Garza-Mayers AC, Shah R, Sykes DB, Nigwekar SU, Kroshinsky D: The Successful Use of Apixaban in Dialysis Patients with Calciphylaxis Who Require Anticoagulation: A Retrospective Analysis. Am J Nephrol 2018;48:168–171
Calciphylaxis is a serious, potentially life-threatening complication of ESRD that may be precipitated (or aggravated) by vitamin K antagonists (such as warfarin) used for necessary anticoagulation. Alternative non-warfarin anti-coagulation strategies are now available by use of oral direct factor Xa antagonism (apixaban or rivaroxaban), but the effect on employing these new strategies in patients with ESRD and calciphylaxis is unknown.
Shah and co-workers conducted a chart review of the use of apixaban in ESRD (dialysis treated) in patients with new onset calciphylaxis previously receiving warfarin for deep vein thrombosis (DVT) or non-valvular atrial fibrillation (AFib) under the care of physicians at the Massachusetts General Hospital or the Brigham and Women’s Hospital in Boston between 2011 and 2017. 41 patients were identified that had both calciphylaxis and apixaban therapy, 20 of whom were on dialysis therapy for ESRD. Apixaban was given for approved indications of DVT or non-valvular AFib. 18 patients showed “improvement” of the calciphylaxis during apixaban use and the one-year mortality was 20 %. 2 patients experienced further progression of calciphylaxis while receiving apixaban and died within 30 days. 4 of the 20 patients (20 %) experienced bleeding complications, 3 of whom required blood transfusions.
This small uncontrolled experience is modestly encouraging, but needs confirmation. Nevertheless, a 90 % improvement in calciphylaxis and a 20 % serious bleeding rate suggests a favorable benefit to risk relationship.