My Bleeding Nephrons!

Abstract

Anticoagulation-related nephropathy (ARN) is an uncommon diagnosis that should be considered in patients presenting with unexplained acute kidney injury (AKI) and coagulopathy. In this article, we present the case of a 70-year-old male with a history of cirrhosis and portal vein thrombosis on Coumadin who presented to the hospital with gross hematuria. The patient was diagnosed with AKI on chronic kidney disease (CKD) secondary to ARN superimposed on sclerosing IgA nephropathy. ARN, also known as warfarin-associated nephropathy, is an uncommon condition in which AKI from glomerular hemorrhage develops in a patient with an international normalized ratio greater than 3. The most common risk factor for development of ARN is CKD. AKI in our patient unearthed preexisting CKD due to IgA nephropathy as evidenced by the biopsy.

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 .…”

“…To the best of our knowledge, at the present time, only 3 case series ( n = 63) 1 , 3 , 4 and 29 case reports have described histologic information on 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 note, 37 of 92 (40%) cases were compatible with IgAN, comprising by far the most common underlying kidney disease associated to ARN. Moreover, in the largest series published to date of biopsy-proven ARN, IgA-predominant immune complexes in the glomeruli were observed in 34% of the patients (without specifying how many of them met IgAN criteria), representing the most frequent histologic lesion in kidney biopsies.…”

“…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.…”

Calciphylaxis in the Setting of Hemodialysis, Liver Cirrhosis, and Warfarin Therapy for Atrial Fibrillation: An Argument for Alternative Anti-Embolic Therapy

“…If it is deemed appropriate to use OAT in these patients, direct oral anticoagulants (DOACs) should generally be favored over warfarin therapy. Warfarin therapy is challenging in patients with renal disease as it can increase the risk of vascular calcification and cause acute kidney injury secondary to anticoagulant-related nephropathy (ARN) or warfarin-related nephropathy (WRN) [18]. In high-risk patients with non-valvular AF who are in need of an alternative to long-term OAT, an FDA-approved left atrial appendage (LAA) closure device, also called a WATCHMAN device, is a possible option for stroke risk reduction and should be considered ( Figure 5) [17,[19][20].…”