Dabigatran-induced anticoagulant-related nephropathy with undiagnosed IgA nephropathy in a patient with normal baseline renal function

Abstract

Occasionally, over-anticoagulation with warfarin induces acute kidney injury (AKI) characterized by glomerular hemorrhage with tubular obstruction by red blood cell casts, which is widely acknowledged as warfarin-related nephropathy. Owing to extensive use of direct oral anticoagulants, similar AKI cases have been reported among patients treated with dabigatran. Dabigatran is primarily excreted by the kidneys; thus, renal impairment is one of the risk factors for dabigatran-induced bleeding complications. Nevertheless, risk factors for dabigatran-induced anticoagulant-related nephropathy (ARN) remain partially clarified. Here, we report a histologically established case of dabigatran-induced ARN with undiagnosed IgA nephropathy in a patient with normal baseline renal function. In addition, we summarize previously published cases of biopsyproven, dabigatran-related ARN. A 67-year-old female with normal preexisting renal function developed macrohematuria and AKI. She had been treated with dabigatran for deep vein thrombosis. A renal biopsy diagnosed ARN with inactive IgA nephropathy. After dabigatran withdrawal, her macrohematuria and renal function improved. This report demonstrates that ARN could occur in patients with normal baseline renal function. Our case and prior reports suggest that IgA nephropathy could be a risk factor for dabigatran-induced ARN.

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.…”

The Risk of Acute Kidney Injury with Oral Anticoagulants in Elderly Adults with Atrial Fibrillation

“…Anticoagulant-related nephropathy was first described in warfarin users and manifests by glomerular hemorrhage and tubular obstruction (1,2). Subsequent reports of anticoagulant-related nephropathy have documented similar pathologic findings among direct oral anticoagulant (DOAC) users, despite a putatively lower risk of bleeding compared with warfarin (3)(4)(5)(6).…”

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.…”