• Hiroki Ishii, Satoshi Kurihara, Keiji Hirai, Katsunori Yanai, Susumu Ookawara, and Yoshiyuki Morishita.
• Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University.
• Medicine (Baltimore). 2020 Jun 19; 99 (25): e20724.

IntroductionThe use of warfarin in patients undergoing hemodialysis is associated with decreased bone mineral density and an increased incidence of bone fracture. However, no studies to date have directly estimated bone quality with bone histomorphometry in patients with bone abnormalities who are taking warfarin and undergoing hemodialysis.Patient ConcernsA 47-year-old female with Noonan syndrome presented with progressive bilateral lower extremity pain on walking, and skin sclerosis. She had been undergoing maintenance hemodialysis for 25 years following 2 years of peritoneal dialysis for chronic glomerulonephritis. She had been taking warfarin as an anticoagulant agent for 13 years after she underwent an aortic valve replacement.DiagnosisWarfarin-induced impairment of bone material quality.Interventions And OutcomesHistomorphometric analysis of the bone biopsy specimens showed impairment in bone calcification processes, a high turnover of bone remodeling, low bone volume, and mild fibrosis. The bone abnormality could not be categorized into any type of representative bone disease classification such as osteitis fibrosa, osteomalacia, adynamic bone disease, uremic osteodystrophy, or hyperparathyroidism, but was consistent with warfarin-induced impairment of bone material quality.ConclusionWarfarin can induce impairment of bone material quality in a patient undergoing hemodialysis.

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