Anticoagulant-Related Nephropathy in Kidney Biopsy: A Single-Center Report of 41 Cases
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Sergey V Brodsky1, Anjali Satoskar1, Jessica Hemminger1
1Departments of Pathology (SVB, AS, JH, TN) and Medicine (BR, LH), Ohio State University, Columbus, OH; and Department of Pathology, Mayo Clinic, Scottsdale, AZ (MSR).
Insights
Anticoagulant-related nephropathy (ARN) is rare but should be considered in kidney biopsies with disproportionate red blood cell (RBC) casts. Anticoagulation may worsen underlying glomerular diseases.
Area of Science:
- Nephrology
- Pathology
- Pharmacology
Background:
- Anticoagulant-related nephropathy (ARN), initially warfarin-related nephropathy, involves acute kidney injury and red blood cell (RBC) tubular casts.
- This condition arises in patients on anticoagulation therapy, with potential links to other anticoagulants.
Purpose of the Study:
- To report a 10-year experience with ARN using kidney biopsy data from a single center.
- To characterize the clinical and pathological features of ARN.
Main Methods:
- A retrospective search of native kidney biopsies at Ohio State University Wexner Medical Center (OSUWMC) from 2009 to 2017.
- Identification of 41 cases where kidney function decline was unexplained without considering anticoagulation.
Main Results:
- ARN was identified in 0.5% of native kidney biopsies (41 cases).
- Patients were predominantly male (63%) and white (95%), with an average age of 62 years.
- Morphological findings included acute tubular necrosis and RBC casts, often disproportionate to glomerular changes; underlying glomerular disease was common.
Conclusions:
- ARN is an uncommon but important diagnosis in kidney pathology.
- Consider ARN in patients with anticoagulation or acute coagulopathy presenting with disproportionate RBC casts and hematuria.
- Anticoagulation appears to exacerbate existing glomerular diseases rather than directly damaging the glomerulus.
Rationale & Objective:
In 2009, the first case of acute kidney injury and occlusive red blood cell (RBC) tubular casts associated with a high international normalized ratio in a patient receiving warfarin was identified. This entity, named warfarin-related nephropathy, was later renamed anticoagulant-related nephropathy (ARN) after similar cases with other anticoagulants were described. We provide our 10-year experience with ARN based on a single-center kidney biopsy laboratory.
Study Design:
The kidney pathology database at the Ohio State University Wexner Medical Center (OSUWMC) was searched for native kidney biopsy cases consistent with ARN. Clinical data were obtained from patient medical records.
Setting & Participants:
Native kidney biopsies evaluated between January 1, 2009, and December 31, 2017 at OSUWMC.
Results:
Among 8,636 native kidney biopsies reviewed at the OSUWMC, there were 41 (0.5%) patients for whom deterioration in kidney function could not be explained by kidney biopsy findings alone if anticoagulation was not considered. There were 63% men and 95% were white; average age was 62 ± 14 years. Most were on warfarin therapy (N = 28), although cases were also attributed to direct-acting anticoagulants (N = 2), antiplatelet medications (N = 1), heparin or enoxaparin (N = 4), and disseminated intravascular coagulopathy (N = 6). Morphologically, there was acute tubular necrosis and RBC casts. The majority of biopsies had an underlying glomerular disease and many patients had positive serologic test results. In all these cases, the severity of kidney failure, RBC tubular casts, and hematuria were disproportionate to glomerular morphologic changes.
Limitations:
Selection bias in the decision to perform a kidney biopsy.
Conclusions:
ARN is an uncommon diagnosis in kidney pathology practice, but it should be considered when the number of RBC tubular casts is disproportionate to the severity of glomerular changes in a kidney biopsy in patients either receiving anticoagulation therapy or who presented with acute coagulopathy. Our data suggest that anticoagulation aggravates underlying glomerular diseases rather than directly affecting the glomerular filtration barrier.
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