Anticoagulant-Related Nephropathy Associated with Vitamin K Antagonists and Direct Oral Anticoagulants: Epidemiology, Pathophysiology, Clinical Features, and Outcomes
DOI:
https://doi.org/10.64229/4zqf7t51Keywords:
Anticoagulant-related nephropathy, Warfarin-related nephropathy, Acute kidney injury, Renal hemorrhage, Direct oral anticoagulants, Chronic kidney disease, Renal biopsyAbstract
Background: Anticoagulant-related nephropathy (ARN) is an underrecognized cause of acute kidney injury (AKI) in patients receiving anticoagulants, classically vitamin K antagonists (VKAs) and increasingly direct oral anticoagulants (DOACs). ARN is characterized by glomerular hemorrhage, tubular obstruction by red blood cell casts, and oxidative tubular injury from hemoglobin, heme, and iron. Literature Search Strategy: A narrative literature review was performed using PubMed/MEDLINE, Scopus, and Web of Science from 2009 to February 2026. Observational studies, biopsy-based case series, systematic reviews, and experimental reports were included when they provided anticoagulant exposure, a defined renal outcome, and sufficient clinical detail. Results: ARN has been reported in approximately 19%–37% of anticoagulated patients who develop AKI, although estimates vary across heterogeneous cohorts. Risk is highest in older adults, patients with chronic kidney disease (CKD), and those with excessive anticoagulation. Observational studies and post hoc analyses suggest lower AKI rates with DOACs than VKAs, but these findings may be influenced by confounding by indication, healthy-user effects, and surveillance bias. Diagnosis remains challenging; renal biopsy is definitive and may reveal concomitant glomerular disease, including IgA deposits that do not necessarily indicate primary IgA nephropathy. Outcomes range from partial to complete recovery, with some patients progressing to CKD. Conclusions: Clinicians should recognize ARN in anticoagulated patients with unexplained AKI with hematuria, particularly when renal reserve is reduced or anticoagulant exposure is excessive. Prompt correction of excessive anticoagulation and individualized reassessment of therapy are essential. Prospective studies should validate diagnostic criteria, clarify comparative renal safety, and define anticoagulation resumption.
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Copyright (c) 2026 Antoine J. Zgheib (Author)
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