Abstract
Autosomal-dominant polycystic kidney disease (ADPKD) is the most prevalent cystic kidney disease, with approximately half of the patients reaching end-stage renal disease by the age of 60. Tolvaptan prevents renal cyst growth by inhibiting intracellular cyclic AMP and is recommended for patients with ADPKD. Reports of thrombotic complications with tolvaptan have been limited. We report a case of a 60-year-old man who developed thromboembolisms during tolvaptan treatment for ADPKD. The patient started tolvaptan in July 2014. He was brought to our hospital in February 2015 with a sudden onset of dyspnea and chest pain after 6 days of persistent watery diarrhea. Blood tests revealed enhanced coagulation and fibrinolysis, and contrast-enhanced computed tomography confirmed the presence of multiple thromboembolisms. Venous thromboembolism (VTE) with acute pulmonary and lower extremity thrombi was diagnosed, and the patient was immediately admitted. Tolvaptan was discontinued on admission, and intravenous fluid loading and monteplase were started. Subsequently, chest pain and dyspnea resolved, with thrombi resolution occurring by day 14; the patient was discharged on day 18 in stable condition. VTE was attributed to continued tolvaptan during diarrhea and dehydration; tolvaptan itself was not associated with enhanced coagulability. Dehydrated patients with ADPKD, such as the patient in this case, are at an increased risk for thrombus formation. Proper education should be provided to maintain appropriate fluid status and discontinue tolvaptan upon volume depletion.
Similar content being viewed by others
References
Higashihara E, Nutahara K, Kojima M, Tamakoshi A, Yoshiyuki O, Sakai H, et al. Prevalence and renal prognosis of diagnosed autosomal dominant polycystic kidney disease in Japan. Nephron. 1998;80:421–7.
Gattone VH 2nd, Wang X, Harris PC, Torres VE. Inhibition of renal cystic disease development and progression by a vasopressin V2 receptor antagonist. Nat Med. 2003;9:1323–6.
Torres VE, Chapman AB, Devuyst O, Gansevoort RT, Grantham JJ, Higashihara E, et al. Tolvaptan in patients with autosomal dominant polycystic kidney disease. N Engl J Med. 2012;367:2407–18.
Yasaka M, Beppu S. Hypercoagulability in the left atrium: Part II: Coagulation factors. J Heart Valve Dis. 1993;2:25–34. discussion 35–6.
Kawakami S, Kaibara M, Kawamoto Y, Yamanaka K. Rheological approach to the analysis of blood coagulation in endothelial cell-coated tubes: activation of the intrinsic reaction on the erythrocyte surface. Biorheology. 1995;32:521–36.
Iwata H, Kaibara M. Activation of factor IX by erythrocyte membranes causes intrinsic coagulation. Blood coagulation and fibrinolysis. Blood Coagul Fibrinolysis. 2002;13:489–96.
Kumar G, Sakhuja A, Taneja A, Majumdar T, Patel J, Whittle J, et al. Pulmonary embolism in patients with CKD and ESRD. Clin J Am Soc Nephrol. 2012;7:1584–90.
Shlipak MG, Fried LF, Crump C, Bleyer AJ, Manolio TA, Tracy RP, et al. Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency. Circulation. 2003;107:87–92.
Hrafnkelsdottir T, Ottosson P, Gudnason T, Samuelsson O, Jern S. Impaired endothelial release of tissue-type plasminogen activator in patients with chronic kidney disease and hypertension. Hypertension. 2004;44:300–4.
Maeda T, Uchida Y, Oyamada K, Nakajima F. Thrombosis in inferior vena cava due to enlarged renal cysts in autosomal dominant polycystic kidney disease. Intern Med (Tokyo. Japan). 2010;49:1891–4.
Kaufmann JE, Oksche A, Wollheim CB, Gunther G, Rosenthal W, Vischer UM. Vasopressin-induced von Willebrand factor secretion from endothelial cells involves V2 receptors and cAMP. J Clin Invest. 2000;106:107–16.
Federici AB. The use of desmopressin in von Willebrand disease: the experience of the first 30 years (1977–2007). Haemophilia. 2008;14(Suppl 1):5–14.
Rose EH, Aledort LM. Nasal spray desmopressin (DDAVP) for mild hemophilia A and von Willebrand disease. Ann Intern Med. 1991;114:563–8.
Blumenfeld JD, Tepler J, Mauer A, Coller B, Bichet DG, Smith B. Tolvaptan inhibition of desmopressin effects on coagulation factors in a patient with decreased von Willebrand factor and polycystic kidney disease. Blood. 2011;118:474–6.
Chen C, Chen RP, Lin HH, Zhang WY, Huang XL, Huang ZM. Tolvaptan regulates aquaporin-2 and fecal water in cirrhotic rats with ascites. World J Gastroenterol. 2016;22(12):3363–71.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Yoshihiko Saito received lecture fees from Merck, Takeda Pharmaceutical Company, Novartis Pharma KK, Daiichi Sankyo Company, Mitsubishi Tanabe Pharma Corp, Pfizer Japan, Otsuka Pharmaceutical, and research funding from Japan Heart Foundation and the Naito Foundation. Dr. Saito belongs to the endowed Department (the Department of Regulatory Medicine of Blood Pressure) sponsored by Merck. Yasuhiro Akai received lecture fees from Dainippon-Sumitomo Pharmaceutical Company and obtained research funding from Nara Red Cross Blood Distributing Center. Other authors have no financial conflicts of interest to disclose.
This article does not contain any studies with human participants or animals performed by any of the authors.
About this article
Cite this article
Morimoto, K., Akai, Y., Matsui, M. et al. Acute pulmonary thromboembolism occurring during treatment with tolvaptan in a patient with autosomal-dominant polycystic kidney disease. CEN Case Rep 6, 61–65 (2017). https://doi.org/10.1007/s13730-016-0245-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13730-016-0245-y