Anticoagulant-related nephropathy (ARN) is a serious yet often overlooked complication of anticoagulation, increasing renal morbidity and mortality. Initially linked to high-dose warfarin, ARN is now recognized in patients with AKI and INR >3.0, also associated with direct oral anticoagulants like dabigatran and acenocoumarol. This case highlights a rare instance of acenocoumarol-induced ARN, diagnosed through clinical findings, elevated INR, and imaging. Pyelonephritis was ruled out due to negative blood and urine cultures.

A 50-year-old female on long-term Acenocoumarol therapy presented with anuria, fever, hematuria, and abdominal pain. Labs showed leukocytosis, renal impairment, and prolonged prothrombin time. Imaging confirmed hemorrhage in the perinephric and pelvicalyceal regions. Management included stopping Acenocoumarol, fresh frozen plasma, catheterization, and furosemide infusion. Urine output and renal function improved, leading to discharge on day 6 with resumed Acenocoumarol and follow-up. Diagnosis was based on clinical and imaging findings

A 50-year-old female on Acenocoumarol therapy presented with anuria, fever, and hematuria. Labs showed renal dysfunction and elevated INR, while imaging confirmed hemorrhagic changes. With anticoagulation correction and supportive care, urine output improved, renal function stabilized, and she was discharged on day six. Negative cultures confirmed Acenocoumarol-induced ARN.

This case reports a rare ARN due to Acitrom therapy in a patient with permanent atrial fibrillation. Diagnosis was based on elevated INR, imaging findings, and gross hematuria. Supportive care and coagulopathy correction ensured quick recovery, highlighting the need for high clinical suspicion.