Dabigatran Reversal in a Patient With End-Stage Liver Disease and Acute Kidney Injury

Dabigatran, a direct thrombin inhibitor and one of the new class of direct oral anticoagulants, is increasingly used in preference to warfarin because of its efficacy and ease of administration. However, because the drug is cleared by the kidneys, it can accumulate in plasma and increase the risk for bleeding in patients with decreased kidney function. We report a patient with end-stage liver disease who developed life-threatening hemorrhage and acute kidney injury while taking dabigatran, 150mg, twice daily. Although the patient received idarucizumab, an anti-dabigatran antibody fragment used as an antidote, hemostasis could not be achieved. Administration of vitamin K, fresh frozen plasma, desmopressin, octreotide, and pantoprazole did not arrest bleeding or affect coagulation parameters, and it was not possible to establish vascular access for hemodialysis. In patients with end-stage liver disease, who are at increased risk for both bleeding and acute kidney injury, dabigatran should be prescribed cautiously and at decreased dose.