An Inconspicuous Offender: Apixaban-Induced Anticoagulant-Related Nephropathy

Direct oral anticoagulants (DOACs) have shifted the landscape of anticoagulation over the past decade, becoming a frequently used pharmaceutical agent. The increased use of DOACs for long-term anticoagulation has led to a rise in reported anticoagulant-related adverse reactions, such as anticoagulant-related nephropathy (ARN). The occurrence of ARN is well reported with warfarin; however, there are few cases of ARN reported with DOAC use. We report the case of an elderly man with coronary artery disease and hypertension who was initiated on apixaban for atrial fibrillation three years prior to presentation but developed rapid renal decline over the six months prior to presentation. The estimated glomerular filtration rate (eGFR) had decreased precipitously from 48 mL/min/1.73 m² to 19 mL/min/1.73 m² with a concurrent drop in hemoglobin in the setting of persistent microscopic hematuria. A renal biopsy showed red blood cell casts consistent with glomerular hematuria, despite no crescents or signs of other forms of glomerulonephritis. The patient's renal function ceased to deteriorate and had a 35% recovery (serum creatinine 2.6 mg/dL, eGFR 25 mL/min/1.73 m²) after the discontinuation of apixaban and conversion to rivaroxaban without the use of corticosteroids. The patient reported at follow-up that he discontinued rivaroxaban four days after initiation on his own accord due to extrarenal bleeding. Our case highlights the importance of prompt recognition and treatment of the underreported but potentially significant incidence of ARN with apixaban in a patient with an otherwise unexplained kidney injury.