scholarly journals Management of Anticoagulant-Related Nephropathy: A Single Center Experience

2021 ◽  
Vol 10 (4) ◽  
pp. 796
Author(s):  
Tanja Belčič Mikič ◽  
Nika Kojc ◽  
Maja Frelih ◽  
Andreja Aleš-Rigler ◽  
Željka Večerić-Haler
Keyword(s):  
Renal Function ◽  
World Literature ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Kidney Injury ◽  
Positive Influence ◽  
Glomerular Injury ◽  
First Case ◽  
Pubmed Database ◽  
Excessive Anticoagulation

Background: Anticoagulant-related nephropathy (ARN) is a form of acute kidney injury that mainly occurs in patients with previously unrecognized glomerular disease in addition to excessive anticoagulation. Since a renal biopsy is not performed in most cases, the diagnosis is often presumptive. Methods: Here, we present the characteristics of a national Slovenian patient cohort with histologically verified ARN, from the first case in 2014 to December 2020, and a review of the current literature (Pubmed database). Results: In Slovenia, ARN has been detected in 13 patients, seven of whom were treated with coumarins, and others with direct oral anticoagulants. In seven patients, ARN appeared after excessive anticoagulation. As many as 11 patients had underlying IgA nephropathy. Similar to the global data presented here, the pathohistological impairment associated with pre-existing glomerulopathy was mild and disproportionate to the degree of functional renal impairment. The majority of our patients with ARN experienced severe deterioration of renal function associated with histological signs of accompanying acute tubular injury, interstitial edema, and occlusive red blood cell casts. These patients were treated with corticosteroids, which (in addition to supportive treatment and discontinuation of the anticoagulant drug) led to a further improvement in renal function. Conclusions: Anticoagulant therapy combined with a pre-existing glomerular injury may lead to ARN. In addition to discontinuation of the anticoagulant and supportive care, corticosteroids, which are currently listed in only a few cases in the world literature, may have a positive influence on the course of treatment. However, the benefits of steroid treatment must be weighed against the risk of complications, especially life-threatening infections.

MO168MANAGEMENT OF ANTICOAGULANT RELATED NEPHROPATHY: SLOVENIAN CASE SERIES AND REVIEW OF CURRENT KNOWLEDGE

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Željka Večerić-Haler ◽  
Tanja Belčič Mikič ◽  
Nika Kojc ◽  
Maja Frelih ◽  
Andreja Ales Rigler
Keyword(s):  
Renal Function ◽  
Current Knowledge ◽  
Treated Patient ◽  
Case Reports ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Case Series ◽  
Kidney Injury ◽  
First Case ◽  
Excessive Anticoagulation

Abstract Background and Aims Anticoagulant-related nephropathy is a recently recognized form of acute kidney injury associated with previously underdiagnosed kidney damage in addition to (usually) excessive anticoagulation. It occurs in patients receiving warfarin as well as those receiving direct oral anticoagulants. Method We collected and analyzed cases of Slovenian patients with pathohistologically documented anticoagulant-related nephropathy associated with all types of anticoagulant treatment from the first case in 2014 to 2020. We also performed an analysis of previously documented cases of anticoagulant-related nephropathy in the global literature (PubMed) in the period from their first mention until recently. Results In Slovenia, 13 patients with anticoagulant-related nephropathy have been histologically verified so far. All patients were diagnosed with concomitant underlying renal disease, and 80% had IgA nephropathy, which was disproportionately mild according to the degree of renal function impairment. After supportive measures and reversal of excessive anticoagulation, 8 of 13 patients were further treated with corticosteroids, resulting in significant improvement in renal function. During the follow-up period, a total of one steroid-treated patient died due to infectious complications and one patient progressed to end-stage renal failure. In the worldwide literature, we found 46 case reports or case series of patients with anticoagulant-related nephropathy. Failure of restitution of renal function with the need for maintenance dialysis was reported much more frequently compared to the results of our cohort (up to 67% vs. 8.3%) Conclusion To our knowledge, the Slovenian cohort of patients with histologically established anticoagulant-related nephropathy is the largest reported series to date that received corticosteroid therapy in addition to conservative measures. Our results indicate that steroids have a beneficial effect, likely exerted via suppression of hemoglobin-associated oxidative stress and inflammation. However, considering the polimorbidity of these patients, the benefit of additional steroid therapy must be weighed against the potential risks of side effects, especially life-threatening infections.

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

2020 ◽  
Vol 2020 ◽  
pp. 1-5 ◽  
Author(s):  
Letizia Zeni ◽  
Chiara Manenti ◽  
Simona Fisogni ◽  
Vincenzo Terlizzi ◽  
Federica Verzeletti ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Kidney Injury ◽  
Cast Nephropathy ◽  
Anca Associated Vasculitis ◽  
A Prospective Study ◽  
The Relationship ◽  
Gross Haematuria ◽  
Strong Suspicion

The relationship between kidneys and anticoagulation is complex, especially after introduction of the direct oral anticoagulants (DOAC). It is recently growing evidence of an anticoagulant-related nephropathy (ARN), a form of acute kidney injury caused by excessive anticoagulation. The pathogenesis of kidney damage in this setting is multifactorial, and nowadays, there is no established treatment. We describe a case of ARN, admitted to our Nephrology Unit with a strong suspicion of ANCA-associated vasculitis due to gross haematuria and haemoptysis; the patient was being given dabigatran. Renal biopsy excluded ANCA-associated vasculitis and diagnosed a red blood cell cast nephropathy superimposed to an underlying IgA nephropathy. Several mechanisms are possibly responsible for kidney injury in ARN: tubular obstruction, cytotoxicity of heme-containing molecules and free iron, and activation of proinflammatory/profibrotic cytokines. Therefore, the patient was given a multilevel strategy of treatment. A combination of reversal of coagulopathy (i.e., withdrawal of dabigatran and infusion of its specific antidote) along with administration of fluids, sodium bicarbonate, steroids, and mannitol resulted in conservative management of AKI and fast recovery of renal function. This observation could suggest a prospective study aiming to find the best therapy of ARN.

scholarly journals 1543. Ceftaroline Model-based Dose Individualization in an Infant with Kidney Disease and Mediastinitis

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S563-S563
Author(s):  
Mark Murphy ◽  
Sonya Tang-Girdwood ◽  
Peter Tang ◽  
Brady C Rebecca ◽  
Tomoyuki Mizuno ◽  
...  
Keyword(s):  
Renal Function ◽  
Kidney Disease ◽  
Renal Dysfunction ◽  
Drug Exposure ◽  
Kidney Injury ◽  
Dosing Regimen ◽  
Dose Individualization ◽  
Model Based ◽  
First Case ◽  
High Concentrations

Abstract Background Options for the treatment of infections caused by resistant gram-positive bacteria are limited in children with kidney disease. Ceftaroline (CFD) may be an attractive option but dosing recommendations are not available for children with renal dysfunction. We present a case of pharmacokinetics (PK) model-based individualization of CFD in an infant with kidney disease and mediastinitis. A 5-week-old infant with a hypoplastic left side of the heart developed mediastinitis following a Norwood and BT shunt. Blood and chest washout cultures grew S. epidermidis. Vancomycin therapy led to acute kidney injury (AKI) (eGFR ~15mL/minute) and therefore, CFD was initiated at 8 mg/kg every 12 hours. The model-based clinical service was consulted to assist with dosing. Methods Plasma levels were drawn on day 2 and 10 of CFD. CFD concentrations were determined by HPLC. The pharmacodynamic (PD) target used the MIC of the isolate, 1 µg/mL, and assumed drug diffusion into the mediastinum at 20% of plasma. The PD target was ƒT>MIC at 100%. Individual PK parameters were estimated using Bayesian estimation with MWPharm++ (Mediware, the Netherlands). Results CFD dosing of 8 mg/kg every 12 hours resulted in concentrations well above the target. The trough level was 10 times higher than levels seen in clinical trials. Repeat levels were checked on day 10 due to improved renal function (eGFR 30 mL/minute) and changes in volume status. Changes in both clearance and volume were noted. ƒT>MIC was maintained 100% during dosing intervals. We dose optimized CFD to achieve the target while minimizing potential toxicity with long-term use. A new dosing regimen, 5.4 mg/kg every 8 hours, was started on day 12 and continued for 6 weeks. Conclusion This is the first case report of CFD use in a child with AKI. Though initial dosing resulted in high concentrations, no adverse effects were noted. Successful treatment was completed with a final dosing regimen of 5.3 mg/kg every 8 hours, below the recommended 8 mg/kg every 8 hours. Lower dosing was needed to decrease high drug exposure due to the decreased clearance. This case also demonstrated the feasibility of PK model-based precision dosing within 48 hours, and documented utility in the setting of changes in renal function. Further PK/PD studies are needed in children with renal dysfunction. Disclosures All authors: No reported disclosures.

scholarly journals 122 Are We Effective Prescribers? A Retrospective Audit of DOAC Prescribing Post Embolic Stroke for Non Valvular Atrial Fibrillation

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Karen Dennehy ◽  
Joseph Morris ◽  
Diarmaid Hughes ◽  
Kate Donlon ◽  
Thomas Walsh
Keyword(s):  
Atrial Fibrillation ◽  
Renal Function ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Embolic Stroke ◽  
Haemorrhagic Transformation ◽  
Retrospective Audit ◽  
Online Laboratory ◽  
Number Of Patients

Abstract Background Direct oral anticoagulants (DOAC) are indicated for stroke prophylaxis in non-valvular atrial fibrillation, which is responsible for up to 20% of all ischaemic strokes(1). We performed a retrospective audit of all consecutive stroke patients in an Irish teaching hospital over a 1-year period to investigate the rate of incorrect dosing and any risk factors for this occurring. Methods We assessed our hospital stroke database from January to December 2017. Our research focused on DOAC prescribing in non valvular atrial fibrillation post embolic stroke. We collected data on baseline characteristics, choice of anticoagulation, dosing, and assessment of renal function, with follow up renal function if available. We reviewed electronic discharge summaries, online laboratory systems and completed a chart review. Results There was a total of 116 people with atrial fibrillation who developed an embolic stroke in our centre, of which 68 were eligible for anticoagulation using a DOAC (59). The main reasons for omission were CKD and haemorrhagic transformation. Patients were discharged on either Apixaban (32 patients), Rivaroxoban (32 patients), or Dabigatran (4 patients). Following our review, we established that 54/68 (79%) of patients were correctly anticoagulated. Over 20% of patients were incorrectly dosed and there was a clear tendency to under-dose 13/14 (93%). There were significant differences between the correct and incorrect dosing groups, with the latter group of patients being older and more at risk of polypharmacy. Renal function did not differ significantly between the groups at discharge or follow up and none of the incorrectly dosed patients were on a concurrent anti platelet. Conclusion A significant number of patients prescribed DOAC in hospital were not appropriately anticoagulated (21%), a majority of which were under-dosed. The patients who were under-dosed were older and more likely to be on 5 or more medications.

scholarly journals Rivaroxaban-related acute kidney injury in a patient with IgA vasculitis

2019 ◽  
Vol 12 (1) ◽  
pp. e227756 ◽  
Author(s):  
Yoshihiko Fujino ◽  
Chisato Takahashi ◽  
Kensuke Mitsumoto ◽  
Takashi Uzu
Keyword(s):  
Atrial Fibrillation ◽  
Acute Kidney Injury ◽  
Renal Function ◽  
Systemic Vasculitis ◽  
Kidney Injury ◽  
Close Monitoring ◽  
Iga Vasculitis ◽  
Direct Oral Anticoagulant ◽  
Macroscopic Haematuria ◽  
First Case

Anticoagulants have recently been recognised as a cause of acute kidney injury (AKI). We describe the case of a 75-year-old man with IgA vasculitis and atrial fibrillation treated with rivaroxaban, who presented with macroscopic haematuria and an acute decline in renal function. Two months before referral, he noted palpable purpuric lesions and was diagnosed with IgA vasculitis based on skin biopsy findings; the skin lesion disappeared following treatment with a steroid external preparation. Renal biopsy revealed glomerular haemorrhage and red blood cell casts. Although rivaroxaban was withdrawn, his kidney function worsened and he was started on haemodialysis. His renal function did not recover. To the best of our knowledge, this is the first case of direct oral anticoagulant (DOAC)-related AKI in systemic vasculitis. During DOAC therapy, close monitoring of a patient’s urinalysis results and their renal function may be required for patients with systemic vasculitis to avoid AKI.

scholarly journals A Survey on the Awareness and Attitude of Physicians on Direct Oral Anticoagulants in Qatar

2018 ◽  
Vol 24 (9_suppl) ◽  
pp. 255S-260S ◽  
Author(s):  
Ahmed El-Bardissy ◽  
Hazem Elewa ◽  
Shaban Mohammed ◽  
Ahmed Shible ◽  
Rizwan Imanullah ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Inappropriate Prescribing ◽  
Positive Influence ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Professional Characteristics ◽  
Education Campaigns ◽  
Future Work ◽  
Significant Positive Influence

Direct oral anticoagulants (DOACs) are more commonly prescribed since their introduction. Reports on inappropriate prescribing have been observed which may indicate poor awareness on these agents. In this study, we aim to evaluate the extent of the physicians’ knowledge on DOACs and its possible impact on physicians’ confidence to prescribe these medications. A prospective cross-sectional survey was developed based on the literature review. Eligible participants were physicians and surgeons currently practicing at Hamad General Hospital in Qatar. The survey included questions on demographic and professional characteristics. It also evaluated the awareness and attitudes regarding safety, efficacy, and prescribing of DOACs. Over 6-month period, 175 practitioners responded to the survey. Overall awareness score was moderate (61% ± 18%). These scores were in alignment with participants’ self-satisfaction with knowledge on DOACs (66% were not satisfied) and participants’ confidence toward prescribing DOACs (48% were not confident). Age, degree of education, and years of experience had significant positive influence on awareness score. This survey indicates that practitioners have moderate awareness on DOACs. Future work should focus on reassessing practitioners’ knowledge after providing well-designed education campaigns

A second administration of glucarpidase in a different cycle of high-dose methotrexate: Is it safe and effective in adults?

2020 ◽  
pp. 107815522094646 ◽  
Author(s):  
Amalia Domingo-González ◽  
Santiago Osorio ◽  
Elena Landete ◽  
Silvia Monsalvo ◽  
Jose L. Díez-Martín
Keyword(s):  
Renal Function ◽  
Case Report ◽  
Adverse Events ◽  
Kidney Injury ◽  
High Dose ◽  
High Dose Methotrexate ◽  
Dose Methotrexate ◽  
First Case ◽  
Methotrexate Concentration ◽  
Unknown Area

Introduction Methotrexate intoxication following high-dose methotrexate-induced acute kidney injury is a life-threatening complication. Glucarpidase can quickly reduce extracellular methotrexate to safe levels, but the effectiveness and safety of its use in different episodes of nephrotoxicity remain an unknown area. Case Report A 30-year-old male diagnosed with acute lymphoblastic T-cell lymphoma received methotrexate 5 g/m2 intravenous (IV) as part of the first consolidation cycle. On Consolidation 3, he restarted methotrexate at a dose of 3 g/m2 IV showing slow methotrexate elimination, associated myelosuppression, and hepatic toxicity. Glucarpidase was administered (total dose of 2000 International Units (IU)). No adverse events were observed, and his renal function returned to normal. One hundred and six days later, he was diagnosed with leptomeningeal and cerebellar relapse and treatment with methotrexate 3,5 g/m2 IV day 1 and cytosine arabinoside (Ara-C) 2 g/m2 IV twice per day days 1, 3, and 5 was started. At 36 h from methotrexate infusion, serum creatinine increased up to 1.89 mg/dL and methotrexate concentration was 100 µmol/L. Management and Outcome: Ara-C was suspended, and a second administration of glucarpidase (2000 IU) was dispensed. No adverse events were noticed, methotrexate levels decreased and renal function progressively improved, recovering completely three weeks later. Discussion The effectiveness and safety of the use of glucarpidase in different episodes of nephrotoxicity remain an unknown area, and the rate and consequences of antiglucarpidase antibody formation remain poorly understood. This case report is, to our knowledge, the first case of a second administration of glucarpidase in a different cycle of high-dose methotrexate in an adult patient.

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