ASN's Mission

To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005


The Latest on X

Kidney Week

Please note that you are viewing an archived section from 2023 and some content may be unavailable. To unlock all content for 2023, please visit the archives.

Abstract: FR-PO083

Apixaban in CKD, a Life-Threatening Cause of Pericardial Bleed with Resultant Acute Tubular Necrosis (ATN) and Dialysis Dependency

Session Information

Category: Acute Kidney Injury

  • 101 AKI: Epidemiology, Risk Factors, and Prevention


  • Rehman, Zahoor Ur, New York City Health and Hospitals Metropolitan, New York, New York, United States
  • Chaudhari, Ashok P., New York City Health and Hospitals Metropolitan, New York, New York, United States
  • Baumstein, Donald I., New York City Health and Hospitals Metropolitan, New York, New York, United States

Bleeding is a common complication associated with oral anticoagulants. It can be revealed or concealed, including upper and lower gastrointestinal hemorrhage, central nervous system macro and microbleeds, and bleeding in the genitourinary system. After a thorough literature search, we found no reported case of a large pericardial bleed causing cardiac tamponade. Therefore, we report a case of a large pericardial bleed that caused tamponade, which resulted in ATN in a patient with chronic kidney disease (CKD) who then required dialysis.

Case Description

A 77-year-old Chinese woman with a history of diabetes mellitus type-2, hypertension, atrial fibrillation, left middle cerebral artery stroke status post thrombectomy, and CKD with a baseline creatinine of 1.8 mg/dl (two months prior) was brought to the emergency department (ED) due to elevated blood urea nitrogen (BUN) and creatinine. On arrival at the ED, her creatinine was elevated at 8.3 mg/dl, BUN at 76 mg/dl, and hemoglobin at 7.0 g/dl, with normal platelet and white cell count. She was alert but not oriented and had jugular venous distension, with a blood pressure of 100/60 mmHg. EKG showed no acute changes, a chest x-ray revealed a globular heart, and the septic workup was negative. Echocardiogram demonstrated severe pericardial effusion with right ventricular collapse. She was taking Apixaban 5 mg twice daily. Renal failure workup was all negative or normal, including autoimmune and hepatitis profile, infection, and myeloma screening. Pericardial bleed was suspected in light of an acute drop in hemoglobin, so a pericardial window was made, and a 2-liter bloody effusion was drained on day-1 with a total of 4 liters over a week. Pericardial fluid was negative for atypical cells, gram stain, AFB stain, QuantiFERON, and viral PCRs, and cultures were negative for bacteria and fungi.


Oral anticoagulants can cause a potentially life-threatening pericardial bleed and resultant cardiac tamponade. Though apixaban and other non-vitamin K analogs require less monitoring than warfarin and may be associated with lesser chances of bleeding, however, it can cause a large pericardial bleed and can lead to shock and ATN. Care should be exercised in prescribing apixaban to patients who have an increased risk of bleeding, especially those with CKD.