Sunday, May 21, 2017

Anticoagulant related nephropathy: huge problem, hugely under-recognized

From a commentary in JACC, here are some key points.

What is it?

Anticoagulant related nephropathy (ARN) is a form of AKI caused by systemic anticoagulation (generally over anticoagulation; in the original reports on warfarin the mean INR was in the mid 4 range).

What are the histopathologic findings?

Severe glomerular, and sometimes tubular, hemorrhage.

It's not just warfarin

Although originally described with warfarin and termed warfarin nephropathy it is now evident that other systemic anticoagulants (and probably any systemic anticoagulant) can cause it. The risk may be higher with warfarin than with the NOACs.

How do you diagnose it?

The difficulties in getting a renal biopsy in patients who are anticoagulated are obvious. Sometimes biopsy is done during a window of anticoagulant interruption. In other cases, if circumstances fit and there is no other plausible explanation “presumptive ARN” is diagnosed without a biopsy.

It is generally not reversible

According to the article, renal recovery tends to be poor.

During periods of excessive anticoagulation the risk is high

From the article:

To date, there have been 5 independent cohort studies...These studies show that the risk of ARN at the onset of coagulopathy is at about 20% overall and about 37% in patients with CKD (3).

According to the article the mortality is high, especially in CKD patients.

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