J Clin Neurol.  2015 Oct;11(4):395-397. 10.3988/jcn.2015.11.4.395.

The Need for a Coagulation Assay after Initiation of New Oral Anticoagulants in Patients with Renal Dysfunction: A Case Report

• Lee MJ
• Jang HM
• Jeong WK
• Bang OY

• KMID: 2179761
• DOI: http://doi.org/10.3988/jcn.2015.11.4.395

Abstract

BACKGROUND
Dabigatran etexilate, a new oral anticoagulant, was recently approved as an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular atrial fibrillation. Limited data are available for dabigatran use in patients with a creatinine clearance rate (CrCL) of 15-30 mL/min. Furthermore, current guidelines do not recommend frequent blood monitoring after dabigatran use. We report herein a patient with severe renal dysfunction who exhibited profound coagulopathy after 2 days of dabigatran use.
CASE REPORT
An 87-year-old woman was admitted for altered mental status and left-side weakness. She was diagnosed with right middle cerebral artery infarction. The baseline assessment revealed a serum creatinine concentration of 1.29 mg/dL and a CrCL of 27.2 mL/min. Dabigatran therapy was started 5 weeks after admission at a dosage of 110 mg twice daily. After 2 days of dabigatran use, the patient developed multiple bruises and evidence of upper-gastrointestinal bleeding. Laboratory tests demonstrated a severe coagulopathy, with a prothrombin time of 85.9 sec, an international normalized ratio of 11.36, an activated partial thromboplastin time of 119.2 sec, and a thrombin time of 230.8 sec. Serial assessment of the patient's renal function revealed substantial fluctuation of the CrCL (range, 17.9-26.5 mL/min).
CONCLUSIONS
The present case emphasizes the need for frequent checking of renal function and assessment using coagulation assays after commencing dabigatran therapy in patients with moderate-to-severe renal impairment.

Keyword

atrial fibrillation; new oral anticoagulant; renal dysfunction; ischemic stroke

MeSH Terms

Aged, 80 and over
Anticoagulants*
Atrial Fibrillation
Contusions
Creatinine
Dabigatran
Female
Hemorrhage
Humans
Infarction, Middle Cerebral Artery
International Normalized Ratio
Partial Thromboplastin Time
Prothrombin Time
Stroke
Thrombin Time
Warfarin
Anticoagulants
Creatinine
Warfarin

Figure

• 

  Fig. 1 Laboratory findings before and after starting dabigatran therapy (at 110 mg twice daily). Dashed line=aPTT (sec); solid black line=PT (INR); solid gray line=CrCL (mL/min); dotted line= creatinine (mg/dL). aPTT: activated partial thromboplastin time, Cr: creatinine, CrCL: creatinine clearance rate, INR: international normalized ratio, PT: prothrombin time, Vit K: vitamin K

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