Abstract: SA-PO283
Novel Oral Anticoagulant and AKI: Apixaban Induced Acute Interstitial Nephritis
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Dimaria, Christina, Einstein Medical Center, Cherry Hill, New Jersey, United States
- Hanna, Wael A., Lehigh Valley Hospital, Breinigsville, Pennsylvania, United States
- Mcenroe, Damon J., Lehigh Valley Health Network, Allentown, Pennsylvania, United States
- Reichart, James P., Valley Kidney Specialists, Macungie, Pennsylvania, United States
Introduction
Novel Oral AntiCoagulants (NOACs) are changing the landscape of clinical practice for patients requiring short and long term anticoagulation. This case presentation of Apixaban-induced acute interstitial nephritis (AIN) shows a side effect of an increasingly common medication.
Case Description
A 70 year-old male with PMH of HTN, CHF, Atrial Fibrillation presented with a 2-month history of fatigue and intermittent hematuria. Home medications were Apixaban, Amlodipine, Epleronone, Cholecaliferol, Dofetilide, Metoprolol, and Rosuvastatin. He denied NSAID or PPI use. Physical exam showed normal vitals with trace edema and no rash.
Laboratory studies showed S Cr of 2.6 mg/dL (baseline 0.90 mg/dL). Renal US showed no hydronephrosis or stones. Urinalysis showed 11-20 WBC, 100 RBC/hpf with urine protein:creatinine ratio of 0.57 g/g. ANA, ANCA, C3, C4 and SPEP were negative.
While holding Apixaban for a renal biopsy, S Cr trended down to 2.2 mg/dL. Renal biopsy showed acute tubulointerstitial nephritis with eosinophilic component. The immunofluorescence microscopy displayed weak mesangial granular staining with IgA and glomerular tuft staining with C3 suggestive of IgA nephropathy.
He received Prednisone 60 mg daily for two weeks with a taper. Apixaban was restarted and the patient's S Cr increased to 3.8 mg/dL. Apixaban was discontinued and Warfarin was started. S Cr improved slowly to 1.3 mg/dL and his hematuria improved to microscopic hematuria over a 4-month period.
Discussion
Oral anticoagulant can cause AKI by inducing glomerular hematuria or rarely AIN. Our patient had IgA nephropathy which can explain his persistent microhematuria while on the anticoagulants. The biopsy results and the patient’s clinical improvement substantiate the diagnosis. Given the increasing use of Apixaban, it is worth recognizing that it can cause AIN at any time. To the best of our knowledge, there are only two reported biopsy proven cases of Apixaban induced AIN.