Abstract: SA-PO0109
A Case of Renal Vein Thrombosis in a Patient on Rivaroxaban
Session Information
- AKI: Clinical Diagnostics and Biomarkers
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Cancarevic, Ivan, Mass General Brigham Inc, Boston, Massachusetts, United States
- Mount, David B., Mass General Brigham Inc, Boston, Massachusetts, United States
Introduction
Patients with nephrotic syndrome (NS) and, in particular, membranous nephropathy (MN), are susceptible to RVT, and it is an important differential diagnosis of AKI in those patients. Traditionally, it is treated with heparin followed by warfarin. Little is known about the efficacy of direct oral anticoagulants (DOACs) in treatment or prophylaxis of thromboembolic complications in MN and NS. Some case reports have raised concerns regarding their efficacy in that context, although a single retrospective study of 21 patients suggested they may be effective.
Case Description
We present a case of a 55-year-old male with a history of obstructive sleep apnea, Graves' disease, acute respiratory distress following cardiac arrest secondary to head injury, unprovoked deep venous thrombosis/pulmonary embolism on rivaroxaban, who presented with abdominal discomfort, lower extremity edema, and 20 lbs weight gain. He was found to have proteinuria of 9 grams/day. His baseline creatinine was around 1.3 mg/dL, but it progressively rose to 3 mg/dL in the two months before presentation. At presentation his anti-FXA rivaroxaban assay was subtherapeutic at <20 ng/ml, suggesting resistance to rivaroxaban. Due to transient gross hematuria his rivaroxaban was held. He was diagnosed with MN based on PLA-2R positivity; renal biopsy revealed MN with mild acute tubular injury. MRV revealed an occlusive thrombus in the left renal vein (RV) extending to the inferior vena cava (IVC) and a near-occlusive thrombus in the right RV and some of its tributaries, extending to the IVC. The patient was started on heparin with a plan to transition to warfarin. An attempt at catheter-directed thrombolysis was only partially successful on the left, and unsuccessful on the right due to ostial occlusion. After a repeat MRV revealed improvement in the right RVT the patient underwent successful bilateral repeat thrombectomy and right RV angioplasty. By discharge his AKI was resolving, with a creatinine of 2.0 from a peak of 5.0 mg/dL.
Discussion
This is, to the best of our knowledge, the first reported case of RVT that developed in a patient who was on rivaroxaban at the time. As this case and other case reports illustrate, DOACs may be ineffective in prophylaxis of thromboembolism associated with NS. Additionally, warfarin should arguably remain the gold standard for oral anticoagulation in RVT associated with MN.