title: Extracorporeal therapy for dabigatran removal in the treatment of acute bleeding: a single center experience.
abstract: OBJECTIVE
  Dabigatran is an oral direct thrombin inhibitor that is Food and Drug Administration-approved for prevention of stroke in patients with atrial fibrillation. No antidote is available for reversal of dabigatran's anticoagulant effect. Despite limited clinical data, hemodialysis has been suggested as a strategy to remove dabigatran during acute bleeding. This work presents five cases, in which extracorporeal therapy was performed for dabigatran removal in acutely bleeding patients.
  
  
  METHODS
  The series is comprised of five consecutive cases of patients receiving dabigatran 150 mg per os two times daily who were admitted with life-threatening bleeding between March of 2012 and January of 2013. Dabigatran plasma concentrations ranged from 149 to 1200 ng/ml. Treatment included administration of blood products to all patients and then, high-flux intermittent hemodialysis alone or followed by continuous renal replacement therapy.
  
  
  RESULTS
  Dabigatran concentrations decreased by 52%-77% during intermittent hemodialysis but rebounded up to 87% within 2 hours after completion of dialysis. Initiation of continuous renal replacement therapy after intermittent hemodialysis attenuated the rebound effect in one patient and contributed to a reduction in dabigatran concentrations of 81% over 30 hours.
  
  
  CONCLUSIONS
  Extracorporeal therapy lowered dabigatran concentrations, suggesting that it removed the drug and may effectively accelerate total clearance, especially in patients with impaired kidney function. The use of prolonged intermittent hemodialysis or intermittent hemodialysis followed by continuous renal replacement therapy is recommended for the management of life-threatening bleeding in patients receiving dabigatran. The advantage of extracorporeal therapy should be weighed against the risk of bleeding with catheter insertion.
authors.affiliation: Renal-Electrolyte Division, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Tripti
authors.initials: T
authors.lastname: Singh
authors.forename: Thin Thin
authors.initials: TT
authors.lastname: Maw
authors.forename: Brian L
authors.initials: BL
authors.lastname: Henry
authors.forename: Núria M
authors.initials: NM
authors.lastname: Pastor-Soler
authors.forename: Mark L
authors.initials: ML
authors.lastname: Unruh
authors.forename: Kenneth R
authors.initials: KR
authors.lastname: Hallows
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Nolin
mesh_terms: D000058:Accidental Falls; D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000991:Antithrombins / Q000009:adverse effects / Q000097:blood*; D001281:Atrial Fibrillation / Q000188:drug therapy; D001562:Benzimidazoles / Q000009:adverse effects / Q000097:blood*; D001803:Blood Transfusion; D003108:Colonic Diseases / Q000209:etiology / Q000628:therapy*; D000069604:Dabigatran; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000628:therapy*; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications; D045822:Intestinal Volvulus / Q000150:complications; D007871:Leg Ulcer / Q000150:complications; D008297:Male; D006435:Renal Dialysis; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000628:therapy*; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000097:blood
chemical_list: D000991:Antithrombins; D001562:Benzimidazoles; D015091:beta-Alanine; D000069604:Dabigatran