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Warfarin Calcification CKD APS — ESENeph MCQ

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HardHypertensionWarfarin Calcification CKD APSESENeph

A 52-year-old woman with SLE and antiphospholipid syndrome is on Warfarin (INR target 2.5-3.5) for recurrent thrombosis. She develops CKD G4 from lupus nephritis. She is being considered for transplant listing. Her transplant team advises stopping Warfarin and switching anticoagulant. Why?

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Correct answer: B — Warfarin promotes vascular calcification (inhibits matrix Gla protein) and increases calciphylaxis risk in CKD

Warfarin inhibits vitamin K-dependent carboxylation of matrix Gla protein, a key inhibitor of vascular calcification. In advanced CKD, where vascular calcification is already accelerated, Warfarin further exacerbates this process and increases calciphylaxis risk. The decision to switch is complex: DOACs are generally not recommended in triple-positive APS (TRAPS trial showed worse outcomes), so the anticoagulation strategy requires careful multidisciplinary discussion. LMWH or dose-adjusted Warfarin with close monitoring may be needed.

Reference: UKKA 2019 – Calciphylaxis; TRAPS Trial – Blood 2020; ESC 2020