RESUMEN
Anticoagulant-related nephropathy (ARN) was initially described in patients on warfarin (as warfarin-related nephropathy) and recently in those using dabigatran. Herein, we report clinical history and kidney biopsy findings in a patient on apixaban (Eliquis). Initiation of treatment with apixaban resulted in aggravation of preexisting mild acute kidney injury (AKI). A few days after apixaban therapy, the patient became oligoanuric, and kidney biopsy showed severe acute tubular necrosis with numerous occlusive red blood cell casts. Only one out of 68 glomeruli with open capillary loops had small segmental cellular crescent. Therefore, there was major discrepancy between the degree of glomerular injury and the glomerular hematuria. Considering that the onset of this AKI was associated with apixaban treatment initiation, we propose that this patient had ARN associated with factor Xa inhibitor (apixaban), which has not previously been described. Monitoring of kidney function is recommended after initiation of anticoagulant therapy.
RESUMEN
Low dose of hemodialysis (HD) and small body size are independent risk factors for mortality. Recent changes in clinical practice, toward higher HD doses and use of more high-flux dialyzers, suggest the need to redetermine the dose level above which no benefit from higher dose can be observed. Data were analyzed from 45,967 HD patients starting end-stage renal disease (ESRD) therapy during April 1, 1997, through December 31, 1998. Data from Health Care Financing Administration (HCFA) billing records during months 10 to 15 of ESRD were used to classify each patient into one of five categories of HD dose by urea reduction ratio (URR) ranging from <60% to >75%. Cox regression models were used to calculate relative risk (RR) of mortality after adjustment for demographics, body mass index (BMI), and 18 comorbid conditions. Of the three body-size groups, the lowest BMI group had a 42% higher mortality risk than the highest BMI tertile. In each of three body-size groups by BMI, the RR was 17%, 17%, and 19% lower per 5% higher URR category among groups with small, medium, and large BMI, respectively (P < 0.0001 for each group). Patients treated with URR >75% had a substantially lower RR than patients treated with URR 70 to 75% (P < 0.005 each, for medium and small BMI groups). It is concluded that a higher dialysis dose, substantially above the Dialysis Outcomes Quality Initiative guidelines (URR >65%), is a strong predictor of lower patient mortality for patients in all body-size groups. Further reductions in mortality might be possible with increased HD dose.