Anticoagulant-related nephropathy: a case report and review of the literature of an increasingly recognized entity

Abstract

Treatment with oral anticoagulants has been associated with worsening kidney function in patients with chronic kidney disease (CKD) as well as among patients without underlying CKD. Thus, anticoagulant-related nephropathy (ARN) is an increasingly recognized entity nowadays, mainly associated with warfarin anticoagulation. Recent evidence indicates that patients treated with the direct anticoagulants may also be at risk of ARN. However, the true incidence of anticoagulant-related nephropathy is difficult to determine. The typical histological lesion involves renal tubular occlusion by red blood cells (RBCs), tubular red blood cell casts on light microscopy and dysmorphic RBCs in the glomerulus on electron microscopy. In the absence of active glomerulonephritis or other inflammatory changes that could account for glomerular hemorrhage, the above findings confirm the diagnosis. Dabigatran etexilate was the first direct oral anticoagulant approved for stroke prevention in patients with non-valvular atrial fibrillation. In this article, we describe a rare case of dabigatran etexilate-induced nephropathy in a patient with preexisting IgA nephropathy and review the recent literature regarding this increasingly recognized entity.

Anticoagulating atrial fibrillation patients: is there a kidney-friendly choice?

“…Co-occurrence of WRN with diverse glomerular diseases, including lupus nephritis, IgA nephropathy, and thin basement membrane disease were also described in case reports. Similar pathologic findings were reported in two cases of dabigatran administration with coexisting IgA nephropathy (19,20). Two retrospective studies in the United States and Korea enrolled patients with excessive anticoagulation (INR >3), 20% of which experienced AKI, defined by the Acute Kidney Injury Network (AKIN) criteria.…”

Dabigatran-Induced Acute Interstitial Nephritis: An Important Complication of Newer Oral Anticoagulation Agents

“…There have been a few case reports of acute kidney injury observed in patients being treated with dabigatran [ 6 , 9 , 10 , 12 ]. In a case described by Escoli et al, the patient presented with acute kidney injury 2 weeks after starting dabigatran, and the patient needed to start on hemodialysis due to progressive deterioration of renal function [ 10 ].…”

“…In a case described by Escoli et al, the patient presented with acute kidney injury 2 weeks after starting dabigatran, and the patient needed to start on hemodialysis due to progressive deterioration of renal function [ 10 ]. In another case report by Kalaitzidis et al, patient developed dabigatran-induced nephropathy within a few days of starting dabigatran; however, AKI improved after stopping dabigatran only [ 12 ]. Similar to our patient, both of the patients had underlying renal disease, one had previously diagnosed glomerular disease and other had IgA nephropathy suggesting that pre-existing renal compromise may contribute to renal failure with anticoagulation therapy, especially dabigatran [ 6 , 9 , 10 , 12 - 14 ].…”

“…In another case report by Kalaitzidis et al, patient developed dabigatran-induced nephropathy within a few days of starting dabigatran; however, AKI improved after stopping dabigatran only [ 12 ]. Similar to our patient, both of the patients had underlying renal disease, one had previously diagnosed glomerular disease and other had IgA nephropathy suggesting that pre-existing renal compromise may contribute to renal failure with anticoagulation therapy, especially dabigatran [ 6 , 9 , 10 , 12 - 14 ]. Renal biopsy in the reported cases revealed large intratubular red blood cell (RBC) casts with tubular necrosis and interstitial hemorrhage [ 10 , 14 ].…”

Anticoagulant-Related Nephropathy

“…It occurs in patients receiving oral anticoagulant therapy, namely warfarin 1,2 or a novel oral anticoagulant (NOAC; either a direct thrombin inhibitor or a factor Xa inhibitor). [3][4][5][6][7][8] The first reports of ARN involved two unrelated cases in which the patients experienced unexplained AKI and gross hematuria while receiving warfarin. After reversal of their international normalized ratio (INR), which was in the INR56-9 range at presentation, the patients underwent renal biopsy, which showed unexplained profuse glomerular hemorrhage.…”