#6376 TREATMENT OF DABIGATRAN INTOXICATION IN CRITICALLY ILL PATIENTS WITH ACUTE KIDNEY INJURY: THE ROLE OF SUSTAINED LOW-EFFICIENCY DIALYSIS

Abstract

Abstract Background and Aims Dabigatran, a direct thrombin inhibitor, is a commonly used direct oral anticoagulant (DOAC) prescribed for non-valvular atrial fibrillation. Despite its benefits in term of safety/effectiveness along with the possibility to treat patients who were ineligible for vitamin K inhibitors (VKAs), a great degree of attention is required in elderly patients with multiple comorbidities. Notably, dabigatran mainly undergoes renal elimination, and dose adjustment is recommended in patients with Chronic Kidney Disease (CKD). In this regard, the onset of an abrupt decrease of kidney function may further affect dabigatran pharmacokinetic profile, increasing the risk of acute intoxication. Idarucizumab is the approved antagonist in the case of dabigatran-associated major bleeding or concomitant need of urgent surgery, but its clinical use is limited by the lack of data in patients with Acute Kidney Injury (AKI). Given the dabigatran PK parameters (low MW, low Vd, negligible protein binding), the early start of Extracorporeal Kidney Replacement Therapy (EKRT) may represent the optimal reversal strategy. We present a case series of three critically ill patients with AKI and dabigatran overdose treated with Sustained Low-Efficiency Dialysis (SLED). Methods Three critically ill patients (Table 1) were admitted to the Renal Intensive Care Unit (ICU) for stage 3 AKI and intercurrent dabigatran intoxication. SLED sessions with Regional Citrate Anticoagulation (RCA) were prescribed with SURDIAL X machine, ELISIO-21M filter (Nipro Co., Osaka, Japan) [blood flow rate 200 mL/min, dialysis fluid rate 300 mL/min; citrate flow rate 350 mL/h (ACD Fresenius Kabi, Italia)]. Dabigatran plasma levels (dilute thrombin time, dTT) along with coagulation parameters were monitored before, during and after SLED session. Results A rapid and sustained decreased of plasma dabigatran level was observed in each patient in course of SLED sessions. No clinically relevant post-treatment rebound was reported (Figure 1). Conclusions SLED meets the requirements to be a viable reversal anticoagulation option in the context of dabigatran overdose. Indeed, it efficiently provides dabigatran removal, by reaching a safe plasma concentration within the first hours and avoiding significant rebound effect.