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Eneman B, Levtchenko E, van den Heuvel B, Van Geet C, Freson K. Platelet abnormalities in nephrotic syndrome. Pediatr Nephrol 2016; 31:1267-79. [PMID: 26267676 DOI: 10.1007/s00467-015-3173-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 01/08/2023]
Abstract
Nephrotic syndrome (NS) is a common kidney disease associated with a significantly increased risk of thrombotic events. Alterations in plasma levels of pro- and anti-coagulant factors are involved in the pathophysiology of venous thrombosis in NS. However, the fact that the risk of both venous and arterial thrombosis is elevated in NS points to an additional role for blood platelets. Increased platelet counts and platelet hyperactivity have been observed in nephrotic children. Platelet hyperaggregability, increased release of active substances, and elevated surface expression of activation-dependent platelet markers have been documented. The mechanisms underlying those platelet alterations are multifactorial and are probably due to changes in plasma levels of platelet-interfering proteins and lipid changes, as a consequence of nephrosis. The causal relationship between platelet alterations seen in NS and the occurrence of thromboembolic phenomena remains unclear. Moreover, the efficiency of prophylactic treatment using antiplatelet agents for the prevention of thrombotic complications in nephrotic patients is also unknown. Thus, antiplatelet medication is currently not generally recommended for routine prophylactic therapy.
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Affiliation(s)
- Benedicte Eneman
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium.
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium.
| | - Elena Levtchenko
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Bert van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | - Kathleen Freson
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
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Al-Mugeiren MM, Gader AMA, Al-Rasheed SA, Bahakim HM, Al-Momen AK, Al-Salloum A. Platelet Aggregometry - Dose-related Responses to Arachidonic Acid in Childhood Nephrotic Syndrome. Platelets 2009; 6:71-4. [DOI: 10.3109/09537109509078446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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3
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Nandish SS, Khardori R, Elamin EM. Transient Ischemic Attack and Nephrotic Syndrome: Case Report and Review of Literature. Am J Med Sci 2006; 332:32-5. [PMID: 16845239 DOI: 10.1097/00000441-200607000-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombotic complications in patients with nephrotic syndrome are attributed to a hypercoagulable state. Venous thrombosis is common, but arterial thrombosis occurs less frequently in adult nephrotic patients. We report a case of recurrent transient ischemic attacks as an initial manifestation of nephrotic syndrome due to early-stage membranous glomerulonephritis, review the literature for similar cases, and briefly discuss this potentially life-threatening condition. We observed that transient ischemic attack or ischemic stroke could be the initial manifestation of nephrotic syndrome. Our observation may serve as reminder to consider nephrotic syndrome as a possible contributor when evaluating patients with transient ischemic attacks with no other discernable clues. A high index of suspicion alone avoids the unnecessary withholding of prophylaxis or treatment that can be life saving.
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Affiliation(s)
- Shailesh S Nandish
- Department of Medicine, Southern Illinois University School of Medicine, Springfield, Illinois 62794-9636, USA.
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Abstract
Thrombosis is a frequent cause of morbidity and mortality in patients with the nephrotic syndrome. Venous thrombotic complications are well recognized but arterial complications are rare. Thrombosis is multifactorial, and has been attributed to a hypercoaguable state due to alterations in blood levels of the various factors involved in the coagulation and fibrinolytic systems, alterations in platelet function, venous stasis, haemoconcentration, increased blood viscosity and possibly the administration of steroids. Thrombosis in general and arterial thrombosis in particular is a significant and potentially serious problem in nephrotic patients. Awareness of the condition and its pathogenesis is needed. Assessment for the risk factors is required to allow appropriate prophylactic measures to be taken.
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Affiliation(s)
- I H Fahal
- Regional Renal Unit, Royal Liverpool University Hospital, UK
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Harker LA, Hanson SR. Platelet factors predisposing to arterial thrombosis. BAILLIERE'S CLINICAL HAEMATOLOGY 1994; 7:499-522. [PMID: 7841598 DOI: 10.1016/s0950-3536(05)80096-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- L A Harker
- Emory University School of Medicine, Atlanta, GA 30322
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Rabelink TJ, Zwaginga JJ, Koomans HA, Sixma JJ. Thrombosis and hemostasis in renal disease. Kidney Int 1994; 46:287-96. [PMID: 7967339 DOI: 10.1038/ki.1994.274] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- T J Rabelink
- Dept. of Nephrology and Hypertension (F03.226), University Hospital Utrecht, The Netherlands
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Zwaginga JJ, Koomans HA, Sixma JJ, Rabelink TJ. Thrombus formation and platelet-vessel wall interaction in the nephrotic syndrome under flow conditions. J Clin Invest 1994; 93:204-11. [PMID: 8282789 PMCID: PMC293754 DOI: 10.1172/jci116947] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Increased in vitro platelet aggregability and hypercoagulability are generally held to be main determinants in the prethrombotic state in nephrosis. In vivo, however, thrombotic events depend on the dynamic interaction of flowing blood with the vessel wall. The present study confirms that aggregability of platelets of nephrotic patients is significantly increased by mere stirring or by exogenous stimuli as adenosine diphosphate and arachidonic acid. Moreover, the nephrotic patients have high von Willebrand factor and decreased red blood cell deformability, which normally increase platelet-vessel wall interaction. However, perfusion studies under well-defined flow conditions, in which anticoagulated nephrotic blood was exposed to deendothelialized human umbilical artery segments and sprayed collagen, showed normal platelet adhesion and only a modest increase in the deposition of platelet aggregates. This suggests that some factor counteracts platelet-vessel wall interaction under flow conditions in the nephrotic syndrome. When tissue factor associated with endothelial extracellular matrix (ECM) was allowed to generate thrombin, perfusions with nephrotic blood over this ECM resulted in a strong increase in fibrin generation. The capacity of patient blood to form increased amounts of fibrin appeared strongly correlated with the level of hyperfibrinogenemia. Platelet adhesion as well as aggregation in these experiments was even decreased below control values. This suggests that fibrin coverage may block the direct contact between blood platelets and matrix. We therefore also studied the isolated effect of high fibrinogen on platelet-vessel wall interaction by increasing fibrinogen concentrations in normal blood. Modulation of fibrinogen concentrations in normal blood could mimic all the observations in nephrotic blood: platelet aggregation in suspension increased with increasing concentrations of fibrinogen, while platelet adhesion and aggregate formation under flow conditions decreased. In perfusions over tissue factor-rich matrix, fibrin deposition increased. Therefore, our observations indicate that nephrotic hyperaggregability in suspension is not associated with increased platelet vessel wall-interaction under flow conditions. The latter is probably counteracted by high levels of fibrinogen. Our observations further suggest that hyperfibrinogenemia may be a major thrombotic risk factor in nephrosis by inducing more fibrin depositions.
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Affiliation(s)
- J J Zwaginga
- Department of Nephrology, University Hospital Utrecht, The Netherlands
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Machleidt C, Mettang T, Stärz E, Weber J, Risler T, Kuhlmann U. Multifactorial genesis of enhanced platelet aggregability in patients with nephrotic syndrome. Kidney Int 1989; 36:1119-24. [PMID: 2532267 DOI: 10.1038/ki.1989.310] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Platelet aggregation, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF 4) release and thromboxane B2 (TxB2) formation in stimulated platelet-rich plasma were investigated in 13 patients with nephrotic syndrome who had normal serum creatinine levels (creatinine clearance greater than 70 ml/min/1.73 m2). In contrast to 13 sex- and age-matched controls, spontaneous platelet aggregation only occurred in patients with nephrotic syndrome with correlation to serum albumin and plasma fibrinogen levels. The EC50 (estimated concentration of aggregating agent to cause half maximum velocity of primary aggregation) for ADP and collagen and threshold concentration of arachidonic acid (threshold AA) were decreased in patients with nephrotic syndrome, reflecting a hyperaggregable state. In patients with nephrotic syndrome EC50 ADP values were significantly correlated to serum albumin, serum cholesterol and plasma fibrinogen, however, EC50 collagen or threshold AA did not correlate to these parameters. Plasma beta-TG levels were increased in patients, whereas plasma PF 4 levels were not significantly changed in patients compared to controls. In vitro TxB2 formation was elevated in patients only after stimulation with AA. Nevertheless, after stimulation with collagen and ADP, TxB2 formation was unchanged in patients compared to controls. Platelet hyperaggregability in nephrotic patients was confirmed in our study. However, unchanged thromboxane B2 formation after collagen stimulus as well as missing correlations between EC50 collagen or threshold AA and serum albumin were contradictory to the hypothesis that enhanced AA availability due to hypoalbuminemia is responsible for platelet hyperaggregability. Platelet hyperaggregability in terms of EC50 ADP being associated with serum albumin levels as well as to serum cholesterol and plasma fibrinogen indicate a multifactorial genesis.
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Affiliation(s)
- C Machleidt
- Department of Nephrology, Robert-Bosch-Krankenhaus Stuttgart, Federal Republic of Germany
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Goubran F, Maklady F. In vivo platelet activity and serum albumin concentration in nephrotic syndrome. BLUT 1988; 57:15-7. [PMID: 2968825 DOI: 10.1007/bf00320629] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
To clarify the relationship between serum albumin concentration and in vivo platelet activity in nephrotic syndrome, Beta-thromboglobulin (B-TG) levels and circulating platelet aggregation ratio (PAR) were determined in 25 nephrotic patients. PAR levels were significantly decreased compared with the controls and showed a positive correlation with serum albumin concentrations. The values of B-TG were high in all nephrotic patients and showed an inverse relationship with serum albumin levels. In addition, increased B-TG levels correlated with decreased PAR values. Therefore serum albumin plays a regulatory role in the activity of circulating platelets in the nephrotic syndrome. Prospective longitudinal studies must be done to elucidate the usefulness of platelet inhibitors as a prophylactic therapy of intravascular thrombosis in nephrotic patients.
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Affiliation(s)
- F Goubran
- Clinical Pathology Department, Suez Canal Medical School, Ismailia, Egypt
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12
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 34-1986. A 62-year-old Haitian woman with strokes, renal disease, and abdominal pain. N Engl J Med 1986; 315:567-77. [PMID: 3736640 DOI: 10.1056/nejm198608283150908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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13
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Llach F. Hypercoagulability, renal vein thrombosis, and other thrombotic complications of nephrotic syndrome. Kidney Int 1985; 28:429-39. [PMID: 3906225 DOI: 10.1038/ki.1985.149] [Citation(s) in RCA: 196] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Nephrotic syndrome characterized by hypoalbuminemia and hyperlipidemia is associated with an increased incidence of thromboembolism and increased platelet hyperaggregability. Although plasma coagulation proteins are also abnormal, changes are too inconsistent to attribute thromboembolic complications to the coagulation cascade alone. Antithrombin III (ATIII) has been shown to be deficient in nephrotic syndrome. There is, however, an increase in alpha 2 macroglobulin. It is clear that platelet to platelet interactions require exposure of platelet fibrinogen receptors, the binding of fibrinogen to these receptors, platelet crossbridging, and subsequent platelet aggregation. Fibrinogen is consistently elevated in nephrotic syndrome. Hyperlipidemia and hypoalbuminemia in nephrotic syndrome increases the availability of thromboxane A2 (TxA2) by increasing the availability of TxA2 precursors and the removal of TxA2 inhibitors. Thromboxane A2 is a known inducer of platelet aggregation probably through the exposure of platelet fibrinogen receptors. Recently, fibronectins a group of adhesive proteins, were implicated in platelet to platelet interactions. Since thrombin increases the expression of platelet surface fibronectin, fibronectin may be involved in thrombus formation in nephrotic syndrome. Thromboembolic formation in nephrotic syndrome is a composite mechanism involving the coagulation cascade, platelet-platelet interactions, and platelet-surface interactions.
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Kubisz P, Parizek M, Seghier F, Holan J, Cronberg S. Relationship between platelet aggregation and plasma beta-thromboglobulin levels in arterio-vascular and renal diseases. Atherosclerosis 1985; 55:363-8. [PMID: 2409989 DOI: 10.1016/0021-9150(85)90114-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The incidence of second wave of platelet aggregation induced by a small dose of ADP (1 mumol/l) was compared with plasma levels of beta-thromboglobulin in 81 normal individuals, 34 patients with acute myocardial infarction, 11 patients with acute cerebrovascular disease and 26 patients with renal disease. Platelet hyperaggregability was observed in 7% of normal individuals. Plasma levels of beta-thromboglobulin were higher in normal individuals over 60 years of age (48 vs. 32 micrograms/l). In contrast, hyperaggregability was observed in 79% of patients with acute myocardial infarction and in 64% of those with acute cerebrovascular disease. Median plasma levels of beta-thromboglobulin were also significantly elevated in patients with acute myocardial infarction (82 micrograms/ml) or acute cerebrovascular disease (99 micrograms/l). Levels of beta-thromboglobulin in plasma were significantly higher in those patients who demonstrated hyperaggregability. In patients with renal disease only 12% had signs of hyperaggregability. Nevertheless their plasma levels of beta-thromboglobulin were elevated (76 micrograms/l) and correlated with the serum creatinine values. These investigations indicate that patients with acute myocardial infarction or stroke have hyperreactive platelets and evidence of increased platelet inactivation in the circulation. However, evaluation of increased levels of beta-thromboglobulin requires consideration of renal function.
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16
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Fear JD, Jackson P, Gray C, Miloszewski KJ, Losowsky MS. Localisation of factor XIII in human tissues using an immunoperoxidase technique. J Clin Pathol 1984; 37:560-3. [PMID: 6373832 PMCID: PMC498780 DOI: 10.1136/jcp.37.5.560] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An immunoperoxidase technique has been used to localise clotting factor XIII subunits A and S in human tissues. The presence of factor XIII in placenta and megakaryocytes was confirmed. Factor XIII was also found in fibroblasts, a hitherto unreported finding. Factor XIII subunits were not detected in hepatocytes, although factor XIII was found in fibroblasts in portal tracts. These findings suggest that factor XIII is not synthesised in the liver as previously thought.
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Schieppati A, Dodesini P, Benigni A, Massazza M, Mecca G, Remuzzi G, Livio M, de Gaetano G, Rossi EC. The metabolism of arachidonic acid by platelets in nephrotic syndrome. Kidney Int 1984; 25:671-6. [PMID: 6434788 DOI: 10.1038/ki.1984.72] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The production of malondialdehyde (MDA) and thromboxane B2 (TxB2) by platelets following an arachidonic acid (AA) challenge was greater in nephrotic platelet rich plasma (PRP) than in normal PRP. The uptake of 14C-AA, and its subsequent conversion to 14C-TxB2 following a thrombin stimulus, was also greater in nephrotic than normal PRP. Normal plasma diminished the MDA production by nephrotic platelets. The addition of albumin to nephrotic PRP, or, the intravenous infusion of albumin in quantities sufficient to correct hypoalbuminemia also diminished the excessive production of prostaglandin metabolites by nephrotic platelets. The platelet aggregate ratio (PAR), which measures circulating platelet aggregates, was abnormal during the acute phase of nephrotic syndrome but reverted to normal following remission. These data indicate that hypoalbuminemia is associated with increased AA metabolism by platelets and suggest that platelet "hyperactivity" may contribute to the proclivity toward thrombosis observed in nephrotic syndrome.
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Self-assessment questions. Dis Mon 1982. [DOI: 10.1016/0011-5029(82)90631-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Douglas JT, Lowe GD, Forbes CD, Prentice CR. Beta-thromboglobulin and platelet counts - effect of malignancy, infection, age and obesity. Thromb Res 1982; 25:459-64. [PMID: 6180499 DOI: 10.1016/0049-3848(82)90087-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Plasma levels of beta-thromboglobulin (BTG) and platelet count were studied in 69 control subjects, 19 patients with operable abdominal malignancy, and 9 patients with acute bacterial infection. In control subjects there was a significant rise in BTG and fall in platelet count with age, and a negative correlation of BTG with obesity. BTG and platelet count were normal in patients with operable malignancy, but significantly increased in patients with acute bacterial infection. These effects must be considered in studies of BTG and thrombosis.
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