Short-term observation of direct oral anticoagulant use in an atrial fibrillation patient with high bleeding risk and kidney transplant: a case report

Abstract

K idney transplant (KTx) is considered to be the best treatment for end-stage renal diseases compared with hemodialysis or peritoneal dialysis, because it significantly improves renal function, reduces cardiovascular events and mortality, enhances quality of life and prolongs life expectancy. Atrial fibrillation (AF) is frequently coexistent with KTx, and a higher risk will occur in KTx recipients with AF compared with those aren’t with AF. Patients with AF are at risk of stroke, systemic emboli and death. It is recommended that high-risk AF patients should use oral anticoagulants for preventive treatment. Direct oral anticoagulants (DOACs), including dabigatran, rivaroxaban, apixaban and edoxaban, are widely recommended for use in the general population compared to vitamin K antagonists (VKA). [4 ,5] However, in the chronic kidney disease population, the evidence for the use of DOACs is limited because all these drugs are partially eliminated by the kidney and may cause subsequent accumulation and bleeding risks. To date, clinical evidence regarding the use of DOACs in KTx recipients is scarce. Herein, we report a successful case of the use of DOACs for an AF patient with high bleeding risk and a history of KTx several months ago and the short-term follow-up shows that its safety is good. A 63-year-old male complained of paroxysmal palpitations for seven years and recurrence in recent months. The electrocardiogram (ECG) showed AF and the medical history of this patient included aspirin antiplatelet therapy which was discontinued five years ago due to massive upper gastrointestinal bleeding and hemorrhagic shock caused by gastric ulcer. For the past several months, the patient felt palpitation and irregular pulses which lasted for about 1 h to 2 h each time and relieved spontaneously. This patient was admitted in Beijing Tsinghua Changgung Hospital for further evaluation, and ECG confirmed AF (Figure 1). At the same time, the patient with a history of hypertension, hyperlipidemia, coronary heart disease, and end-stage renal disease caused by IgA nephropathy and allograft renal transplantation. Currently, the drugs, including tacrolimus 3.5 mg twice daily, mycophenolate mofetil dispersible tablets 0.5 mg twice daily, prednisone acetate tablets 10 mg once daily, metoprolol tartrate sustained-release tablets 11.875 mg once daily, nifedipine controlled release tablets 30 mg once daily, eseomeprazole enteric coated tablets 40 mg once daily, calcium carbonate tablets 750 mg once daily and atorvastatin calcium tablets 10 mg once nightly, have been taken. Blood tests showed serum creatinine of 147.1 umol/L, estimated glomerular filtration rate (eGFR) of 43.5 mL/min per 1.73 m, mild anemia (red blood counter: 2.9 × 10/L, hemoglobin: 94 g/L, and hematocrit: 29.1%), normal range of white blood cell count and platelet count, routine urine and liver function, negative occult blood, and D-dimer of 2.2 mg/L. The 24-hour Holter monitoring revealed paroxysmal AF (Figure 2) and ultrasonic cardiogram (Figure 3) showed left and Journal of Geriatric Cardiology