metformin prevents the development of severe chronic kidney disease and its associated mineral and bone disorder. Kidney Int 2018; 94:102-113. [DOI: 10.1016/j.kint.2018.01.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 01/17/2018] [Accepted: 01/25/2018] [Indexed: 12/15/2022]
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23
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Jansky L, Mukkamala P, Jebakumar D, Rao A, Goldson TM, Forjuoh SN. Acute kidney injury and undiagnosed immunoglobulin A nephropathy after dabigatran therapy. Proc (Bayl Univ Med Cent) 2018; 31:321-323. [PMID: 29904298 DOI: 10.1080/08998280.2018.1463036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 12/27/2022] Open
Abstract
Dabigatran, a new oral anticoagulant, is a direct thrombin inhibitor used as an alternative to warfarin to reduce the risk of stroke and systemic embolism with nonvalvular atrial fibrillation. We report a case of a man who resumed dabigatran after 6 weeks of prior therapy and began experiencing hematuria with worsening kidney function. Renal biopsy with immunofluorescence and electron microscopy showed mesangial deposits consistent with immunoglobulin A nephropathy. With discontinuation of dabigatran and addition of methylprednisolone, the gross hematuria cleared and urine output improved.
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Affiliation(s)
- Laurie Jansky
- Department of Family and Community Medicine, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Pallavi Mukkamala
- Department of Family and Community Medicine, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Deborah Jebakumar
- Department of Pathology, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Arundhati Rao
- Department of Pathology, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Tove M Goldson
- Department of Family and Community Medicine, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Samuel N Forjuoh
- Department of Family and Community Medicine, Baylor Scott & White Health and College of Medicine, Texas A&M Health Science Center, Temple, Texas
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