Reversal of Dabigatran Bleeding and Coagulopathy Using Idarucizumab in a Patient With Acute Kidney Injury.

Idarucizumab is approved for patients treated with dabigatran when reversal of the anticoagulant effects is needed. Like dabigatran, idarucizumab is excreted in the urine. The effect of renal dysfunction on drug elimination is uncertain, as patients in the RE-VERSE AD trial had a median creatinine clearance of 58 mL/min. Also, dabigatran accumulation can occur if the international normalized ratio (INR) is greater than two. A 73-year-old female was admitted for lower extremity edema and increased abdominal girth. On admission, the patient was in acute kidney injury (AKI) with an estimated creatinine clearance of 34.5 mL/min. Her prothrombin time (PT) on admission was 17 seconds, her INR was 1.4, and her hemoglobin was 8.7 gm/dL (12-16 gm/dL). Throughout her admission, she was continued on her home regimen of dabigatran 150 mg twice daily for atrial fibrillation. On day 4, she had rectal bleeding and altered mental status. At this time, her PT was elevated to 25.6 seconds, her INR had increased to 2.3, and her hemoglobin had dropped to 6.8 gm/dL. Two doses of idarucizumab 2.5 gm were administered, and dabigatran was successfully reversed with cessation of bleeding and normalization of the INR to 1.5. An additional dose of idarucizumab was not required. The patient was discharged home two days later. Idarucizumab successfully reversed the bleeding and coagulopathy associated with dabigatran in a patient with AKI.