[Life-threatening bleeding during dabigatran treatment because of acute renal failure]

We report a case where a 64-year-old woman treated with dabigatran developed life-threatening bleeding due to lack of dose adjustment following identification of acute renal failure. Many commonly used drugs, e.g. new oral anticoagulants, digoxin, ACE-inhibitors, antibiotics, are eliminated by the kidneys. The case illustrates that lack of medication reconciliation can lead to serious adverse events in case of deteriorating organ function. The use of medication reconciliation should be performed on a daily basis and special attention should be exercised in case of reduced kidney function.