Introduction. Dabigatran is an oral direct thrombin inhibitor which has been 
approved for prophylaxis of stroke in patients with atrial fibrillation. The use 
of dabigatran etexilate increased rapidly due to many benefits. However, 
questions have been raised constantly regarding the safety of dabigatran 
etexilate. Case. A 58-year-old Caucasian male with a history of recurrent 
paroxysmal atrial fibrillation status after pacemaker and end-stage renal 
disease on hemodialysis came to the Emergency Department with the complaint of 
severe epistaxis. He had been started on dabigatran 150 mg twice a day about 4 
months ago as an outpatient by his cardiologist. His prothrombin time (PT) was 
63 seconds with international normalized ratio (INR) of 8.8 and his activated 
partial thromboplastin time (aPTT) was 105.7 seconds. Otherwise, all labs were 
unremarkable including the liver function test. Dabigatran was stopped 
immediately. His INR and aPTT trended downward, reaching normal levels 5 days 
after admission. Conclusion. Dabigatran is contraindicated in patients with 
severe kidney insufficiency as it is predominantly excreted via the kidney 
(~80%). Elderly patients over 75 and patients with chronic renal impairment 
should be carefully evaluated before starting dabigatran. Despite studies 
showing only mild increase in aPTT and PT/INR in patients receiving dabigatran, 
close monitoring may be reasonable in patients with renal insufficiency.