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Pacchiarini MC, Regolisti G, Greco P, Di Motta T, Benigno GD, Delsante M, Fiaccadori E, Di Mario F. Treatment of dabigatran intoxication in critically ill patients with Acute Kidney Injury: The role of Sustained Low-Efficiency Dialysis. Int J Artif Organs 2023; 46:574-580. [PMID: 37853619 DOI: 10.1177/03913988231204516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
The use of dabigatran in patients with non-valvular atrial fibrillation (AF) has widely increased in the last decades, due to its positive effects in terms of safety/efficacy. However, because of the risk of major bleeding, a great degree of attention has been suggested in elderly patients with multiple comorbidities. Notably, dabigatran mainly undergoes renal elimination and dose adjustment is recommended in patients with Chronic Kidney Disease (CKD). In this regard, the onset of an abrupt decrease of kidney function may further affect dabigatran pharmacokinetic profile, increasing the risk of acute intoxication. Idarucizumab is the approved antagonist in the case of dabigatran-associated major bleeding or concomitant need of urgent surgery, but its clinical use is limited by the lack of data in patients with Acute Kidney Injury (AKI). Thus, the early start of Extracorporeal Kidney Replacement Therapy (EKRT) could be indicated to remove the drug and to reverse the associated excess anticoagulation. Sustained Low-Efficiency Dialysis (SLED) could represent an effective therapeutic option to reduce the dabigatran plasma levels rapidly while avoiding post-treatment rebound. We present here a case series of three AKI patients with acute dabigatran intoxication, effectively and safely resolved with a single SLED session.
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Affiliation(s)
- Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Tommaso Di Motta
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Daniele Benigno
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Marco Delsante
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
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Sánchez-González C, Herrero Calvo JA. Nonvalvular atrial fibrillation in patients undergoing chronic hemodialysis. Should dialysis patients with atrial fibrillation receive oral anticoagulation? Nefrologia 2022; 42:633-644. [PMID: 36907719 DOI: 10.1016/j.nefroe.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 06/18/2023] Open
Abstract
Chronic kidney disease (CKD) is an independent risk factor for presenting atrial fibrillation (AF), which conditions an increased risk already present in CKD of suffering a thromboembolic event. And this risk is even higher in the hemodialysis (HD) population. On the other hand, in CKD patients and even more so in HD patients, the probability of suffering serious bleeding is also higher. Therefore, there is no consensus on whether or not to anticoagulate this population. Taking as a model what is advised for the general population, the most common attitude among nephrologists has been to opt for anticoagulation, even though there is no randomized studies to support it. Classically, anticoagulation has been done with vitamin K antagonists, at high cost for our patients: severe bleeding events, vascular calcification, and progression of nephropathy, among other complications. With the emergence of direct-acting anticoagulants, a hopeful outlook was opened in the field of anticoagulation, as they were postulated as more effective and safer drugs than antivitamin K. However, in clinical practice, this has not been the case. In this paper we review various aspects of AF and its anticoagulant treatment in the HD population.
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Fibrilación auricular no valvular en pacientes en hemodiálisis crónica. ¿Debemos anticoagular? Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Athavale A, Jamshidi N, Roberts DM. Incomplete responses to the recommended dose of idarucizumab: a systematic review and pharmacokinetic analysis. Clin Toxicol (Phila) 2020; 58:789-800. [DOI: 10.1080/15563650.2020.1743846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Akshay Athavale
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nazila Jamshidi
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Sydney, Australia
- Department of Renal Medicine and Transplantation, St. Vincent’s Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Zanetto A, Senzolo M, Blasi A. Perioperative management of antithrombotic treatment. Best Pract Res Clin Anaesthesiol 2020; 34:35-50. [PMID: 32334786 DOI: 10.1016/j.bpa.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 01/10/2023]
Abstract
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain.
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Zhang C, Zhang P, Li H, Han L, Zhang L, Zhang L, Yang X. The effect of dabigatran on thrombin generation and coagulation assays in rabbit and human plasma. Thromb Res 2018; 165:38-43. [DOI: 10.1016/j.thromres.2018.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/10/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
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Yip L, Deng JF. Idarucizumab Dosing in Kidney Failure. Am J Kidney Dis 2018; 71:146. [DOI: 10.1053/j.ajkd.2017.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/23/2017] [Indexed: 11/11/2022]
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Novak JE, Alamiri K, Yee J. In Reply to ‘Idarucizumab Dosing in Kidney Failure’. Am J Kidney Dis 2018; 71:146-147. [DOI: 10.1053/j.ajkd.2017.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 08/29/2017] [Indexed: 11/11/2022]
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Yip L, Deng JF. The recommended dose of idarucizumab may not always be sufficient for sustained reversal of dabigatran: comment. J Thromb Haemost 2017; 15:2466-2467. [PMID: 28976628 DOI: 10.1111/jth.13854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Indexed: 11/29/2022]
Affiliation(s)
- L Yip
- Department of Medicine - Section of Medical Toxicology, Denver Health, Rocky Mountain Poison and Drug Center, Denver, CO, USA
| | - J-F Deng
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Hutcherson TC, Cieri-Hutcherson NE, Bhatt R. Evidence for Idarucizumab (Praxbind) in the Reversal Of the Direct Thrombin Inhibitor Dabigatran: Review Following the RE-VERSE AD Full Cohort Analysis. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:692-698. [PMID: 29089725 PMCID: PMC5642158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Idarucizumab is the first reversal agent approved for the direct thrombin inhibitor dabigatran. The authors summarize the findings from the clinical trial series and describe case reports, post-marketing data, and ongoing studies.
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