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Zheng Z, Pandit K, Chang AR, Shin JI, Charytan DM, Grams ME, Surapaneni A. Association of eGFR and Albuminuria with Venous Thromboembolism. Clin J Am Soc Nephrol 2024; 19:301-308. [PMID: 37971889 PMCID: PMC10937012 DOI: 10.2215/cjn.0000000000000352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND CKD has been implicated as a risk factor of venous thromboembolism, but the evidence is limited to relatively healthy populations. The objective of this study was to discern whether parameters of kidney function and damage are associated with the occurrence of venous thromboembolism after hospitalization. METHODS We conducted a retrospective study including 23,899 and 11,552 adult individuals hospitalized within Geisinger Health System and New York University (NYU) Langone Health from 2004 to 2019 and 2012 to 2022, respectively. A Poisson model was used to evaluate adjusted incidence rates of venous thromboembolism according to eGFR and albuminuria categories in each cohort. Cox proportional hazards models were used to analyze associations of eGFR and urinary albumin-to-creatinine ratio (UACR) with venous thromboembolism, and hazard ratios (HRs) were meta-analyzed across cohorts. RESULTS Both lower eGFR and higher UACR were associated with higher risks of venous thromboembolism. In the Geisinger cohort, the incidence of venous thromboembolism after hospital discharge ranged from 10.7 (95% confidence interval [CI], 9.2 to 12.6) events per 1000 person-years in individuals in G1A1 (eGFR >90 ml/min per 1.73 m 2 and UACR <30 mg/g) to 27.7 (95% CI, 20.6 to 37.2) events per 1000 person-years in individuals with G4-5A3 (eGFR <30 ml/min per 1.73 m 2 and UACR >300 mg/g). A similar pattern was observed in the NYU cohort. Meta-analyses of the two cohorts showed that every 10 ml/min per 1.73 m 2 reduction in eGFR below 60 ml/min per 1.73 m 2 was associated with a 6% higher risk of venous thromboembolism (HR 1.06 [95% CI, 1.02 to 1.11], P = 0.01), and each two-fold higher UACR was associated with a 5% higher risk of venous thromboembolism (HR 1.05 [95% CI, 1.03 to 1.07], P < 0.001). CONCLUSIONS Both eGFR and UACR were independently associated with higher risk of venous thromboembolism after hospitalization. The incidence rate was higher with greater severity of CKD. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_14_CJN0000000000000352.mp3.
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Affiliation(s)
- Zhong Zheng
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Krutika Pandit
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David M. Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Morgan E. Grams
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Aditya Surapaneni
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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De Pascali F, Brunini F, Rombolà G, Squizzato A. Efficacy and safety of prophylactic anticoagulation in patients with primary nephrotic syndrome: a systematic review and meta-analysis. Intern Med J 2024; 54:214-223. [PMID: 37713623 DOI: 10.1111/imj.16227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/13/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND AND AIMS Nephrotic syndrome (NS) is associated with an increased incidence of venous thromboembolism (VTE), approximately 10%. We performed a systematic review to evaluate the efficacy and safety of prophylactic anticoagulation in patients with NS. METHODS Studies evaluating prophylactic anticoagulation in NS were identified by an electronic search of MEDLINE and EMBASE databases until December 2021. Weighted mean proportion and 95% confidence intervals (CIs) of thromboembolic and haemorrhagic events were calculated using a fixed-effects and a random-effects model. The differences in the outcomes among groups were estimated as pooled odds ratio (OR) and corresponding 95% CI. Statistical heterogeneity was evaluated using the I2 statistic. RESULTS Five cohort studies, for a total of 414 adult patients, were included. Only two studies had a control group. The weighted mean incidence of pulmonary embolism (PE) and deep vein thrombosis in patients who received VTE prophylaxis was 1.8% (95% CI: 0.6-3.5%; I2 : 4.4%) and 0.9% (95% CI: 0.2-2.2%; I2 : 43.4%) respectively. The weighted mean incidence of major bleeding in patients who received VTE prophylaxis was 2.3% (95% CI: 1-4.2%; I2 : 25.4%). Patients with NS that received VTE prophylaxis had a non-significant reduced risk of PE (OR: 0.63 (95% CI: 0.03-14.8; I2 : 64.4%)) and an increased risk of major bleeding (OR: 2.08 (95% CI: 0.41-10.45; I2 : 0%)) compared to patients with NS that did not receive VTE prophylaxis. CONCLUSIONS Our findings suggest that prophylactic anticoagulation in adult patients with primary NS may reduce the risk of VTE, even if it may be associated with a not negligible bleeding risk.
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Affiliation(s)
- Federica De Pascali
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | - Francesca Brunini
- Nephrology Unit, 'Ospedale di Circolo', ASST Sette Laghi, Varese, Italy
| | - Giuseppe Rombolà
- Nephrology Unit, 'Ospedale di Circolo', ASST Sette Laghi, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
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Gao XY, Liu YM, Zheng DN, Li YW, Li H, Xiong XL, Chen HY, Wang H, Yu XY, Qu K, Jin J, Lin B, He Q. Comparison of the prophylactic antithrombotic effect of indobufen and warfarin in patients with nephrotic syndrome: a randomized controlled trial. Ren Fail 2023; 45:2163505. [PMID: 36636998 PMCID: PMC9848225 DOI: 10.1080/0886022x.2022.2163505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The risk of thromboembolic events is elevated in patients with nephrotic syndrome, and warfarin use has been associated with an increased risk of bleeding. Indobufen, a selective cyclooxygenase-1 inhibitor, is currently being evaluated for the prevention of thromboembolic events in nephrotic syndrome. This study aimed to compare the efficacy and safety of indobufen with that of warfarin in patients with nephrotic syndrome. MATERIALS AND METHODS This multicenter, randomized, three-arm, open-label, parallel controlled trial involved a total of 180 adult patients with nephrotic syndrome from four centers in China. Patients were randomly assigned to receive 100 mg indobufen (bid), 200 mg indobufen (bid), and 3 mg warfarin (qd) daily for 12 weeks. The primary endpoints included thromboembolic and bleeding events, while laboratory results and adverse events constituted secondary endpoints. RESULTS No thromboembolic events occurred in the high-/low-dose indobufen and warfarin groups. Moreover, the use of a low dose of indobufen significantly reduced the risk of minor bleeding events compared with warfarin use (2% versus 18%, p < .05). Finally, adverse events were more frequent in warfarin-treated patients. CONCLUSIONS This study found that indobufen therapy provided equivalent effects in preventing thromboembolic events compared with warfarin therapy, while low dose of indobufen was associated with a reduced risk of bleeding events, thus it should be recommended for the prevention of thromboembolic events in clinical practice in patients with nephrotic syndrome. TRIAL REGISTRATION NUMBER ChiCTR-IPR-17013428.
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Affiliation(s)
- Xin-Yi Gao
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yue-Ming Liu
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Dan-Na Zheng
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yi-Wen Li
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Hua Li
- Department of Nephrology, Sir Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Ling Xiong
- Department of Nephrology, Sir Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong-Yu Chen
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Hua Wang
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Xiao-Yong Yu
- Department of Nephrology, Shaanxi Traditional Chinese Medicine Hospital, Xi’an, China
| | - Kai Qu
- Department of Nephrology, Shaanxi Traditional Chinese Medicine Hospital, Xi’an, China
| | - Juan Jin
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China,Juan Jin
| | - Bo Lin
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China,Bo Lin Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qiang He
- Department of Nephrology, First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China,CONTACT Qiang He Department of Nephrology, First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, China
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Torun C, Vural Keskinler M, Mesci B. Renal Vein Thrombosis Associated with Nephrotic Syndrome and Factor V Leiden. Indian J Nephrol 2023; 33:478-479. [PMID: 38174311 PMCID: PMC10752399 DOI: 10.4103/ijn.ijn_37_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Cundullah Torun
- Department of Internal Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Kadikoy/Istanbul, Turkey
| | - Mirac Vural Keskinler
- Department of Internal Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Kadikoy/Istanbul, Turkey
| | - Banu Mesci
- Department of Internal Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Kadikoy/Istanbul, Turkey
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Zhang L, Li C, Hua Z, Xu P, Jiao Z, Cao H, Liu S, Guo C, Li Z. Comparative outcomes of anticoagulation alone versus anticoagulation plus endovascular intervention in adults with isolated renal vein thrombosis. J Vasc Surg Venous Lymphat Disord 2023; 11:816-823. [PMID: 37062360 DOI: 10.1016/j.jvsv.2023.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Limited therapeutic strategies are available for adults with isolated renal vein thrombosis (RVT). In the present study, we explore and compare the efficacy of anticoagulation therapy alone vs anticoagulation plus endovascular intervention in the treatment of this rare disease. METHODS In the present study, we analyzed the clinical data of RVT patients treated in a tertiary referral center in urban China from April 2012 to April 2022. These patients were classified into anticoagulation therapy (best medical treatment [BMT]) and endovascular intervention (endovascular-based treatment [EBT]) groups. The primary end points, including thrombus clearance and renal function changes, were evaluated by measuring the serum creatinine levels and glomerular filtration rates (GFRs). RESULTS A total of 40 consecutive patients with RVT (25 men and 15 women) were included in the present study, with a median age of 37 years (range, 18-72 years). Some patients developed symptoms, including 12 with low back pain (30%), 11 with lower extremity edema (28%), and 10 with abdominal pain (30%). Nephrotic syndrome was the underlying etiology for most patients (30 of 40; 75%). Additionally, 28 patients (70%) developed unilateral RVT, including 18 cases of left RVT (45%). Of the 40 patients, 17 had received BMT (42%) and 23 had received EBT (58%). In the acute phase of RVT, defined as <14 days from symptom onset, the EBT group had higher thrombus clearance and better improvement of creatinine and GFR after treatment compared with the BMT group (P < .05). In the subacute phase, defined as 14 to 30 days after symptom onset, thrombus clearance was higher in the EBT group than in the BMT group (P < .05). However, the improvement in creatinine and GFR were insignificantly different between the two groups (P > .05). CONCLUSIONS The etiologies of RVT can and should be investigated. In the present study, RVT was primarily caused by nephrotic syndrome in young patients and also was attributed to malignancy and lupus nephritis. In addition to anticoagulation therapy, endovascular intervention, including catheter-directed thrombolysis and mechanical thrombectomy, contributed to the improvement of renal function in patients with acute RVT. Endovascular intervention markedly promoted thrombus clearance in patients in the subacute phase but did not improve renal function. Therefore, endovascular intervention should be considered if RVT is diagnosed in the acute phase.
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Affiliation(s)
- Linfeng Zhang
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chong Li
- Division of Vascular Surgery, New York University Langone Health, New York, NY
| | - Zhaohui Hua
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Xu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhouyang Jiao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Cao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shirui Liu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunguang Guo
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Zabala Ramirez MJ, Stein EJ, Jain K. Nephrotic Syndrome for the Internist. Med Clin North Am 2023; 107:727-737. [PMID: 37258010 DOI: 10.1016/j.mcna.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Nephrotic syndrome (NS) is a key clinical entity for the internist to recognize and understand. A wide range of infectious, metabolic, malignant, and autoimmune processes drive nephrosis, leading to a syndrome defined by proteinuria, edema, and hypoalbuminemia. NS occurs due to increased permeability to proteins at the level of the glomerulus, which allows for passage of albumin and other proteins into the urine. Proteinuria leads to a cascade of clinical complications characterized by fluid accumulation, kidney inflammation, and dysregulation of coagulation and immunity. In this article, the authors review the clinically important etiologies of NS that should inform an initial clinical evaluation.
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Affiliation(s)
- Maria Jose Zabala Ramirez
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, 7024 Burnett Womack Building, CB 7155, Chapel Hill, NC 27599, USA
| | - Eva J Stein
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, 7024 Burnett Womack Building, CB 7155, Chapel Hill, NC 27599, USA
| | - Koyal Jain
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, 7024 Burnett Womack Building, CB 7155, Chapel Hill, NC 27599, USA.
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Dhaese SAM, De Vriese AS. Oral Anticoagulation in Patients With Advanced Chronic Kidney Disease and Atrial Fibrillation: Beyond Anticoagulation. Mayo Clin Proc 2023; 98:750-770. [PMID: 37028979 DOI: 10.1016/j.mayocp.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/14/2022] [Accepted: 01/06/2023] [Indexed: 04/09/2023]
Abstract
The optimal approach to prevent stroke and systemic embolism in patients with advanced chronic kidney disease (CKD) and atrial fibrillation remains unresolved. We conducted a narrative review to explore areas of uncertainty and opportunities for future research. First, the relationship between atrial fibrillation and stroke is more complex in patients with advanced CKD than in the general population. The currently employed risk stratification tools do not adequately discriminate between patients deriving a net benefit and those suffering a net harm from oral anticoagulation. Anticoagulation initiation should probably be more restrictive than is currently advocated by official guidelines. Recent evidence reveals that the superior benefit-risk profile of non-vitamin K antagonist oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) observed in the general population and in moderate CKD can be extended to advanced CKD. The NOACs yield better protection against stroke, cause less major bleeding, are associated with less acute kidney injury and a slower decline of CKD, and are associated with a lower incidence of cardiovascular events than VKAs. The VKAs may be harmful in CKD patients, in particular in patients with a high bleeding risk and labile international normalized ratio. The better safety and efficacy of NOACs as opposed to VKAs may be particularly evident in advanced CKD as a result of better on-target anticoagulation with NOACs, harmful off-target vascular effects of VKAs, and beneficial off-target vascular effects of NOACs. The intrinsic vasculoprotective effects of NOACs are supported by animal experimental evidence as well as by findings of large clinical trials and may result in use of NOACs beyond their anticoagulant properties.
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Affiliation(s)
- Sofie A M Dhaese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium, and Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium, and Department of Internal Medicine, Ghent University, Ghent, Belgium.
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Sirvent AE, Urzola-Rodríguez G, Lorenzo A, Callejas-Martínez R, Saiz A, Calle-García L, Molina-Ordás Á, Rodríguez-Gómez A, Martin-Varas C, Fernández-Reyes-Luis MJ. Arterial thrombosis in a patient with nephrotic syndrome and antithrombin Cambrigde II. Nefrologia 2023; 42:729-731. [PMID: 36870820 DOI: 10.1016/j.nefroe.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 03/06/2023] Open
Affiliation(s)
- Ana Esther Sirvent
- Servicio de Nefrología, Complejo Asistencial de Segovia, Segovia, Spain.
| | | | - Alicia Lorenzo
- Servicio de Hematología, Complejo Asistencial de Segovia, Segovia, Spain
| | | | - Ana Saiz
- Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Pradhan J, Han S, Girishkumar H. A patient with spontaneous bilateral renal vein thrombosis but no risk factors. Int J Surg Case Rep 2023; 104:107963. [PMID: 36889156 PMCID: PMC10015233 DOI: 10.1016/j.ijscr.2023.107963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/17/2023] [Accepted: 02/26/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Spontaneous bilateral renal vein thrombosis is a rare condition, especially when the patient has no risk factors. CASE PRESENTATION In this report, we describe a patient with bilateral renal vein thrombosis who presented with severe flank pain, renal functions remained normal, and the thrombus resolved completely with anticoagulation. There is no history of hypercoagulable condition in our patient. A one-year followup with CT angiogram revealed that the kidney was functioning normally and that the thrombus in the renal veins had completely resolved. CLINICAL DISCUSSION Management of an acute renal vein thrombosis depends upon whether the patient presents with acute kidney injury. In general, patients without acute kidney injury can be treated with therapeutic anticoagulation, whereas those with acute kidney injury should undergo dissolution or removal of the thrombus with thrombolytic therapy with or without thrombectomy. CONCLUSION Diagnosis of spontaneous renal vein thrombosis requires a high index of suspicion. Patient can be managed with therapeutic anticoagulation if renal function is intact. If thrombolysis and/or thrombectomy are performed on time, kidney function can be fully restored.
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Affiliation(s)
- Jigyasha Pradhan
- Department of Surgery, BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shiwei Han
- Department of Surgery, BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hanasoge Girishkumar
- Department of Surgery, BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Research progress of nephrotic syndrome accompanied by thromboembolism. Int Urol Nephrol 2023:10.1007/s11255-023-03474-8. [PMID: 36757656 DOI: 10.1007/s11255-023-03474-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
Thromboembolism (TE) is a common and serious complication of nephrotic syndrome (NS). NS is associated with hypercoagulability, which may be induced by changes in coagulation, anticoagulant, and fibrinolytic factors. Moreover, accumulating evidence supports the hypothesis that the complex interactions between genetic and acquired risk factors in TE should be considered and that genetic susceptibility should not be ignored. Extracellular vesicles (EVs) also play unique roles. Further research on EVs may provide new insights into the discovery and treatment of TE associated with NS. The occurrence of NS accompanied by TE may be associated with various risk factors. Preventive anticoagulant therapy can not only reduce the risk of TE in patients but also aggravate the risk of bleeding. Heparin and vitamin K antagonists (VKAs), traditional anticoagulant drugs, have been extensively applied in the prevention and treatment of thromboembolic diseases, and emerging direct oral anticoagulants (DOACs) also provide an alternative choice. Owing to the particularity of NS, the safe application of DOACs still needs to be addressed. This review aimed to comprehensively describe the pathophysiology of TE in NS, as well as analyze the associated risk factors, the opportunity for preventive anticoagulation, and current anticoagulant information.
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Sinha P, Singh V, Siddiqui E. Free Flap Reconstruction in a Tongue Cancer Patient with Nephrotic Syndrome: A Case Report. Indian J Otolaryngol Head Neck Surg 2022; 74:5814-5816. [PMID: 36742881 PMCID: PMC9895210 DOI: 10.1007/s12070-021-02406-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Free flap has become crucial for reconstruction in head and neck oncology post resection since the time of its advent. It has shown a high success rate and provides a better quality of life over loco regional flaps. Literature has shown the success of free flaps does get influenced by preexisting medical conditions of the patient. Nephrotic syndrome being a hypercoagulable state doesn't find much mention in literature and its effect on free flaps has been less studied. Hence, using a free flap in such condition creates a decision making dilemma. Here we present a case report to show the feasibility of such flaps in nephrotic syndrome patients under structured environment successfully.
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Affiliation(s)
- Piyush Sinha
- Department of Head and Neck Oncology, Medanta Hospital, Lucknow, India
| | - Vivekanand Singh
- Department of Head and Neck Oncology, Medanta Hospital, Lucknow, India
| | - Ehsanuzzaman Siddiqui
- Department of Plastic and Reconstructive Surgery, Dharamshila Hospital, New Delhi, India
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Zhao YL, Zhang XH, Guo F, Wei Y, Shang JH, Luo XD. Yi Shen An, a Chinese traditional prescription, ameliorates membranous glomerulonephritis induced by cationic bovine serum albumin in rats. PHARMACEUTICAL BIOLOGY 2022; 60:163-174. [PMID: 35001799 PMCID: PMC8745358 DOI: 10.1080/13880209.2021.2021947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 11/15/2021] [Accepted: 12/19/2021] [Indexed: 06/14/2023]
Abstract
CONTEXT Yi Shen An (YSA) is an investigational composite of traditional Chinese medicine (Reference: 2010L000974) for the treatment of renal disease. OBJECTIVE To investigate the protective effects of YSA against membranous glomerulonephritis (MGN). MATERIALS AND METHODS Male Sprague-Dawley rats were injected with cationic bovine serum albumin (C-BSA) to create a model of MGN. Then, rats were orally treated with YSA at doses of 0.25, 0.5, 1 and 2 g/kg for 35 successive days; prednisone (5 mg/kg) was used as a positive control. At the end of the experimental period, we performed a series of tests, including 24 h urinary protein, and biochemical, immunological, antioxidative, coagulation indices, and histopathological examination. RESULTS YSA-1 g/kg significantly lowered urinary protein from 68.37 to 30.74 mg (p < 0.01). Meantime, total protein (TP) and albumin (ALB) recovered from 66.26 and 20.51 g/L to 76.08 and 35.64 g/L (p < 0.01), respectively. YSA removed the deposition of immunoglobulin G (IgG) and complement 3c (C3c), prevented inter-capillary cell hyperplasia on the glomerular basement membrane (GBM), and reduced electron-dense deposits and fusion of podocytes. In addition, serum IgG and superoxide dismutase were significantly elevated. In contrast, malondialdehyde, total cholesterol, triglyceride, circulating immune complex (CIC), and immunoglobulin M decreased in the YSA-treated group. Moreover, the blood coagulation dysfunction was adjusted. DISCUSSION AND CONCLUSIONS These findings indicate YSA may exert a therapeutic effect against MGN through the inhibition of CIC formation, and the removal of IgG and C3c deposition from the GBM, thus supporting the development of further clinical trials.
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Affiliation(s)
- Yun-Li Zhao
- Key Laboratory of Medicinal Chemistry for Natural Resource, Ministry of Education, Yunnan Provincial Center for Research & Development of Natural Products, School of Chemical Science and Technology, Yunnan University, Kunming, P. R. China
| | - Xiang-Hua Zhang
- New Drug R&D Department of Kunming Institute of Kidney Disease, Kunming, P. R. China
| | - Feng Guo
- New Drug R&D Department of Kunming Institute of Kidney Disease, Kunming, P. R. China
| | - Ying Wei
- Shang Hai University of Medicine & Health Sciences, Shang Hai, P. R. China
| | - Jian-Hua Shang
- State Key Laboratory of Phytochemistry and Plant Resources in West China, Kunming Institute of Botany, Chinese Academy of Sciences, Kunming, P. R. China
| | - Xiao-Dong Luo
- Key Laboratory of Medicinal Chemistry for Natural Resource, Ministry of Education, Yunnan Provincial Center for Research & Development of Natural Products, School of Chemical Science and Technology, Yunnan University, Kunming, P. R. China
- State Key Laboratory of Phytochemistry and Plant Resources in West China, Kunming Institute of Botany, Chinese Academy of Sciences, Kunming, P. R. China
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13
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Odimegwu CL, Ikefuna AN, Okafor HU, Nwagha T, Ubesie A, Chinawa JM. Haemostatic profile of children with nephrotic syndrome attending University of Nigeria Teaching Hospital Ituku-Ozalla, Nigeria. BMC Nephrol 2022; 23:274. [PMID: 35927678 PMCID: PMC9351170 DOI: 10.1186/s12882-022-02894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
Background Haemostatic derangements are thought to be due to an imbalance between hepatic synthesis of pro-coagulants and urinary losses of anticoagulants. Objectives This study evaluated the coagulation profile of Nigerian children with nephrotic syndrome and examined the relationship between coagulation variables, disease state and steroid responsiveness. Methods A cross- sectional hospital based study on evaluation of coagulation profile of children with nephrotic syndrome compared with their age- and gender- matched controls. Results The median fibrinogen level in subjects and controls was the same (2.9 g/L). Sixteen of 46 (35%) children with nephrotic syndrome had hyperfibrinogenaemia. The median fibrinogen level of children in remission was 2.3 g/L and differed significantly when compared with those of children in relapse (p = 0.001). The median APTT of children with nephrotic syndrome was 45.0 s and differed significantly compared with those of controls (42.0 s) (p value = 0.02). The median prothrombin time in children with and without nephrotic syndrome were 12.0 and 13.0 s respectively, (p = 0.004). About 90% of children with nephrotic syndrome had INR within reference range. Thrombocytosis was found in 15% of children with nephrotic syndrome. The median platelet count in children with new disease was 432 × 103cells/mm3 and differed significantly when compared with those of controls (p = 0.01). INR was significantly shorter in children with steroid resistant nephrotic syndrome (SRNS) (median 0.8 s; IQR 0.8 -0.9 s) compared with controls (median 1.0 s; IQR 1.0 -1.1 s) (p = 0.01). Steroid sensitivity was the strongest predictor of remission in children with nephrotic syndrome; steroid sensitive patients were 30 times more likely to be in remission than in relapse (OR 30.03; CI 2.01 – 448.04). Conclusion This study shows that the haemostatic derangements in childhood nephrotic involve mostly fibrinogen, APTT, PT, INR and platelet counts. Antithrombin levels are largely unaffected. Variations in fibrinogen, APTT, PT and INR values may be due to the heterogeneous nature of the disease.
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Affiliation(s)
- Chioma L Odimegwu
- Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu, Nigeria
| | - Anthony N Ikefuna
- Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu, Nigeria
| | - Henrietta U Okafor
- Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu, Nigeria
| | - Theresa Nwagha
- Department of Haematology and Blood Transfusion, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Agozie Ubesie
- Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu, Nigeria
| | - Josephat M Chinawa
- Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu, Nigeria.
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14
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Yasui Y, Ishii T, Tatebe J, Morita T. Comparative analysis on characteristics of two activated partial thromboplastin time reagents. J Clin Lab Anal 2022; 36:e24608. [PMID: 35853032 PMCID: PMC9459292 DOI: 10.1002/jcla.24608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 06/05/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background For the lack of standardized activated partial thromboplastin time (APTT), it has been pointed out that there are differences in values among several reagents. Recently, we have performed a parallel measurement on two reagents, Thrombocheck APTT‐SLA and Coagpia APTT‐n, and resulted with some dissociated samples. The purpose of this study is to clarify the possible factors related to ΔAPTT, the difference in measured values between the two reagents. Materials and Methods In order to clarify the factors related to ΔAPTT, multiple regression analysis was performed on 8324 samples, using clinical laboratory data of all test items requested simultaneously with APTT. To confirm the items extracted from the multiple regression analysis, the target substance was spiked to pooled plasma and measured with two APTT reagents. Additionally, by spiking phospholipids, the effect on APTT measurement system was assessed. Result Multiple regression analysis detected albumin–globulin ratio (AGR), C‐reactive protein (CRP), hematocrit, and prothrombin time as factors related to ΔAPTT (p < 0.001). Results revealed no significant differences when albumin was added to change the AGR. Whereas with the addition of CRP, prolongation of APTT was observed in Coagpia APTT‐n compared to Thrombocheck APTT‐SLA (p < 0.001). This prolongation was canceled by the addition of phospholipids, suggesting the interaction of CRP with phospholipids leads to the pseudo‐prolongation. Conclusion It is considered that the pseudo‐prolongation of APTT is triggered by the interaction of CRP on the phospholipid in Coagpia APTT‐n, which contributed to the APTT dissociation.
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Affiliation(s)
- Yutaro Yasui
- Department of Laboratory Medicine Toho University Graduate School of Medicine Tokyo Japan
- Department of Clinical Laboratory Toho University Omori Medical Center Tokyo Japan
| | - Toshiaki Ishii
- Department of Clinical Laboratory Toho University Omori Medical Center Tokyo Japan
| | - Junko Tatebe
- Department of Laboratory Medicine, Faculty of Medicine Toho University Tokyo Japan
| | - Toshisuke Morita
- Department of Clinical Laboratory Toho University Omori Medical Center Tokyo Japan
- Department of Laboratory Medicine, Faculty of Medicine Toho University Tokyo Japan
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15
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Wu T, Tang LV, Hu Y. Venous Thromboembolism in Kidney Diseases and Genetic Predisposition. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:181-189. [PMID: 35702706 PMCID: PMC9149476 DOI: 10.1159/000523777] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Many renal diseases have been associated with profound clinical effects on thrombosis. To our knowledge, patients with nephrotic syndrome (NS) and chronic kidney disease (CKD) display an elevated risk of vein thrombosis, which is among the common causes of mortality in patients with renal diseases. In addition, venous thrombosis, as a complication, has also been reported in a variety of other renal diseases such as glomerulonephritis without the NS, hypertensive nephropathy, and polycystic kidney disease. With the increasing incidence of kidney diseases and the deeper understanding of the disease, clinicians are becoming more and more aware of the complications of thrombus formation in kidney disease. SUMMARY We reviewed recent publications of vein thrombosis in kidney diseases, including primary and secondary glomerular diseases, CKD, hereditary kidney disease, renal transplantation, and hemodialysis-induced, catheter-related thrombus, focusing mainly on the main clinical manifestations, possible mechanisms, related risk factors as well as hereditary influencing factors. KEY MESSAGES Vein thrombosis is a complicated complication of a wide spectrum of kidney diseases due to different possible underlying mechanisms.
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16
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Zhu H, Xu L, Liu X, Liu B, Zhai C, Wang R, Yang X. Anti-PLA2R antibody measured by ELISA predicts the risk of vein thrombosis in patients with primary membranous nephropathy. Ren Fail 2022; 44:594-600. [PMID: 35380081 PMCID: PMC8986254 DOI: 10.1080/0886022x.2022.2057861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Primary membranous nephropathy (PMN) is associated with the highest risk for developing venous thrombosis compared with other nephrotic diseases. The aim of the study was to assess the predictive value of the pathognomonic anti-phospholipase A2 receptor (PLA2R) antibody with regard to incidence of venous thrombosis in PMN. Methods A total of 365 in-hospital patients diagnosed with PMN were enrolled in the study. Anti-PLA2R antibody was detected by commercial enzyme-linked immunosorbent assay. Multivariate logistic regression was used to detect the independent risk factors for venous thrombosis. Results Thirty-seven patients (10.14%) had venous thrombosis. Patients with venous thrombosis had higher levels of cholesterol (CHOL), low-density lipoprotein (LDL), and D-dimer than those without venous thrombosis (p < .05). Patients with venous thrombosis had significantly lower levels of albumin (23.95 ± 5.53 vs. 26.18 ± 6.59 g/L, p = .049). No significant differences were found in proteinuria, serum creatinine, estimated glomerular filtration rate, platelets, and fibrinogen between patients with and without thrombosis. Anti-PLA2R antibody levels in patients with venous thrombosis were significantly higher than in patients without it (p = .002). In the univariate logistic regression, Ln anti-PLA2R antibody (OR: 1.340; p = .004), albumin (OR: 0.945; p = .050), CHOL (OR: 1.191; p = .006), and LDL (OR: 1.271, p = .006) were associated with venous thrombosis. Ln anti-PLA2R antibody (OR = 1.269; 95%CI: 1.032–1.561), and LDL (OR = 1.213; 95%CI: 1.017–1.448) were the independent risk factors for venous thrombosis (p < .05) in multivariate analysis. Conclusions Anti-PLA2R antibody was the independent risk factor for venous thrombosis in PMN. Larger prospective studies were warranted to verify the results in future.
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Affiliation(s)
- Huizi Zhu
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Liang Xu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiang Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiaowei Yang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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17
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Revythis A, Boussios S, Ganesh V, Sarkar R. Case of cerebral venous thrombosis on a patient with background of nephrotic syndrome. BMJ Case Rep 2022; 15:e248329. [PMID: 35236700 PMCID: PMC8895991 DOI: 10.1136/bcr-2021-248329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 11/04/2022] Open
Abstract
Hypercoagulability is a well-described feature of nephrotic syndrome. The risk of developing a venous thrombus is higher at the time of diagnosis or shortly after. The resulting deep vein thrombosis involves the pulmonary, the deep veins of the lower limbs and renal veins, as described in the literature. We present a case of a man in his 20s with background of nephrotic syndrome, diagnosed at an age of 3 years old, with multiple relapses and on maintenance immunosuppression which is unusual, in two respects: First, the site of thrombosis was in the cerebral venous sinus and second, the onset of the thrombotic episode was years after the initial diagnosis. This case report also focuses on the perspective of the patient, who experienced a rare complication after more than two decades of living with the condition. In a literature search with the search words of 'nephrotic syndrome' AND 'cerebral venous thrombosis in adults', written in English and published from 1970 to 2/2021, we could only find a review article including 5 cases and 10 individual case reports, of which there were only 16 number of cerebral sinus venous thrombosis reported.
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Affiliation(s)
- Antonios Revythis
- Department of Respiratory Medicine, Medway Maritime Hospital, Gillingham, UK
| | - Stergios Boussios
- Department of Medical Oncology, Medway Maritime Hospital, Gillingham, UK
- School of Cancer & Pharmaceutical Sciences, King's College London Faculty of Life Sciences and Medicine, London, UK
| | | | - Rahuldeb Sarkar
- Intensive Care Unit, Medway Maritime Hospital, Gillingham, UK
- Faculty of Life Sciences, King's College London, London, UK
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18
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Haimowitz M, Gonzalez L. Renal Vein Thrombosis on Point-of-care Ultrasound in the Emergency Department: A Case Report. Clin Pract Cases Emerg Med 2022; 6:17-20. [PMID: 35226840 PMCID: PMC8885229 DOI: 10.5811/cpcem.2021.9.53714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction This case report of renal vein thrombosis found on emergency bedside
ultrasound illustrates the expanding role of point-of-care ultrasound
(POCUS) in rapidly identifying rare renal pathologies. Case Report A 16-year-old female with a complex medical history presenting with
right-sided abdominal pain and tenderness was found to have significant
renal POCUS findings consistent with renal vein thrombosis. Conclusion In the medically complex patient with nonspecific chief complaints, it can be
challenging to rapidly narrow a broad differential diagnosis. Point-of-care
ultrasound has proven to be an extremely useful tool for this purpose. As
emergency physicians become more proficient in the use of ultrasonography,
it is likely that POCUS will be used with increasing frequency to identify
additional pathology outside its traditional applications.
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Affiliation(s)
- Michelle Haimowitz
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Laura Gonzalez
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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19
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Bankole AA, Nwaonu JN. The Shifting Landscape of Lupus Nephritis Management: A Review. Cureus 2022; 14:e20950. [PMID: 35154930 PMCID: PMC8815326 DOI: 10.7759/cureus.20950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is commonly the first autoimmune disease that comes to mind for most people when rheumatology is mentioned. It remains an enigma that many of us, including patients and healthcare providers, do not fully understand. Although an ancient disease, it still remains difficult to both diagnose and treat. Historically, there has always been a paucity of therapeutic interventions for SLE as a whole. One of the most distressing manifestations for the patient and diagnostic and therapeutically challenging aspects of SLE is lupus nephritis (LN). There has historically been some difficultly in the development of LN drugs that provide significant therapeutic benefits while having an acceptable side-effect profile. This difficulty led to decades in which no drugs were approved for LN. With a better understanding of the pathogenesis of SLE and LN and improvement in trial design, great therapeutic strides have recently been made. The immunosuppressive landscape of LN has changed recently with the approval of two newer agents as well as a number of promising trials in LN. With the increased number of therapeutic agents (both immunosuppressive and non-immunosuppressive), the clinical question is how and when to use these medications, and, more importantly, which agents to use first. With the increased number of agents, the answers to these questions are becoming more difficult to answer. The purpose of the paper is to review updates in LN diagnosis and management.
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20
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Matyjek A, Rymarz A, Nowicka Z, Literacki S, Rozmyslowicz T, Niemczyk S. Anti-Xa Activity of Enoxaparin for Prevention of Venous Thromboembolism in Severe Nephrotic Syndrome-A Single Center Prospective Study. J Clin Med 2021; 10:5709. [PMID: 34884411 PMCID: PMC8658079 DOI: 10.3390/jcm10235709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/28/2021] [Accepted: 12/05/2021] [Indexed: 11/17/2022] Open
Abstract
Severe nephrotic syndrome (NS) is associated with high risk of venous thromboembolic events (VTE), as well as presumably altered heparin pharmacokinetics and pharmacodynamics. Although prophylactic anticoagulation is recommended, the optimal dose is not established. The aim of the study was to test two co-primary hypotheses: of reduced enoxaparin effectiveness and of the need for dose-adjustment in NS. Forty two nephrotic patients with serum albumin ≤2.5 g/dL were alternately assigned to a standard fixed-dose of enoxaparin (NS-FD: 40 mg/day) or ideal body weight (IBW)-based adjusted-dose (NS-AD: 1 mg/kg/day). Twenty one matched non-proteinuric individuals (C-FD) also received fixed-dose. Co-primary outcomes were: the achievement of low- and high-VTE risk threshold of antifactor-Xa activity (anti-FXa) defined as 0.2 IU/mL and 0.3 IU/mL, respectively. Low-VTE-risk threshold was achieved less often in NS-FD than C-FD group (91 vs. 62%, p = 0.024), while the high-VTE-risk threshold more often in NS-AD than in NS-FD group (90 vs. 38%, p < 0.001). Two VTE were observed in NS during 12 months of follow-up (incidence: 5.88%/year). In both cases anti-FXa were 0.3 IU/mL implying the use of anti-FXa >0.3 IU/mL as a target for dose-adjustment logistic regression models. We determined the optimal dose/IBW cut-off value at 0.8 mg/kg and further developed bivariate model (termed the DoAT model) including dose/IBW and antithrombin activity that improved the diagnostic accuracy (AUC 0.85 ± 0.06 vs. AUC 0.75 ± 0.08). Enoxaparin efficacy is reduced in severe NS and the dose should be adjusted to ideal body weight to achieve target anti-FXa activity.
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Affiliation(s)
- Anna Matyjek
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (S.N.)
| | - Aleksandra Rymarz
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (S.N.)
| | - Zuzanna Nowicka
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Slawomir Literacki
- Department of Laboratory Diagnostics, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Tomasz Rozmyslowicz
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Stanislaw Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (S.N.)
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21
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Jeele MOO, Addow ROB, Mohamud MFY. A young woman presented with massive pulmonary embolism with inferior vena cava thrombus as a complication of nephrotic syndrome: a case report. Int J Emerg Med 2021; 14:46. [PMID: 34425751 PMCID: PMC8383440 DOI: 10.1186/s12245-021-00369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
Nephrotic syndrome (NS) was first described in 1827 as the presence of proteinuria of ≥ 3.5 g/24 h, hypoalbuminemia < 3.0 g/dl, peripheral edema, hyperlipidemia, lipiduria, and increased thrombotic risk. Nephrotic syndrome has an incidence of three cases per 100,000 each year in adults. Nephrotic syndrome also has serious complications due to hypercoagulable state in both various venous and arteries which could lead thromboembolic events. The pathophysiology of hypercoagulability in the nephrotic syndrome is due to an imbalance of prothrombotic and antithrombotic factors, as well as impaired thrombolytic activities.Here, we will present a 19-year-old woman who presented to the emergency department complaining of chest pain and shortness of breath for 3 days. The patient was quickly diagnosed with pulmonary embolism and inferior vena cava thrombosis as a complication of nephrotic syndrome, allowing prompt initiation of anticoagulant therapy. After 2 weeks of admission, the patient's condition resolved, her laboratory results returned to almost normal and the patient was discharged with oral prednisolone, coumadin, atorvastatin, and ramipril. We aim to determine which is the likely cause of pulmonary embolism in patients with nephrotic syndrome.
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22
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Prophylactic anticoagulants to prevent venous thromboembolism in patients with nephrotic syndrome-A retrospective observational study. PLoS One 2021; 16:e0255009. [PMID: 34319998 PMCID: PMC8318234 DOI: 10.1371/journal.pone.0255009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/08/2021] [Indexed: 01/10/2023] Open
Abstract
Background Nephrotic syndrome (NS) is associated with increased risk of venous thromboembolism (VTE). Guidelines suggest prophylactic anticoagulants to patients with high risk of thrombosis and low risk of bleeding, but the evidence behind this is poor. This study aims to investigate the effectiveness and risks of prophylactic anticoagulants (PAC) and investigate risk factors for VTE and bleeding in NS. Methods A retrospective medical records study including adults with NS, biopsy proven glomerular disease in the county of Västernorrland, Sweden. Outcomes were VTE, bleeding and death. Patients divided into PAC- and no PAC group were compared using Fisher’s exact test. Patient time was divided into serum/plasma(S/P)-albumin intervals (<20g/L and ≥20g/L) and VTE- and bleeding rates were calculated. Results In 95 included NS patients (PAC = 40, no PAC = 55), 7 VTE (7.4%) and 17 bleedings (18%) were found. Outcomes didn’t differ significantly between the PAC and no PAC group. Time with S/P-albumin <20g/L conferred higher rates/100 years of VTE (IRR 21.7 (95%CI 4.5–116.5)) and bleeding (IRR 5.0 (1.4–14.7)), compared to time with S/P-albumin>20g/L. Conclusion Duration of severe hypoalbuminemia (S/P-albumin <20g/L) in NS is a risk factor for both VTE and bleeding. There is a need for randomized controlled studies regarding the benefit of PAC in NS as well as risk factors of thrombosis and bleeding in NS.
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23
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Cooley I, Derebail VK, Gibson KL, Álvarez C, Poulton CJ, Blazek LN, Love A, Hogan SL, Jennette JC, Falk RJ, Sheikh SZ. Association of Lupus Nephritis Histopathologic Classification With Venous Thromboembolism-Modification by Age at Biopsy. Kidney Int Rep 2021; 6:1653-1660. [PMID: 34169206 PMCID: PMC8207328 DOI: 10.1016/j.ekir.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Lupus nephritis (LN) is an independent risk factor for venous thromboembolism (VTE). The risk of VTE has not been analyzed by International Society of Nephrology/Renal Pathology Society or World Health Organization LN class. Study goals were to measure VTE incidence in an LN patient cohort, to evaluate associations between VTE and LN class, and to investigate factors modifying associations between VTE and LN class. METHODS A retrospective analysis was performed using Glomerular Disease Collaborative Network data. Image-confirmed VTE was compared between patients with any LN class V lesion and patients with only LN class III or IV. Logistic regression was used to calculate odds ratios and 95% confidence intervals. Effect modification was assessed between main effect and covariates. RESULTS Our cohort consisted of 534 LN patients, 310 (58%) with class III/IV and 224 (42%) with class V with or without class III/IV, including 106 with class V alone. The VTE incidence was 62 of 534 (11.6%). The odds of VTE were not significantly different between patients with class III/IV and class V in adjusted analyses (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.45-1.48). An age interaction was observed (P = 0.009), with increased odds of VTE with class III/IV diagnosed at a younger age (2.75, 0.90-8.41 estimated at age 16 years) and decreased odds with class III/IV diagnosed at an older age (0.23, 0.07-0.72 estimated at age 46 years), compared to class V. CONCLUSIONS The VTE incidence was similar among patients with LN classes III/IV and V, suggesting that VTE risk is not limited to class V-related nephrotic syndrome and that age may modulate LN class-specific VTE risk.
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Affiliation(s)
- Ian Cooley
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Keisha L. Gibson
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carolina Álvarez
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren N. Blazek
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrew Love
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Saira Z. Sheikh
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Chapel Hill Alliance Promoting Excellence in Lupus (CHAPEL) group of investigators
- UNC Thurston Arthritis Research Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- UNC Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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24
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Nagalla VK, Raju SB, Ramesh Bura NR. Arterial Thrombosis Associated with Factor V Leiden Mutation in a Child with Nephrotic Syndrome. Indian J Nephrol 2021; 31:187-189. [PMID: 34267445 PMCID: PMC8240935 DOI: 10.4103/ijn.ijn_32_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 10/01/2018] [Accepted: 12/02/2018] [Indexed: 11/18/2022] Open
Abstract
Thromboembolism remains a common complication of nephrotic syndrome (NS) in adults and a less common complication in children. Venous thrombosis is well recognized, but arterial thrombosis occurs less frequently and is seen primarily in children. We report a case of arterial thrombosis associated with factor V Leiden (FVL) mutation in a young girl with NS. Screening for inherited thrombophilias such as FVL mutation may be beneficial for NS patients with thromboembolic vascular events not explained by conventional risk factors.
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Affiliation(s)
- Vamsi Krishna Nagalla
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sree Bhushan Raju
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Naga Raja Ramesh Bura
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Sirvent AE, Urzola-Rodríguez G, Lorenzo A, Callejas-Martínez R, Saiz A, Calle-García L, Molina-Ordás Á, Rodríguez-Gómez A, Martin-Varas C, Fernández-Reyes-Luis MJ. Arterial thrombosis in a patient with nephrotic syndrome and antithrombin Cambrigde II. Nefrologia 2021; 42:S0211-6995(21)00006-0. [PMID: 33593604 DOI: 10.1016/j.nefro.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ana Esther Sirvent
- Servicio de Nefrología, Complejo Asistencial de Segovia, Segovia, España.
| | | | - Alicia Lorenzo
- Servicio de Hematología, Complejo Asistencial de Segovia, Segovia, España
| | | | - Ana Saiz
- Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, España
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Cedeira F, Cedeira F, Martinez Pagano E, Castañeda G, Rivadera R. Bilateral nephrectomy as an extreme measure management for methicillin-resistant staphylococcus aureus (MRSA): A case report. Urol Case Rep 2020; 33:101373. [PMID: 33102072 PMCID: PMC7574030 DOI: 10.1016/j.eucr.2020.101373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) infections are cases of urgent management that often leads to hospitalizations in intensive care and prolonged management of antibiotic therapy. In this occasion, we present the case of a 38-year-old female patient with sepsis secondary to banal dermal infection due MRSA that complicates with infectious thrombus of the left renal vein associated with multiple foci of bilateral renal abscesses. As an extreme and exceptional measure, emergency bilateral radical nephrectomy was performed to save the patient's life. Methicillin-resistant Staphylococcus aureus (MRSA) infections are cases of urgent management. The aggressiveness of resistant methicillin staphylococcus aureus can compromise life in a few days. An underestimated banal dermal infection can end in renal abscesses, and infectious thrombophlebitis of the renal veins. Aggressive decisions must be made to save patients lives.
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Affiliation(s)
- Francisco Cedeira
- National University of Litoral (Universidad Nacional del Litoral.UNL), School of Medicine, Urology Division, Santa Fe City, Argentina
- Corresponding author. National University of Litoral (Universidad Nacional del Litoral) School of Medicine, Urology Division, Ruta Nacional 168, Nro: 80, Bv. Pellegrini 2750 - (3000), Santa Fe, Argentina.
| | - F. Cedeira
- National University of Litoral (Universidad Nacional del Litoral.UNL), School of Medicine, Urology Division, Santa Fe City, Argentina
| | | | - G. Castañeda
- Hospital J.M. Cullen, Urology Division, Santa Fe City, Argentina
| | - R. Rivadera
- Hospital J.M. Cullen, Urology Division, Santa Fe City, Argentina
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Goyal S, Dhull RS, Deepthi B, Saha A. First episode of nephrotic syndrome with acute abdominal pain. Clin Exp Pediatr 2020; 63:411-414. [PMID: 32689763 PMCID: PMC7568953 DOI: 10.3345/cep.2019.01333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/26/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Samridhi Goyal
- Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
| | - Rachita Singh Dhull
- Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
| | - Bobbity Deepthi
- Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
| | - Abhijeet Saha
- Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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Shinkawa K, Yoshida S, Seki T, Yanagita M, Kawakami K. Risk factors of venous thromboembolism in patients with nephrotic syndrome: a retrospective cohort study. Nephrol Dial Transplant 2020; 36:gfaa134. [PMID: 32658957 DOI: 10.1093/ndt/gfaa134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Nephrotic syndrome is associated with an increased risk of venous thromboembolism (VTE). However, the risk factors of VTE in nephrotic syndrome, other than hypoalbuminemia and severe proteinuria, are not well established. Therefore we aimed to investigate the risk factors of VTE in patients with nephrotic syndrome. METHODS This retrospective cohort study used data from a Japanese nationwide claims database. We identified patients ≥18 years of age hospitalized with nephrotic syndrome. Through multivariable logistic regression, we determined the risk factors of VTE in patients with nephrotic syndrome during hospitalization. RESULTS Of the 7473 hospitalized patients with nephrotic syndrome without VTE, 221 (3.0%) developed VTE. In the VTE group, 14 (6.3%), 11 (5.0%) and 198 (89.6%) patients developed pulmonary embolism, renal vein thrombosis and deep vein thrombosis, respectively. We found that female sex {odds ratio [OR] 1.39 [95% confidence interval (CI) 1.05-1.85]}, body mass index (BMI) ≥30 [OR 2.01 (95% CI 1.35-2.99)], acute kidney injury [AKI; OR 1.67 (95% CI 1.07-2.62)], sepsis [OR 2.85 (95% CI 1.37-5.93)], lupus nephritis [OR 3.64 (95% CI 1.58-8.37)] and intravenous corticosteroids use [OR 2.40 (95% CI 1.52-3.80)] were associated with a significantly higher risk of developing VTE. CONCLUSIONS In patients with nephrotic syndrome, female sex, BMI ≥30, AKI, sepsis, lupus nephritis and intravenous corticosteroid use may help evaluate the risk of VTE.
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Affiliation(s)
- Kanna Shinkawa
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Pharmacoepidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Bobrova LA, Kozlovskaya NL. [Thromboembolic complications in nephrotic syndrome]. TERAPEVT ARKH 2020; 92:105-116. [PMID: 33346503 DOI: 10.26442/00403660.2020.06.000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 11/22/2022]
Abstract
This review devoted to the nephrotic syndrome (NS) subsequent thrombotic outcomes. The pathogenesis of hypercoagulation disorders that cause venous and arterial vascular system thrombosis are studied. Discussed procoagulant and anticoagulant mechanisms imbalance due to the anticoagulants natural urinal loss, affected by disfunction of the glomerular filter selective permeability, leading to high molecular weight liver-derived proteins (at least of the albumin size) leakage, fibrinolysis depression, excessive liver synthesis of plasma clotting cascade factors and platelet activation. Presented new data on the thrombogenesis at NS concerning the role of endothelial microparticles with high prothrombogenic activity that go from damaged glomerulus endothelial capillary cells into the systemic circulation, which can turn the local renal hypercoagulation (concomitant to the kidney immune inflammation process) into the generalized, working towards the thrombosis development. The most frequent adverse variants of arterial and venous thromboses are studied, specified their basic and general risk factors, as well as individual, varying in different patients. Indications and prophylactic anticoagulant therapy regimen and thrombosis treatment duration in patients with NS are discussed. It also stressed that the decision on time and method of anticoagulant therapy for a NS patients is still a challenge for healthcare providers.
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Affiliation(s)
- L A Bobrova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N L Kozlovskaya
- People's Friendship University of Russia.,Yeramishantsev City Clinical Hospital
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Inherited Risk Factors of Thromboembolic Events in Patients with Primary Nephrotic Syndrome. ACTA ACUST UNITED AC 2020; 56:medicina56050242. [PMID: 32438633 PMCID: PMC7279319 DOI: 10.3390/medicina56050242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/10/2020] [Accepted: 05/16/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives. Venous thromboembolic events (VTEs) are among the most important complications of nephrotic syndrome (NS). We conducted a study that aimed to determine the prevalence of inherited risk factors for VTE in NS and to identify which factors are independent predictors of VTE. Materials and Methods. Thirty-six consecutive patients with primary NS that underwent percutaneous kidney biopsy between January 2017 and December 2017 were enrolled in this retrospective, observational study. VTEs were the primary outcome. Baseline demographic and biochemical data were collected from medical records, and genetic testing was done for polymorphisms of Factor V, PAI, MTHFR, and prothrombin genes. Results. The incidence of VTE was 28%, and the median time to event was 3 months (IQR: 2-9). The prevalence of inherited risk factors was 14% for Factor V Leiden mutation, 5.6% for prothrombin G20210A, 44.5% for PAI, and 27.8% for each of the two polymorphisms of the MTHFR gene. On multivariate analysis, the presence of at least two mutations was independently associated with the risk of VTE (HR, 8.92; 95% confidence interval, CI: 1.001 to 79.58, p = 0,05). Conclusions. These findings suggest that genetic testing for inherited thrombophilia in NS could play an important role in detecting high-risk patients that warrant prophylactic anticoagulation.
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Comparison of Hemostatic Disturbances between Patients on Capd and Patients on Hemodialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080102100209] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Disturbances in hemostasis are common findings in uremic patients. Both bleeding diathesis and thrombosis are observed. The purpose of this study was to assess whether renal replacement therapy in the form of hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD) affects coagulation and fibrinolysis in patients with end-stage renal failure. Design Comparison of hemostatic measures in patients on CAPD, HD, and matched healthy controls. Setting Department of Nephrology and Internal Medicine, Bialystok University School of Medicine. Patients and Methods Twenty-four HD patients and 23 CAPD patients were evaluated with respect to platelet aggregation, hemostatic parameters, serum lipids, lipoprotein(a), and cytokines [tumor necrosis factor alpha (TNFα) and interleukin-1 (IL-1)]. Interventions Four exchanges of CAPD per day, using 2.0 L dialysate over a period of 25 ± 31 months; or 4 – 5 hours of HD 3 times per week for a period of 31 ± 22 months. Results Platelet aggregation in whole blood and platelet-rich plasma was significantly impaired in both groups of dialyzed patients compared to healthy volunteers. Markers of endothelial cell injury (thrombomodulin and von Willebrand factor) were significantly higher in HD and CAPD patients compared to the control group. A similar pattern of changes was observed for lipoprotein(a), fibrinogen, tissue factor pathway activity, and factor VII activity. Activity of factor X was significantly enhanced in CAPD compared to HD patients and controls. Euglobulin clot lysis time was significantly prolonged in HD and CAPD patients over controls, being more prolonged in CAPD patients. Markers of ongoing coagulation (thrombin–antithrombin complexes and prothrombin fragments 1+2) were higher in uremic patients, significantly higher in CAPD than in HD. A marker of ongoing fibrinolysis (plasmin–antiplasmin complexes) was higher in uremic patients but was lower in CAPD than in HD patients. Concentrations of TNFα and IL-1 were higher in HD than in CAPD patients. Conclusion Patients on CAPD showed evidence of a higher degree of hypercoagulation than HD patients. Thus, hemostatic abnormalities in end-stage renal failure may be affected to some extent by the choice of renal replacement therapy.
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Abstract
ObjectiveBleeding diathesis and simultaneous thrombotic complications may be seen in dialyzed patients. Erythropoietin (EPO) may shift the precarious balance of the hemostatic system toward thrombosis. Platelets and tissue factor (TF) play a major role in plug formation. Tissue factor pathway inhibitor (TFPI) appears to play a primary role in regulating TF-induced coagulation. Thrombin activatable fibrinolysis inhibitor (TAFI) is a key protein linking coagulation and fibrinolysis. The aim of the study was to assess whether 6 months of EPO therapy affects platelet function, that is, platelet aggregation and P-selectin level; moieties of the extrinsic coagulation pathway: TF, TFPI, and TFPI/Xa complexes, and factors VII and X; markers of ongoing coagulation: thrombin–antithrombin complexes (TAT) and prothrombin fragments 1+2; a marker of ongoing fibrinolysis: plasmin–antiplasmin complexes (PAP); fibrinolytic activity: euglobulin clot lysis time (ECLT); and markers of endothelial cell injury: von Willebrand factor, thrombomodulin, E-selectin, and TAFI, in continuous ambulatory peritoneal dialysis (CAPD) patients.Patients and Methods22 patients on CAPD were given EPO 6000 U/week. 12 patients with chronic renal failure and 12 healthy volunteers served as control groups. All parameters were studied before, and after 1, 3, and 6 months of EPO therapy.SettingDepartment of Nephrology and Internal Medicine, Medical Academy of Bialystok, Poland.ResultsPlatelet aggregation in whole blood did not change significantly during EPO treatment. A significant rise in arachidonic acid-induced platelet aggregation in platelet-rich plasma was observed after 3 and 6 months, and in collagen-induced platelet aggregation after 6 months of EPO therapy, compared to the baseline values. The TFPI concentration decreased significantly after 6 months of EPO therapy. The activity of factor VII increased transiently after 1 month of EPO therapy, compared to the baseline values. The TAFI concentration and activity in the CAPD group were significantly higher than in the control group. Erythropoietin therapy resulted in a significant decrease in TAFI concentration and activity after 6 months of EPO treatment. The ECLT was shortened significantly as early as after 1 month of EPO therapy. Thrombomodulin, von Willebrand factor concentration and activity, PAP, TAT, TFPI/Xa complexes, prothrombin fragments 1+2, factor X activity, P-selectin, E-selectin, and lipoprotein(a) did not change significantly during EPO treatment.ConclusionErythropoietin treatment has a minimal effect on hemostasis in CAPD patients. A tendency toward a decline in TAFI is of unknown clinical relevance so far, and awaits further research.
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Togashi H, Shimosato Y, Saida K, Miyake N, Nakamura T, Ito S. Childhood Nephrotic Syndrome Complicated by Catastrophic Multiple Arterial Thrombosis Requiring Bilateral Above-Knee Amputation. Front Pediatr 2020; 8:107. [PMID: 32266186 PMCID: PMC7096371 DOI: 10.3389/fped.2020.00107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Thromboembolic events are rare but critical complications in childhood nephrotic syndrome. The veins are more commonly affected, while arterial thrombosis is extremely rare but often life-threatening. Herein, we describe the clinical course of a 10-years-old girl with catastrophic multiple arterial thrombosis at the primary onset of nephrotic syndrome who underwent bilateral above-knee amputation. Case diagnosis/treatment: A previous healthy 10-years-old girl contracted the influenza B virus. Five days later, she suddenly developed severe ischemia in both legs. Physical examination showed eyelid and leg edema, and laboratory tests revealed hypoalbuminemia and acute kidney injury. After undergoing contrast-enhanced computed tomography, the patient was diagnosed with multiple arterial thrombosis (including the bilateral iliac arteries) due to nephrotic syndrome. Despite the performance of surgical thrombectomies, fasciotomy, and systematic heparinization, she required bilateral above-knee amputation. The patient achieved spontaneous remission of nephrotic syndrome, and her renal function fully recovered. There were no findings suggestive of secondary nephrotic syndrome and antiphospholipid syndrome. Her protein C and protein S concentrations were slightly decreased at admission. However, whole-exome sequencing revealed a thrombotic risk variant (T630I) in the PROS1 gene encoding protein S. This missense variant is often reported in patients with thrombosis or protein S deficiency, and may result in a thrombotic predisposition in some situations, such as nephrotic syndrome. Conclusions: Arterial thrombosis is a rare complication; however, it must be considered, especially in patients with new-onset nephrotic syndrome. Early recognition is important for early intervention and prevention of serious sequelae.
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Affiliation(s)
- Hayato Togashi
- Department of Pediatrics, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan.,Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuko Shimosato
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ken Saida
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Noriko Miyake
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takeshi Nakamura
- Department of Rehabilitation Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Lionaki S, Liapis G, Boletis JN. Pathogenesis and Management of Acute Kidney Injury in Patients with Nephrotic Syndrome Due to Primary Glomerulopathies. ACTA ACUST UNITED AC 2019; 55:medicina55070365. [PMID: 31336742 PMCID: PMC6681356 DOI: 10.3390/medicina55070365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
Acute kidney injury in the context of nephrotic syndrome is a serious and alarming clinical problem. Largely, acute kidney injury is a relatively frequent complication among patients with comorbidities while it has been independently associated with an increased risk of adverse outcomes, including death and chronic kidney disease. Nephrotic syndrome, without hematuria or with minimal hematuria, includes a list of certain glomerulopathies; minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy. In the light of primary nephrotic syndrome, pathophysiology of acute kidney injury is differentiated by the nature of the primary disease and the severity of the nephrotic state. This review aims to explore the clinical circumstances and pathogenetic mechanisms of acute kidney injury in patients with nephrotic syndrome due to primary glomerulopathies, focusing on newer perceptions regarding the pathogenesis and management of this complicated condition, for the prompt recognition and timely initiation of appropriate treatment in order to restore renal function to its baseline level. Prompt recognition of the precise cause of acute kidney injury is crucial for renal recovery. Clinical characteristics, laboratory and serological findings along with histopathological findings, if required, will reveal the implicated pathway leading to individualized approach and management.
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Affiliation(s)
- Sophia Lionaki
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece.
| | - George Liapis
- Department of Pathology, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John N Boletis
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
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Portal Vein Thrombosis in a 21-Year-Old Man with Membranoproliferative Glomerulonephritis and Nephrotic Syndrome. Case Rep Nephrol 2019; 2019:3409832. [PMID: 31275677 PMCID: PMC6558605 DOI: 10.1155/2019/3409832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/20/2019] [Indexed: 11/17/2022] Open
Abstract
Membranoproliferative glomerulonephritis, one of the main causes of nephrotic syndrome, is associated with a state of hypercoagulability that leads to increased risk of thrombotic events. Portosystemic collaterals may reopen due to reversal of the flow within the existing veins and be a presenting feature of thrombosis. We describe a patient who presented with large portosystemic collaterals and signs of portal hypertension and was subsequently found to be affected by membranous proliferative glomerulonephritis. Proteinuria and microscopic haematuria in a patient with signs of portal hypertension and no pre-existing liver disease should raise the suspicion of an underlying kidney disease.
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Kelddal S, Nykjær KM, Gregersen JW, Birn H. Prophylactic anticoagulation in nephrotic syndrome prevents thromboembolic complications. BMC Nephrol 2019; 20:139. [PMID: 31023275 PMCID: PMC6482554 DOI: 10.1186/s12882-019-1336-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background An increased incidence of thromboembolic events (TE) are reported in nephrotic syndrome (NS) leading to recommendations for prophylactic anticoagulation (PAC). However, as no randomized clinical trial has established the efficacy or risks associated with PAC, guidelines are empiric or substantiated only by estimates of risks and benefits. This study evaluates the risk of TE and hemorrhagic complications in patients with NS treated with PAC and compares to patients not receiving PAC. Methods We included patients diagnosed with NS from two Danish nephrology departments with different practices for the use of PAC. Patients were included if presenting with NS from September 2006 to January 2012, a P-albumin < 30 g/L, and renal biopsy confirming non-diabetic, glomerular disease. Patients aged < 16 years, on renal replacement therapy, or administered anticoagulants at the onset of NS were excluded. Bleeding episodes and/or TE were identified from patient records. Bleeding episodes were divided into minor and major bleeding. Results Of the 79 patients included, 44 patients received PAC either as low or high dose low-molecular-weight heparin (LMWH) or as warfarin with or without LMWH as bridging, while 35 did not receive PAC. P-albumin was significant lower in the PAC group compared to those not receiving PAC. Significantly more TEs was observed in the non-PAC group compared to the PAC group (4 versus 0 episodes, P = 0.035). The TEs observed included one patient with pulmonary embolism (PE), one with PE and deep vein thrombosis, one with PE and renal vein thrombosis, and one with a stroke. Five patients with bleeding episodes were identified among those receiving PAC, of which two were major and three were minor, while two patients in the non-PAC group experienced a minor bleeding episode (P = 0.45 between groups). The major bleeding episodes only occurred in patients receiving PAC in combination with low dose aspirin. Conclusions In patients with NS the use of PAC was associated with a decreased risk of clinically significant TE, but may also be associated with more bleeding episodes although not statistically significant. Only patients treated with PAC in combination with anti-platelet therapy had major bleeding episodes.
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Affiliation(s)
- Sarah Kelddal
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark. .,Department of Internal Medicine, Viborg Regional Hospital, Heibergs Alle 4, 8800, Viborg, Denmark.
| | - Karen Marie Nykjær
- Accidents and Emergency Department, Herning Regional Hospital, Gl Landevej 61, 7400, Herning, Denmark
| | - Jon Waarst Gregersen
- Department of Nephrology, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark.,Department of Biomedicine, Aarhus University Health, Vennelyst Blvd. 4, 8000, Aarhus, Denmark
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Alawami M, Wimalasena S, Ghashi R, Alnasrallah B. Acute arterial cardiovascular events risk in patients with primary membranous nephropathy. Intern Med J 2018; 49:855-858. [PMID: 30346109 DOI: 10.1111/imj.14146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Venous thromboembolism is a well established risk in patients with primary membranous nephropathy (MN) due to deficiency in natural anti-coagulants. Recent studies suggested a higher risk of arterial thrombotic events as well in this group. AIM To identify that risk in our cohort. METHODS We reviewed the data of all patients who had biopsy proven primary MN at our institute between 2003 and 2013. Clinical data were retrospectively reviewed until November 2016. The cardiovascular (CV) events, including acute coronary syndromes and strokes were determined and included only if occurred after the diagnosis of the nephropathy. RESULTS A total of 204 patients had biopsy proven MN. Follow up information was available for 166 patients. Thirty-one patients (18.6%) developed CV events during follow up. Thirty-eight per cent of total events occurred within 1 year of MN diagnosis. Forty-two per cent of those who developed CV events were not on anti-thrombotic medications and 60% were not on statin therapy. Male gender, age, diabetes and absence of statins therapy were associated with higher rates of CV events in this group. CONCLUSION There is an increased risk of arterial events in patients with primary MN. This risk is greatest in the first year of diagnosis. The risk should be highlighted in this group of patients and anti-platelets and statin therapy should be considered especially during the initial phase of the disease.
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Affiliation(s)
- Mohammed Alawami
- Greenlane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Rajaie Ghashi
- Science Department, Auckland University, Auckland, New Zealand
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Speckle Reduction on Ultrasound Liver Images Based on a Sparse Representation over a Learned Dictionary. APPLIED SCIENCES-BASEL 2018. [DOI: 10.3390/app8060903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kunutsor SK, Seidu S, Katechia DT, Laukkanen JA. Inverse association between serum albumin and future risk of venous thromboembolism: interrelationship with high sensitivity C-reactive protein. Ann Med 2018; 50:240-248. [PMID: 29448840 DOI: 10.1080/07853890.2018.1441537] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
PURPOSE We aimed to assess the prospective association of serum albumin with venous thromboembolism (VTE) risk and evaluate if the association is independent of or modified by inflammation, as measured by high sensitivity C-reactive protein (hsCRP). DESIGN We analysed data of 2176 men aged 42-61 years free from VTE in the Kuopio Ischemic Heart Disease study, with serum albumin concentrations measured at baseline using Coulter's bromocresol purple colorimetric assays. Hazard ratios (HRs) (95% confidence intervals [CI]) were calculated for VTE. RESULTS There were 109 validated cases of VTE recorded during a median follow-up of 24.9 years. The risk of VTE increased linearly below a serum albumin concentration of ∼48 g/l. In Cox regression analysis adjusted for established risk factors and other potential confounders, the HR (95% CI) for VTE per 1 standard deviation lower serum albumin was 1.23 (1.02-1.47). The association remained persistent on further adjustment for hsCRP 1.22 (1.01-1.46). Furthermore, the association was not modified by hsCRP and persisted on exclusion of men with elevated hsCRP levels. CONCLUSIONS In middle-aged Caucasian men, low serum albumin is associated with an increased risk of VTE, consistent with a linear dose-response relationship. The association is independent of and not modified by inflammation. Key messages • Serum albumin may be associated with future risk of venous thromboembolism (VTE); however, the shape, nature, magnitude and consistency of the association is uncertain. • In a population-based prospective cohort study, low serum albumin was associated with an increased risk of VTE in a linear dose-response manner and this association was independent of and not modified by inflammation. • Serum albumin concentrations may play a role in the development of VTE.
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Affiliation(s)
- Setor K Kunutsor
- a Translational Health Sciences, Bristol Medical School , Learning & Research Building (Level 1), Southmead Hospital, University of Bristol , Bristol , UK
| | - Samuel Seidu
- b Leicester Diabetes Centre , Leicester General Hospital , Leicester , UK.,c Diabetes Research Centre , Leicester General Hospital, University of Leicester , Leicester , UK
| | | | - Jari A Laukkanen
- e Institute of Public Health and Clinical Nutrition , University of Eastern Finland , Kuopio , Finland.,f Central Finland Central Hospital , Jyväskylä , Finland
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41
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Erben Y, Miller SM, Sumpio BJ, Dillon BJ, Lee AI, Blume P, Sumpio BE, Mena-Hurtado C. Acute Limb Ischemia in an 8-Year-Old Patient: A Case Report. Ann Vasc Surg 2018; 51:327.e1-327.e8. [PMID: 29655809 DOI: 10.1016/j.avsg.2018.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/19/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
We report the case of an 8-year-old patient with a history of nephrotic syndrome, who presented to the emergency department with right foot pain. The patient's mother described intermittent pain that woke her son from sleep and was accompanied by the foot turning purple and becoming cold to touch. Physical examination revealed capillary refill of over 10 seconds in the right and less than 2 seconds in the left foot. Ankle-brachial indices (ABIs) were 0.0 on the right and 0.96 on the left. The patient was admitted and started on therapeutic intravenous heparin. After consultation with his parents, right lower extremity angiography and thrombolysis was performed over 2 days. He subsequently underwent fasciotomy and amputation of the tip of all 5 toes. Eighteen months later, there is no leg length discrepancy, he is walking with foot inserts and has normal ABIs bilaterally.
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Affiliation(s)
- Young Erben
- Section of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT.
| | - Samuel M Miller
- Warren Alpert Medical School at Brown University, Providence, RI
| | - Brandon J Sumpio
- Section of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT
| | - Brian J Dillon
- Section of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Peter Blume
- Department of Orthopedic Surgery and Anesthesia, Yale University School of Medicine, New Haven, CT; Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Bauer E Sumpio
- Section of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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42
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Aboobacker IN, Krishnakumar A, Narayanan S, Hafeeque B, Gopinathan JC, Aziz F. Nail-Patella Syndrome: A Rare Cause of Nephrotic Syndrome in Pregnancy. Indian J Nephrol 2018. [PMID: 29515307 PMCID: PMC5830815 DOI: 10.4103/ijn.ijn_362_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nail–Patella syndrome (NPS) is an inherited disease with characteristic nail, limb, and renal anomalies. While almost all patients manifest classical skeletal and nail abnormalities, renal involvement is seen in only 40% of patients. Asymptomatic proteinuria is the most common renal presentation. Although a substantial number of patients can progress to nephrotic range proteinuria, development of end-stage kidney disease is rare. Pathological abnormalities are appreciable only by electron microscopy. Our patient who had not been diagnosed with NPS previously presented with new-onset proteinuria during the second trimester of her first pregnancy. The characteristic physical and radiological features confirmed the diagnosis of NPS. Her clinical course was complicated by nephrotic syndrome with fetal loss at 22 weeks and postpartum renal vein thrombosis. Nephrotic state improved after termination of pregnancy. She was managed with angiotensin receptor blocker and anticoagulation. At the end of 2 years of follow-up, she has normal glomerular filtration rate with minimal proteinuria.
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Affiliation(s)
- I N Aboobacker
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - A Krishnakumar
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - S Narayanan
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - B Hafeeque
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - J C Gopinathan
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - F Aziz
- Department of Nephrology and Transplantation, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
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43
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Loewen JM, Cianciolo RE, Zhang L, Yaeger M, Ward JL, Smith JD, LeVine DN. Concurrent renal amyloidosis and thymoma resulting in a fatal ventricular thrombus in a dog. J Vet Intern Med 2018; 32:1160-1165. [PMID: 29485186 PMCID: PMC5980280 DOI: 10.1111/jvim.15062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/31/2017] [Accepted: 01/15/2018] [Indexed: 11/27/2022] Open
Abstract
Thymoma-associated nephropathies have been reported in people but not in dogs. In this report, we describe a dog with thymoma and concurrent renal amyloidosis. A 7-year-old castrated male Weimaraner was presented for progressive anorexia, lethargy, and tachypnea. The dog was diagnosed with azotemia, marked proteinuria, and a thymoma that was surgically removed. Postoperatively, the dog developed a large left ventricular thrombus and was euthanized. Necropsy confirmed the presence of a left ventricular thrombus and histopathology revealed renal amyloidosis. We speculate that the renal amyloidosis occurred secondary to the thymoma, with amyloidosis in turn leading to nephrotic syndrome, hypercoagulability, and ventricular thrombosis. This case illustrates the potential for thymoma-associated nephropathies to occur in dogs and that dogs suspected to have thymoma should have a urinalysis and urine protein creatinine ratio performed as part of the pre-surgical database.
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Affiliation(s)
- Jennifer M Loewen
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Rachel E Cianciolo
- Department of Veterinary Biosciences and International Veterinary Renal Pathology Service, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio
| | - Liwen Zhang
- Mass Spectrometry and Proteomics Facility, Campus Chemical Instrument Center, The Ohio State University, Columbus, Ohio
| | - Michael Yaeger
- Department of Veterinary Pathology, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Jessica L Ward
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Jodi D Smith
- Department of Veterinary Pathology, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Dana N LeVine
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa
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44
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Assimakopoulos SF, Kraniotis P, Gogos C, Marangos M. Renal vein thrombosis complicating severe acute pyelonephritis with renal abscesses and associated bacteraemia caused by extended-spectrum beta-lactamase producing Escherichia coli. CEN Case Rep 2018; 7:90-93. [PMID: 29327131 DOI: 10.1007/s13730-017-0301-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/27/2017] [Indexed: 11/25/2022] Open
Abstract
Acute pyelonephritis might be complicated by the formation of renal and perirenal abscesses and very rarely by renal vein thrombosis, which is a life-threatening condition. The main causative agents of acute pyelonephritis are enterobacteriaceae with the incidence of extended-spectrum beta-lactamase (ESBL)-producing strains increasing worldwide. We present the case of a 71-year-old Greek man with history of diabetes mellitus and recent hospitalization, who suffered from severe pyelonephritis with renal abscesses formation and associated bacteraemia caused by ESBL-producing Escherichia coli, complicated by extensive thrombosis of the ipsilateral renal vein and its branches, protruding also in the inferior venal cava. Our patient was effectively treated with anticoagulants and targeted antibiotic therapy, respectively, consisted of low molecular weight heparin transitioned to oral acenocoumarol for 3 months and 2-week course of intravenous meropenem followed by oral fosfomycin for additional 3 weeks as quidded by clinical and computed tomographic follow-up. In conclusion, in complicated urinary infections, caused by ESBL-producing enterobacteriaceae, oral fosfomycin might represent an effective option for step-down therapy of carbapenems, allowing the shortness of the duration of patient's hospitalization and carbapenem use.
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Affiliation(s)
- Stelios F Assimakopoulos
- Division of Infectious Diseases, Department of Internal Medicine, University General Hospital of Patras, 26504, Patras, Greece.
| | - Pantelis Kraniotis
- Department of Radiology, University General Hospital of Patras, 26504, Patras, Greece
| | - Charalambos Gogos
- Division of Infectious Diseases, Department of Internal Medicine, University General Hospital of Patras, 26504, Patras, Greece
| | - Markos Marangos
- Division of Infectious Diseases, Department of Internal Medicine, University General Hospital of Patras, 26504, Patras, Greece
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45
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Massicotte-Azarniouch D, Bader Eddeen A, LazoLanger A, Molnar AO, Lam NN, McCallum MK, Bota S, Zimmerman D, Garg AX, Harel Z, Perl J, Wald R, Sood MM. Risk of Venous Thromboembolism in Patients by Albuminuria and Estimated GFR. Am J Kidney Dis 2017; 70:826-833. [DOI: 10.1053/j.ajkd.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 07/03/2017] [Indexed: 12/30/2022]
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46
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Evolving presentation of leg cramps in a child with nephrotic syndrome: Answers. Pediatr Nephrol 2017; 32:2247-2252. [PMID: 28233098 DOI: 10.1007/s00467-017-3606-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 01/28/2023]
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47
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Abstract
Nephrotic syndrome is a highly prevalent disease that is associated with high morbidity despite notable advances in its treatment. Many of the complications of nephrotic syndrome, including the increased risk of atherosclerosis and thromboembolism, can be linked to dysregulated lipid metabolism and dyslipidaemia. These abnormalities include elevated plasma levels of cholesterol, triglycerides and the apolipoprotein B-containing lipoproteins VLDL and IDL; decreased lipoprotein lipase activity in the endothelium, muscle and adipose tissues; decreased hepatic lipase activity; and increased levels of the enzyme PCSK9. In addition, there is an increase in the plasma levels of immature HDL particles and reduced cholesterol efflux. Studies from the past few years have markedly improved our understanding of the molecular pathogenesis of nephrotic syndrome-associated dyslipidaemia, and also heightened our awareness of the associated exacerbated risks of cardiovascular complications, progressive kidney disease and thromboembolism. Despite the absence of clear guidelines regarding treatment, various strategies are being increasingly utilized, including statins, bile acid sequestrants, fibrates, nicotinic acid and ezetimibe, as well as lipid apheresis, which seem to also induce partial or complete clinical remission of nephrotic syndrome in a substantial percentage of patients. Future potential treatments will likely also include inhibition of PCSK9 using recently-developed anti-PCSK9 monoclonal antibodies and small inhibitory RNAs, as well as targeting newly identified molecular regulators of lipid metabolism that are dysregulated in nephrotic syndrome.
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48
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Zhang L, Zhang H, Zhang J, Tian H, Liang J, Liu Z. Rivaroxaban for the treatment of venous thromboembolism in patients with nephrotic syndrome and low AT-III: A pilot study. Exp Ther Med 2017; 15:739-744. [PMID: 29399079 PMCID: PMC5772665 DOI: 10.3892/etm.2017.5471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022] Open
Abstract
The anticoagulation effect of heparin requires adequate serum antithrombin (AT)-III levels. Rivaroxaban, however, exhibits its anticoagulation effects independent of AT-III. The aim of the present study was to evaluate the efficacy and safety of rivaroxaban as a treatment for venous thromboembolism in patients with AT-III deficiency due to nephrotic syndrome. Patients with nephrotic syndrome and low serum concentration and functional activity of AT-III and venous thromboembolism were randomly assigned to the rivaroxaban group (n=8) and low weight molecular heparin group (n=8). The patients were treated for 4 weeks and evaluated at weeks 2 and 4. The primary endpoint was thrombus dissolution or a >90% decrease in thrombus volume in 4 weeks. Secondary endpoints included an increase in the volume of the pre-existing thrombosis and safety assessments. In each of the two groups, 7/8 patients achieved a primary endpoint. At week 2, 5 patients in the rivaroxaban group and 4 in the low weight molecular heparin group had achieved the primary endpoint. Notably, at week 2 the patients whose AT-III levels and functional activity remained low in the low weight molecular heparin group did not achieve the primary endpoint. The adverse effects were similar in both groups, with no severe hemorrhage observed. In conclusion, the results of this pilot study demonstrate that rivaroxaban may be an effective, safe, single-agent approach for treating vein thromboembolism in patients with nephrotic syndrome and low AT-III levels. The potential benefits of rivaroxaban over low weight molecular heparin treatment require further investigation with a larger sample size in order to validate the findings of the present study.
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Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Jiong Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Hong Tian
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Ju Liang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
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49
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Lempp S, Schwenger V. Isolated right ventricular thrombus in an adult patient with nephrotic syndrome: a case report. J Med Case Rep 2017; 11:311. [PMID: 29100540 PMCID: PMC5670526 DOI: 10.1186/s13256-017-1491-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 10/11/2017] [Indexed: 11/13/2022] Open
Abstract
Background Venous thrombosis in nephrotic syndrome is a well-described phenomenon. We report a case of an adult patient with an isolated thrombus in the right ventricle due to nephrotic syndrome, which was initially suspected to be a myxoma. Case presentation A 28-year-old white woman presented to our emergency department with signs of fluid overload. On further evaluation, a right ventricular mass was detected, which was resected and was found to be a thrombus. No other manifestations of venous thrombosis were found. Further evaluation of the patient revealed a nephrotic syndrome, which caused augmented coagulopathy. Conclusions We present a case of a patient in whom a right ventricular mass was the first sign of a renally derived coagulopathy. To the best of our knowledge, this is the first report of an isolated thrombus in the right ventricle due to nephrotic syndrome in an adult. In cases of isolated cardiac thrombi in adults, a further search for renal disease might be helpful to reveal the underlying cause.
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Affiliation(s)
- Severin Lempp
- Clinic for Kidney, Hypertension and Autoimmune Diseases, Transplant Center Stuttgart, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Vedat Schwenger
- Clinic for Kidney, Hypertension and Autoimmune Diseases, Transplant Center Stuttgart, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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50
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Gyamlani G, Molnar MZ, Lu JL, Sumida K, Kalantar-Zadeh K, Kovesdy CP. Association of serum albumin level and venous thromboembolic events in a large cohort of patients with nephrotic syndrome. Nephrol Dial Transplant 2017; 32:157-164. [PMID: 28391310 DOI: 10.1093/ndt/gfw227] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/04/2016] [Indexed: 11/13/2022] Open
Abstract
Background Prior small studies have suggested an association between low serum albumin and increased risk of venous thromboembolic (VTE) events in patients with nephrotic syndrome (NS). Methods From a nationally representative prospective cohort of over 3 million US veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m 2 , we identified 7037 patients with NS based on ICD-9 codes. Association between serum albumin and risk of incident VTE was assessed using Cox regression analysis with adjustments for age, gender, race, comorbidities, eGFR, body mass index and anticoagulant treatment. Results Mean age was 57 ± 11 years, patients were 96% male, 32% African-American and 60% diabetic. There were a total of 158 VTE events over a median follow-up of 8.1 years; 16 events [absolute event rate (AER) 4.1%, event rate 8.5/1000 patient-years (PY)] in patients with albumin <2.5 g/dL, 18 events (AER 3.4%, event rate 5.7/1000 patient-years) in patients with albumin 2.5-2.99 g/dL, 89 events (AER 2.5%, event rate 3.4/1000 patient-years) in patients with albumin 3-3.99 g/dL and 35 events (AER 1.4%, event rate 1.9/1000 patient-years) in patients with albumin ≥4 g/dL. Compared with patients with albumin ≥4 g/dL, those with albumin levels of 3-3.99 g/dL [adjusted hazard ratio (HR): 1.51, 95% confidence interval (CI): 1.01-2.26], 2.5-2.99 g/dL (HR: 2.24, 95% CI: 1.24-4.05) and <2.5 g/dL (HR: 2.79, 95% CI: 1.45-5.37) experienced a linearly higher risk of VTE events. Conclusions Lower serum albumin is a strong independent predictor for VTE events in NS. The risk increases proportionately with declining albumin levels. Clinical trials are needed to determine benefit of prophylactic anticoagulation in NS patients with moderately lower serum albumin levels.
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Affiliation(s)
- Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
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