Spontaneous renal subcapsular hematoma in a very old patient presenting with shock and severe anemia: An uncommon oral anticoagulant treatment‐related complication

Abstract

Dear Editor,Bleeding represents the most feared complication of oral anticoagulant therapy (OAT) with vitamin K antagonists (VKA), one of the major classes of drugs used in cardiovascular medicine. Of the general population in developed countries, 1-1.5% is subject to OAT, 1 with widespread use over the last two decades. 2,3 Elderly patients represent the main group of patients treated with OAT, with a high prevalence in this group of diseases needing OAT, such as atrial fibrillation. 4 But advanced age also represents one of the main risk factors for VKA-related bleeding, together with severe liver and kidney diseases, severe thrombocytopenia, history of previous bleeding, anemia, dementia and risk of falls. 5 The incidence rate of major hemorrhage rises gradually with age from 1.5 per 100 patient-years for patients younger than 60 years to 4.2 per 100 patientyears for patients older than 80 years, yielding a hazard ratio of 2.7 (95% confidence interval, 1.7-4.4). 6 Bleeding is classified as major if it leads directly to death, it occurs in critical organs (brain, retroperitoneum, peritoneum, chest, spinal cord, joints, gastrointestinal tract), if it results in hemorrhagic shock, a decrease of 2 g/dL in hemoglobin (Hb) levels, or if it requires surgical or invasive maneuvers. The remaining bleedings are classified as minor bleedings. 7 Spontaneous and/or traumatic retroperitoneal bleedings represents a well-recognized OAT-related major complication, often related to a rupture of the iliopsoas muscle, whereas spontaneous renal hematoma (SRH) is a very uncommon example of OAT-related bleeding, diagnosis of it being often difficult and late, especially when signs such as macrohematuria are absent. Prothrombin complex concentrate (PCC) is now considered the first choice for urgent OAT reversal together with intravenous vitamin K1 (VK1) in VKA-related major bleedings. 8 The cornerstone of OAT reversal is bringing the International Normalized Ratio (INR) to a value less than 1.5, to restore normal coagulation, in association with maneuvers to stop bleedings and/or resolve hemorrhagic shock. 9,10 Recently, an 86-year-old man taking warfarin for chronic atrial fibrillation came to our attention for the abrupt onset of dyspnea and fatigue; he suffered from left sciatica for 3 days and left lumbar pain for a few hours. He denied fever, and macrohematuria was absent. Recent trauma was excluded.His past history revealed previous coronary artery bypass and prostatic cancer. Physical examination showed pallor and sweating. Systemic blood pressure (SBP) measured 75/50 mmHg, demonstrating a status of shock. Blood arterial gas analysis was substantially normal. A 12-lead electrocardiogram (ECG) revealed tachycardic atrial fibrillation (120 beats per minute) and complete right bundle branch block. Chest and abdominal radiographs and abdominal ultrasonography performed in the emergency department were unremarkable. Results of laboratory assays showed Hb levels of 10.6 g/dL, creatinine 1.41 mg/dL, normal values of brain natriuretic...

A spontaneous renal subcapsular hematoma case due to uncontrolled hipertension and anticoagulant therapy

“…Bu uygulamanın yan etkilerinden biri de çeşitli organ veya boşluklar içine (retroperitoneal, intraspinal, pulmoner, plevral, mediastinal, hepatik vs) kendiliğinden oluşabilen kanama olarak bildirilmiştir (16). Olgumuzda izlenen hematomun kullandığı uzun süreli antikoagülan tedavisine bağlı olabileceği düşünülerek klinik olarak daha güvenli düşük molekül ağırlıklı heparin tedavisine geçilmesi tedavinin bir parçasıdır.…”