PB1027 - Efficacy of haemodialysis in the long-lasting elimination of dabigatran

Background: Direct oral anticoagulants have a more predictable dose-response, with less need for laboratory monitoring. However, clinical intercurrences may alter their metabolization. For dabigatran, renal function is particularly important, considering the preponderant role in its clearance. Besides idarucizumab, haemodialysis is also a tool in the elimination of its anticoagulant effect.

Aims: Description of a case of dabigatran intoxication in the setting of acute renal failure.

Methods: Collection of clinical data in SClínico® application.

Results: A 67-year-old German man was admitted to the emergency department of a Portuguese hospital, after being found fallen. Language-barrier hindered communication, but it was later assessed that prostration and anorexia were progressively presented over the previous two weeks. Antecedents of diabetes, dyslipidaemia, arterial hypertension, chronic kidney disease and atrial fibrillation were inferred through is usual medication (which included dabigatran 150mg twice daily).
Analysis revealed a severe acute renal failure (Creatinine 8,22mg/dL, Urea 281mgd/L), with hyperkalaemia (K+ 9,5mmol/L). Electrocardiogram presented sinus bradycardia with pronounced widening of the QRS-complex. Dabigatran was in supratherapeutic levels (>460ng/mL; trough range: 28-155ng/mL), without evidence of haemorrhage.
Urgent haemodialysis was initiated. A central venous catheter was placed without complications. Idarucizumab was effective, but there was a rebound effect hours later. Four haemodialysis sessions were performed during the hospitalization and dabigatran concentration pre- and post-haemodialysis was measured (Table 1). There was a mean decrease of 49% (42,9-55,2%) in plasma dabigatran levels per session. Trough range was reached on the eleventh day.
Renal failure, attributed to ischemic acute tubular necrosis associated with persistent hypotension, was stabilized and the patient returned to Germany.

Conclusion(s): Although haemodialysis was initiated due to hyperkalaemia and electrocardiographic findings, its high-efficacy in long-lasting elimination of dabigatran was demonstrated. The observed rebound-effect and the average elimination rate per session emphasize that intra/extravascular balance of dabigatran, especially in intoxication cases, should be considered.