Apixaban in a Dialysis Patient With Valvular Heart Disease and Calciphylaxis: Rethinking Conventional Anticoagulation

Vitamin K antagonists (VKAs) remain the standard anticoagulation for mechanical heart valves but may promote vascular calcification and calciphylaxis.

An 88-year-old woman with a longstanding mechanical aortic valve and advanced chronic kidney disease developed biopsy-confirmed calciphylaxis during VKA therapy. Following initiation of hemodialysis, anticoagulation was switched to low-dose apixaban (2.5 mg twice a day) with plasma level monitoring. Over 2.5 years of follow-up, no bleeding, thromboembolic events, or valve-related complications occurred, and renal recovery allowed dialysis withdrawal. WHY BEYOND THE GUIDELINES?: Direct oral anticoagulants are contraindicated in patients with mechanical heart valves and not recommended in dialysis. Apixaban was introduced because of VKA-associated calciphylaxis and limited therapeutic alternatives.

Apixaban may be used safely in patients with long-standing mechanical aortic valves because of its predictable pharmacokinetics.

Apixaban may represent a pragmatic option in selected patients with long-standing mechanical aortic valves when guideline-recommended VKA therapy cannot be maintained.