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Kidney Week

Abstract: PO0118

Rivaroxaban-Induced Anticoagulant-Related Nephropathy

Session Information

Category: Trainee Case Report

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Neelam Raju, Bharat, TriHealth, Cincinnati, Ohio, United States
  • Ali, Birmaji, TriHealth, Cincinnati, Ohio, United States
  • Namdarizandi, Vahid, TriHealth, Cincinnati, Ohio, United States
  • Abdul-Massih, Cesar Elias, TriHealth, Cincinnati, Ohio, United States
  • Rajput, Amit K., TriHealth, Cincinnati, Ohio, United States
Introduction

Anticoagulant-related nephropathy (ARN) is a rare and newly recognized cause of acute renal failure (ARF). A lack of serologic studies and hesitancy to perform high risk biopsies due to concerns for thrombosis or hemorrhage, make ARN a challenging diagnosis. The pathophysiology is believed to be from diffuse glomerular hemorrhage which manifests as numerous RBC casts. These RBC casts obstruct and damage tubular epithelial cells resulting in renal failure. We will examine a case of ARN.

Case Description

An 83-year-old Caucasian female presented with complaints of lower extremity weakness and was found to have ARF on laboratory investigation (Cr 5.18mg/dL from 1.1mg/dL one month prior). The patient was recently started on rivaroxaban after being diagnosed with a stroke caused by atrial fibrillation. The patient was admitted for evaluation and management of oliguric ARF, requiring the initiation of HD. Initial evaluation was significant for uncontrolled hypertension, 1+ pitting bilateral lower extremity edema, hypoalbuminemia (Alb 1.8 mg/dL), UA with 3+ blood but no casts on microscopy, and non-nephrotic range proteinuria (UPCR 2.9g), raising concern for rapidly progressive glomerulonephritis. Serologic work up was only remarkable for a mildly positive rheumatoid factor. A renal biopsy was performed after holding rivaroxaban for 5 days. Preliminary results showed IgA nephropathy with oxford classification score of M1E0S1T1C0, prompting initiation of steroid therapy. With no crescentic glomerular lesions to explain the degree of renal failure upon further investigation, the prominent RBC casts provided the diagnosis of ARN with underlying non-proliferative IgA nephropathy. Steroids were tapered and the patient is slowly recovering renal function.

Discussion

The use of novel oral anticoagulants (NOAC), has become prevalent in the medical community as a treatment strategy for various diseases. While previous cases have been mostly described in patients on warfarin, this case illustrates the importance of recognizing the new phenomenon of ARN as a risk factor for patients on NOACs. Due to limited data and no prospective studies, expert opinion has recommended switching one oral anticoagulant to another or reducing the dose of the offending agent. Further research is needed to understand this disease process to help design prevention and treatment strategies.