Refractory Dabigatran-Induced Hemorrhage Despite Multiple Idarucizumab Administration and Renal Replacement Therapy

Purpose: This case report describes a patient with dabigatran accumulation due to acute kidney injury on chronic kidney disease, requiring multiple administration of idarucizumab along with renal replacement therapy because of rebound effect causing numerous episodes of bleeding.

Summary: An 86-year-old man on dabigatran etexilate 110 mg twice daily for stroke prevention with atrial fibrillation was admitted to the hospital for bowel obstruction and severe acute kidney injury on chronic kidney disease. The patient had an abnormal coagulation profile and no history of bleeding. Initial laboratory values revealed a hemoglobin concentration of 10.7 g/dL, a platelet count of 115 × 10³ platelets/μL, an activated partial thromboplastin time of 150.4 seconds, an international normalized ratio of 10.28, a thrombin time greater than 100 seconds and a serum creatinine of 5.54 mg/dL (490 μmol/L). An initial dose of idarucizumab was administered 1 hour prior to surgery to prevent bleeding. Significant bleeding and hemodynamic instability occurred following surgery. Three additional doses of idarucizumab, 2 sessions of intermittent hemodialysis, continuous venovenous hemofiltration and blood products were required to achieve normalization of coagulation parameters and hemodynamic stability due to rebound coagulopathy after each dose of idarucizumab.

Conclusion: Acute kidney injury on chronic kidney disease and third-space redistribution could have led to important dabigatran accumulation and favored rebound coagulopathy. Multiple therapeutic approaches may be required in the management of complex dabigatran intoxication.