Dabigatran causing severe acute kidney injury in a patient with liver cirrhosis

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.

IgA Nephropathy Is the Most Common Underlying Disease in Patients With Anticoagulant-Related Nephropathy

“…We found 3 case series ( n = 63) 1 , 3 , 4 and 29 case reports describing histologic findings in patients with ARN. 2 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 Of 92 cases, 37 (40%) were compatible with IgAN. The main characteristics and outcomes of patients with ARN and IgAN available in the literature are summarized in Supplementary Table S1 .…”

“…We used the search terms “anticoagulant-related nephropathy,” “warfarin-related nephropathy,” “hematuria and anticoagulant treatment,” “IgA nephropathy and anticoagulation,” OR “acute kidney injury” in combination with the terms “anticoagulation,” OR “anticoagulant therapy,” OR “anticoagulant treatment,” OR “warfarin,” OR “vitamin K antagonists,” OR “novel oral anticoagulants,” OR “hematuria,” OR “gross hematuria,” OR “macrohematuria.” Only English language papers were reviewed. This search revealed 3 case series 1 , 3 , 4 and 29 case reports, 2 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 comprising a total of 92 further cases of adult patients with biopsy-proven ARN.…”

Anticoagulant-Related Nephropathy in Kidney Biopsy: A Single-Center Report of 41 Cases

“…Accordingly, the term "anticoagulant-related nephropathy" (ARN) is preferred. Since the seminal report of pathologic features of warfarin-related nephropathy, 1 several investigators published case reports and retrospective studies showing AKI in association with different anticoagulants, including multiple case reports and case series that describe warfarin-related nephropathy, [7][8][9][10][11][12] case reports of dabigatran-associated AKI, [13][14][15][16][17] a case report of AKI in a patient with thrombocytopenia, 18 and a case of biopsy-proven ARN in a patient receiving antiplatelet medications. 19 Given the existing data for this newly described entity and the presence of multiple causes for anticoagulation, we explored our database of existing kidney biopsies since our initial description of ARN to describe ARN with additional details, including agents that may predispose to this unusual cause of AKI.…”

“…Accordingly, the term “anticoagulant-related nephropathy” (ARN) is preferred. Since the seminal report of pathologic features of warfarin-related nephropathy, 1 several investigators published case reports and retrospective studies showing AKI in association with different anticoagulants, including multiple case reports and case series that describe warfarin-related nephropathy, 7 , 8 , 9 , 10 , 11 , 12 case reports of dabigatran-associated AKI, 13 , 14 , 15 , 16 , 17 a case report of AKI in a patient with thrombocytopenia, 18 and a case of biopsy-proven ARN in a patient receiving antiplatelet medications. 19…”

Acute Kidney Injury due to Anticoagulant-Related Nephropathy : A Suggestion for Therapy

“…ree patients needed RRT, with only two patients with eventually full recovery of renal function. Among patients conservatively treated, sCr returned to the baseline value in three patients only [10,11,[16][17][18][19][20][21]. In the contest of overanticoagulation in a subject on NOAC, haematuria suggests that ARN should be taken into account in differential diagnosis; renal biopsy plays a crucial role in this field.…”