Objective:To analyze the clinical characteristics of warfarin-related nephropathy (WRN).Methods:Medical records of patients with WRN admitted to Linyi People′s Hospital Affiliated to Shandong Second Medical University from January 1, 2020 to December 31, 2024 were collected. The patients′ basic information (gender, age), warfarin medication details (indications, dosage, frequency, etc.), comorbidities, concomitant medication usage, international normalized ratio (INR) and serum creatinine (Scr) test results before and after the occurrence of WRN, as well as the clinical manifestations, interventions, and outcomes of WRN were extracted. The causal relationship between warfarin and renal dysfunction was evaluated according to the Adverse Drug Reaction Reporting and Monitoring Manual. The clinical data of patients were descriptively and statistically analyzed. Results:A total of 11 patients were entered in the analysis, including 7 males and 4 females; the age ranged from 49 to 85 years, with a median age of 70 years, and 9 cases were older than 60 years. The causality evaluation showed that 3 patients were definite and 8 patients were probable. All the 11 patients had at least one comorbidity, including 6 cases of heart failure, 6 cases of hypoproteinemia, 4 cases of chronic kidney disease, 3 cases of hypertension, 3 cases of pulmonary infection, and 1 case of diabetes. Seven patients were treated with warfarin combined with broad-spectrum antibiotics, 6 combined with diuretics, and 3 combined with renin angiotensin system blockers. The time from the highest INR to the highest Scr level was 0-6 days, with a median time of 2 days, and it was ≤2 days in 9 patients. Six patients had bleeding manifestations such as microscopic hematuria, melena, epistaxis, hematochezia, and skin ecchymosis. Among the 11 patients, 10 stopped warfarin immediately and 1 reduced dosage. All patients received different doses of vitamin K 1 according to the INR level. Among the 6 patients of bleeding, 4 received symptomatic treatments such as omeprazole, tranexamic acid, somatostatin, thrombin powder and octreotide, and 2 patients received hemodialysis due to high Scr level. One patient with severe anemia received blood transfusion. After 1-5 days of treatments (with a median time of 2 days), the INR in all patients decreased to <3.00, of which 5 patients continued to take warfarin, 1 changed warfarin to rivaroxaban, and 5 did not continue anticoagulation therapy. After 2 to 14 days of treatments, Scr in 8 patients recovered to the reference value range, and Scr in 3 patients was still at a high level, of which 1 patient died of unexplained cardiac arrest. Conclusions:WRN is a common adverse reaction of warfarin, with or without bleeding. After the occurrence of WRN, the drug should be stopped as soon as possible and symptomatic treatment should be given. The prognosis is generally good, but it may also lead to chronic kidney disease.

Objective:To analyze the clinical characteristics of warfarin-related nephropathy (WRN).Methods:Medical records of patients with WRN admitted to Linyi People′s Hospital Affiliated to Shandong Second Medical University from January 1, 2020 to December 31, 2024 were collected. The patients′ basic information (gender, age), warfarin medication details (indications, dosage, frequency, etc.), comorbidities, concomitant medication usage, international normalized ratio (INR) and serum creatinine (Scr) test results before and after the occurrence of WRN, as well as the clinical manifestations, interventions, and outcomes of WRN were extracted. The causal relationship between warfarin and renal dysfunction was evaluated according to the Adverse Drug Reaction Reporting and Monitoring Manual. The clinical data of patients were descriptively and statistically analyzed. Results:A total of 11 patients were entered in the analysis, including 7 males and 4 females; the age ranged from 49 to 85 years, with a median age of 70 years, and 9 cases were older than 60 years. The causality evaluation showed that 3 patients were definite and 8 patients were probable. All the 11 patients had at least one comorbidity, including 6 cases of heart failure, 6 cases of hypoproteinemia, 4 cases of chronic kidney disease, 3 cases of hypertension, 3 cases of pulmonary infection, and 1 case of diabetes. Seven patients were treated with warfarin combined with broad-spectrum antibiotics, 6 combined with diuretics, and 3 combined with renin angiotensin system blockers. The time from the highest INR to the highest Scr level was 0-6 days, with a median time of 2 days, and it was ≤2 days in 9 patients. Six patients had bleeding manifestations such as microscopic hematuria, melena, epistaxis, hematochezia, and skin ecchymosis. Among the 11 patients, 10 stopped warfarin immediately and 1 reduced dosage. All patients received different doses of vitamin K 1 according to the INR level. Among the 6 patients of bleeding, 4 received symptomatic treatments such as omeprazole, tranexamic acid, somatostatin, thrombin powder and octreotide, and 2 patients received hemodialysis due to high Scr level. One patient with severe anemia received blood transfusion. After 1-5 days of treatments (with a median time of 2 days), the INR in all patients decreased to <3.00, of which 5 patients continued to take warfarin, 1 changed warfarin to rivaroxaban, and 5 did not continue anticoagulation therapy. After 2 to 14 days of treatments, Scr in 8 patients recovered to the reference value range, and Scr in 3 patients was still at a high level, of which 1 patient died of unexplained cardiac arrest. Conclusions:WRN is a common adverse reaction of warfarin, with or without bleeding. After the occurrence of WRN, the drug should be stopped as soon as possible and symptomatic treatment should be given. The prognosis is generally good, but it may also lead to chronic kidney disease.

A 49-year-old male patient received long-term use of warfarin 5 mg once daily orally after the operation of aortic mechanical valve replacement, and the international normalized ratio (INR) was maintained at 1.80~2.50. The patient was treated with amiodarone due to atrial tachycardia, and developed nasal bleeding 1 week later. Laboratory tests showed prothrombin time (PT) 79.7 s, INR 10.17, serum creatinine (Scr) 1 032 μmol/L, and blood urea nitrogen (BUN) 29.4 mmol/L; urine routine examination showed urinary occult blood (+) and urinary protein (±). Considering that it was warfarin-related nephropathy caused by the combination of amiodarone, which can enhance the anticoagulant effect of warfarin, leading to excessive anticoagulation. Warfarin was discontinued and the treatments such as local hemostasis, vitamin K 1, tranexamic acid, Bailing capsules (百令胶囊), lanthanum carbonate chewable tablets, and continuous hemodialysis were given. Five days of drug withdrawal, warfarin was restored. Two weeks later, laboratory tests showed PT 21.0 s, INR 1.82, Scr 179 μmol/L, and BUN 19.0 mmol/L. Renal function indicators were within the reference range at 2 and 6 months of follow-up.

A 49-year-old male patient received long-term use of warfarin 5 mg once daily orally after the operation of aortic mechanical valve replacement, and the international normalized ratio (INR) was maintained at 1.80~2.50. The patient was treated with amiodarone due to atrial tachycardia, and developed nasal bleeding 1 week later. Laboratory tests showed prothrombin time (PT) 79.7 s, INR 10.17, serum creatinine (Scr) 1 032 μmol/L, and blood urea nitrogen (BUN) 29.4 mmol/L; urine routine examination showed urinary occult blood (+) and urinary protein (±). Considering that it was warfarin-related nephropathy caused by the combination of amiodarone, which can enhance the anticoagulant effect of warfarin, leading to excessive anticoagulation. Warfarin was discontinued and the treatments such as local hemostasis, vitamin K 1, tranexamic acid, Bailing capsules (百令胶囊), lanthanum carbonate chewable tablets, and continuous hemodialysis were given. Five days of drug withdrawal, warfarin was restored. Two weeks later, laboratory tests showed PT 21.0 s, INR 1.82, Scr 179 μmol/L, and BUN 19.0 mmol/L. Renal function indicators were within the reference range at 2 and 6 months of follow-up.

Objective:To investigate the relationship between early international normalized ratio(INR)and overanticoagulation in elderly patients with atrial fibrillation(AF)treated with Warfarin, and to evaluate its clinical value in predicting overanticoagulation.Methods:A total of 470 elderly patients with AF treated with Warfarin for anticoagulation were enrolled retrospectively.INR was detected in the morning of the next day after 3 days and 7 days of Warfarin treatment.According to whether INR was greater than 3.0 after 7 days of Warfarin treatment, the patients were divided into over-anticoagulation group(n=107)and non-over-anticoagulation group(n=363). The general clinical data of the two groups were analyzed.The receiver operating characteristic curve(ROC)was used to evaluate the value of 3-day INR(early INR)level in predicting overanticoagulation.Logistic regression was used to analyze the factors related to overanticoagulation in elderly AF patients receiving Warfarin treatment.Results:The age, initial warfarin dose, early INR and serum aspartate transferase level in the over-anticoagulation group were higher than those in the non-over-anticoagulation group( P<0.05 for all). The proportions of patients with initial Warfarin dose≥2.5 mg, age≥70 years old, body weight≤65 kg, valvular atrial fibrillation, hypoproteinemia, abnormal liver function, and combined use of antibiotics were higher in the over-anticoagulation group than those in the non-over-anticoagulation group( P<0.05 for all). The body weight, serum albumin level and the proportion of diabetes mellitus in the over-anticoagulation group were lower than those in the non-over-anticoagulation group( P<0.05). ROC curve showed that the area under the curve(AUC)of early INR in predicting over-anticoagulation was 0.927(95% CI: 0.900-0.949, P<0.0001), the sensitivity was 82.86% and the specificity was 88.43%, the optimal cutoff value for predicting overanticoagulation was INR≥1.66.Multiple Logistic regression analysis showed that early INR level≥1.66( OR=33.871, P<0.001), initial warfarin dose≥2.5 mg( OR=17.062, P=0.011), body weight≤65 kg( OR=2.824, P=0.002), age≥70 years old( OR=2.678, P=0.003), and abnormal liver function( OR=2.091, P=0.022)were related factors for over-anticoagulation in elderly patients with atrial fibrillation. Conclusions:Early INR level is closely related to overuse of anticoagulation in elderly AF patients receiving Warfarin treatment, which can be regarded as a predictor of overuse of anticoagulation.Early INR level in elderly AF patients receiving warfarin treatment should be monitored to reduce the incidence of anticoagulant overuse.

Objective:To investigate the effect of preoperative use of diuretics on cardiac surgery-associated acute kidney injury(CSA-AKI)in elderly patients.Methods:In this single-center retrospective study, 1 638 patients aged ≥60 years and undergone cardiac surgery(including coronary artery bypass grafting, valve replacement and valvuloplasty)in the Department of Cardiovascular Surgery, Linyi People's Hospital between January 2015 and December 2022 were recruited.The last preoperative serum creatinine(SCr)level was taken as the baseline value, and AKI was diagnosed according to the Kidney Disease Improving Global Outcomes(KDIGO)criteria.Patients were divided into an AKI group and a non-AKI group according to whether AKI occurred after surgery.The clinical characteristics of the two groups were compared, and the effect of preoperative use of diuretics on CSA-AKI was evaluated by multivariate Logistic regression analysis.Results:Of 1638 patients enrolled in the study, 284 patients(17.3%)developed CSA-AKI.Compared with the non-AKI group, there were higher proportions of patients in the AKI group receiving furosemide(62.7% or 178/284 vs.46.2% or 626/1 354, χ2=25.397, P<0.001), spironolactone(70.1% or 199/284 vs.49.9% or 676/1 354, χ2=38.284, P<0.001), and hydrochlorothiazide(8.1% or 23/284 vs.3.5% or 47/1354, χ2=12.288, P<0.001). The number of diuretics in the AKI group was higher than in the non-AKI group[2(0, 2) vs.1(0, 2), Z=-6.381, P<0.001], and the proportion of patients using ≥2 diuretics was higher in the AKI group than in the non-AKI group(70.1% or 199/284 vs.49.0% or 664/1354, χ2=41.652, P<0.001). Multivariate Logistic regression analysis showed that, after adjusting for hypertension, diabetes mellitus, hypoalbuminemia, NYHA functional class Ⅲ/Ⅳ, cardiopulmonary bypass during surgery, operative duration≥6 h, postoperative blood transfusion>600 ml, postoperative use of >3 vasoactive drugs and other variables, preoperative use of ≥2 diuretics remained an independent risk factor for CSA-AKI in elderly patients( OR=1.580, 95% CI: 1.042-2.396, P=0.031). Conclusions:AKI is a common complication after cardiac surgery in elderly patients.Preoperative use of ≥2 diuretics used may be an independent risk factor for CSA-AKI.