Antikoagülan ilişkili nefropati

Öz

Antikoagülan ilişkili nefropati, varfarin veya diğer antikoagülan ajanlarla antikoagülasyonun neden olduğu bir tür akut böbrek hasarıdır. INR> 4 olduğunda antikoagülan ilişkili nefropati gelişim riskinin arttığı görülmektedir. Bu yazıda supraterapötik doz varfarin kullanımı sonucu akut böbrek hasarı gelişen bir olgu sunulmuştur. Atrial fibrilasyon nedeniyle varfarin kullanan, eşlik eden, obezite, hipertansiyon, tip 2 diabetes mellitus ve kronik böbrek hastalığı tanıları olan 61 yaşında erkek hasta sol böğründe şişlik ve morluk ile acil servise başvurdu. Göğüs sol posterolateral duvarında hematomu olan hastanın laboratuvar analizlerinde INR:9,7 serum kreatinin seviyesi bazal değerinin 2 katının üzerinde (bazal değeri:3mg/dL, en yüksek:6,2mg/dL) saptandı. Hemoglobin 6,8 g/dL’ye kadar düştü. Varfarin kesilip INR güvenli aralığa çekilmesiyle hastanın serum kreatinini bazal düzeyine geriledi. Akut böbrek hasarı yapabilecek diğer nedenler dışlandı ve supraterapötik doz varfarin kullanımı olan hastada antikoagülan ilişkili nefropati geliştiği düşünüldü. Bu olgu komorditeleri fazla olan özellikle kronik böbrek hastalarında antikoagülan tedavilerin dikkatli takip gerektirdiğini göstermektedir. Antikoagülan kullanan hastalarda akut böbrek hasarı etiyolojisinde antikoagülan ilişkili nefropati akılda tutulmalıdır.

Anahtar Kelimeler

• Antikoagülan
• varfarin
• akut böbrek hasarı
• kronik böbrek hastalığı

Anticoagulant-related nephropathy

Öz

Anticoagulant-related nephropathy is a type of acute kidney injury caused by anticoagulation with warfarin or other anticoagulant agents. It appears that the risk of developing anticoagulant-related nephropathy increases when INR> 4. In this article, we present a case who developed acute kidney injury as a result of supratherapeutic dose of warfarin. A 61-year-old male patient, who was on warfarin treatment for atrial fibrillation and had comorbid hypertension, type 2 diabetes mellitus and chronic kidney disease, presented to the emergency department with swelling and bruising on his left flank area. He had a hematoma on the left posterolateral wall of the chest. In the laboratory analysis INR: 9.7 and serum creatinine level was above 2 times the baseline value (baseline:3 mg/dL, maximum:6,2 mg/dL). By discontinuing warfarin, INR returned to the safe range and serum creatinine decreased to his baseline levels. Other causes of acute kidney injury were excluded, and the patient with supratherapeutic dose of warfarin was thought to develop anticoagulant-related nephropathy. This case shows that anticoagulant therapies require careful follow-up in patients with comorbidites especially chronic kidney disease. Anticoagulant related nephropathy should be kept in mind in the etiology of acute kidney injury in patients using anticoagulants.

Anahtar Kelimeler

• anticoagulant
• warfarin
• acute kidney injury
• chronic kidney disease

Kaynakça

1. Bansal N, Xie D, Tao K, et al. Atrial fibrillation and risk of ESRD in adults with CKD. Clin J Am SocNephrol 2016;11:1189–96. https://doi.org/10.2215/CJN.10921015
2. Ryan M, Ware K, Qamri Z, et al. Warfarin-related nephropathy is the tip of the iceberg: direct thrombin inhibitor dabigatran induces glomerular hemorrhage with acute kidney injury in rats. Nephrol Dial Transplant 2014;29:2228. https://doi.org/10.1093/ndt/gft380
3. Brodsky SV, Nadasdy T, Rovin BH, et al. Warfarin-related nephropathy occurs in patients with and without chronic kidney disease and is associated with an increased mortality rate. Kidney Int 2011;80:181. https://doi.org/10.1038/ki.2011.44
4. Brodsky SV, Satoskar A, Chen J, et al. Acute kidney injury during warfarin therapy associated with obstructive tubular red blood cell casts: a report of 9 cases. Am J Kidney Dis 2009;54:1121. https://doi.org/10.1053/j.ajkd.2009.04.024
5. Brodsky SV, Collins M, Park E, et al. Warfarin therapy that results in an International Normalization Ratio above the therapeutic range is associated with accelerated progression of chronic kidney disease. Nephron Clin Pract 2010;115:c142. https://doi.org/10.1159/000312877
6. Ware K, Brodsky P, Satoskar AA, et al. Warfarin-related nephropathy modeled by nephron reduction and excessive anticoagulation. J Am Soc Nephrol 2011;22:1856. https://doi.org/10.1681/ASN.2010101110
7. Schützer KM, Svensson MK, Zetterstrand S, et al. Reversible elevations of serum creatinine levels but no effect on glomerular filtration during treatment with the direct thrombin inhibitor AZD0837. Eur J Clin Pharmacol 2010;66:903. https://doi.org/10.1007/s00228-010-0849-7
8. An JN, Ahn SY, Yoon CH, et al. The occurrence of warfarin-related nephropathy and effects on renal and patient outcomes in korean patients. PLoS One 2013;8:e57661. https://doi.org/10.1371/journal.pone.0057661