Markers of endothelial cell injury and thrombin activatable fibrinolysis inhibitor in nephrotic syndrome

Nephrotic Syndrome – Different Risk of Venous Thromboembolism with Different Approaches to Justify Prophylactic Anticoagulation

All of the circumstances influencing any of the elements of Virchow’s Triad can increase the risk of venous thromboembolism. Assessing prothrombotic factors can sometimes be difficult. One of the examples of such a condition is nephrotic syndrome. In this condition at least two elements of Virchow’s triad are affected: physiological blood composition and the venous blood flow which is slowed down by the edema. Except for the cases mentioned in KDIGO (Kidney Disease: Improving Global Outcomes), the use of anticoagulant drugs in the prophylaxis of VTE (Venous Thromboembolism) in nephrotic syndrome seems unclear. Nevertheless, due to the increased risk of VTE, it is worth implementing mechanical anticoagulant prophylaxis, which can also improve the quality of life of patients by reducing swelling. The article analyzes the current knowledge on the field and gives some proposals with low bleeding risk.

Thrombotic microangiopathy triggered by podocytopathy

Thrombotic microangiopathy (TMA) is a rare group of diseases characterized by microangiopathic hemolytic anemia, thrombocytopenia, and target organ damage. It can be divided into primary and secondary TMA. Herein we report a case of TMA associated to a primary glomerular disease. We report the case of a 31-year-old Black male from Cape Verde admitted in March 2018 with nephrotic syndrome and upper gastrointestinal bleeding, the latter due to severe erythematous gastritis. He was discharged after clinical stabilization. The patient came to Portugal 8 months later. On admission, he presented with rapid deterioration of kidney function and hyperkalemia. The etiologic study revealed microangiopathic hemolytic anemia, nephrotic syndrome and microscopic hematuria. Immunologic study and viral serology were negative. ADAMTS13 activity and inhibitor testing were within normal range, genetic complement evaluation showed CFH-H3 in homozygosity, functional complement studies revealed decreased function of alternative pathway. Kidney biopsy was consistent with the diagnosis of TMA, and electron microscopy was compatible with minimal change disease. Patient underwent plasmapheresis with resolution of hemolysis, fluid overload and recovery of renal function. Two months later, he presented with nephrotic syndrome and started prednisolone with remission. Six months later, the nephrotic syndrome relapsed, and it became steroid-, MMF-, and rituximab-resistant. Tacrolimus was initiated, achieving partial remission. Atypical hemolytic uremic syndrome is an uncommon disease and is rarely reported as secondary to glomerular diseases. This case showcases the challenges regarding treatment options in a resistant glomerulopathy and the implications of therapeutic choices and kidney outcomes with the coexisting TMA.

Relationship between soluble urokinase-type plasminogen activator receptor and serum biomarkers of endothelial activation in patients with idiopathic nephrotic syndrome

Background

Serum levels of soluble urokinase-type plasminogen activator receptor (suPAR) are high in some patients with idiopathic nephrotic syndrome (INS). Given that suPAR constitutes a predictor of vascular disease and has been associated with endothelial dysfunction, we hypothesized that suPAR levels are related to endothelial activation or dysfunction in INS patients. The aims of this study were to evaluate the relationship between serum concentrations of endothelial biomarkers and suPAR in patients with different histological patterns of INS and healthy controls, and to determine the demographic, clinical and biochemical characteristics of INS patients that influence suPAR serum levels.

Methods

This observational, cross-sectional study included patients with INS, diagnosed with minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS) or membranous nephropathy (MN) by renal biopsy. Patient demographic, clinical and biochemical characteristics were recorded and blood samples were obtained at the time of diagnosis. Measurements of suPAR and endothelial molecules via serum levels were performed using Enzyme-Linked ImmunoSorbent Assay kits.

Results

Patients with nephrotic syndrome (n = 152) caused by FSGS, MCD or MN had increased circulating levels of endothelial markers. suPAR levels positively correlated with age and the serum levels of almost all endothelial markers. Generally, endothelial cell molecules positively correlated with each other. suPAR levels were not associated with the histopathological pattern of INS.

Conclusions

In patients with INS secondary to FSGS, MCD and NM, circulating levels of suPAR are independent of the primary renal disease, and significantly associated with age, glomerular filtration rate and the levels of various endothelial markers.

Soluble Vascular Cell Adhesion Molecule-1 Is Associated With Disease Activity in Adult-Onset Minimal Change Disease

BACKGROUND

Cell adhesion molecules have been documented to be elevated in numerous immune inflammatory diseases. Minimal change disease (MCD) is an immune disorder. This study aimed to evaluate whether levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble E-selectin (sE-selectin) reflect disease activity in adult-onset MCD.

METHODS

A sandwich enzyme-linked immunosorbent assay was used to measure the soluble adhesion molecules in 40 patients with nephrotic-range proteinuria and biopsy-proven MCD, obtained at the time of diagnosis and during remission. Thirty-five age- and sex-matched healthy volunteers served as controls.

RESULTS

Patients with MCD during the active stage showed significantly higher levels of sVCAM-1 and sE-selectin when compared to controls. Moreover, sVCAM-1 had significantly positive correlations with both urine protein and serum cholesterol, and was negatively associated with serum albumin. Multiple analyses showed that serum albumin was an independent predictor of sVCAM-1. The correlations between sE-selectin and other clinical parameters were not statistically significant. At follow-up, these markers systematically decreased as the disease went into remission, but the increase in sVCAM-1 persisted even in patients obtaining complete remission for 6 months.

CONCLUSIONS

Patients with active MCD had increased levels of sVCAM-1 and sE-selectin. The correlation between sVCAM-1 and proteinuria, serum albumin and cholesterol and its decline during remission indicate that sVCAM-1 is associated with disease activity.

Decreased Protein Z Concentrations Complicating the Hypercoagulable State of Behqet's Disease

Protein Z is a vitamin-K-dependent plasma protein that serves as a cofactor for the inhibition of factor Xa. Although the precise physiologic function of protein Z is still unknown, abnornal plasma protein Z concentrations have been associated with a number of thrombotic disease states. There is the evidence of universal activation of the hemostatic system in Behqet's disease (BD), which represents a hypercoagulable/prothrombotic state. Circulating protein Z levels in patients with BD were evaluated. Plasma protein Z concentrations were assayed in 24 patients with BD (male/female: 13/11, mean age 35.4 years) and in 24 healthy controls (males/females: 14/10, mean age 59.8 years). The disease duration was 10.6 years (range, 1-30 years). None of the subjects in either group had received anticoagulants within 3 weeks before the study, and none of them had liver dysfunction. Patients complicated with vascular disease were also excluded from the study. Mean plasma concentrations of protein Z were 141 ng/mL (range, 56.8-257) in healthy controls and 107.8 ng/mL (range, 21.2-202) in BD patients (p<0.05). There was a positive correlation between the disease duration and protein Z levels in the study group (p<0.05, r=0.448). Alterations of protein Z concentrations could complicate the pathobiology of the prothrombotic state of BD. Furthermore, the tendency of increment in the protein Z with the passage of time may reflect the diminution of the disease activity.

Fibrinolysis and the control of blood coagulation

Fibrin plays an essential role in hemostasis as both the primary product of the coagulation cascade and the ultimate substrate for fibrinolysis. Fibrinolysis efficiency is greatly influenced by clot structure, fibrinogen isoforms and polymorphisms, the rate of thrombin generation, the reactivity of thrombus-associated cells such as platelets, and the overall biochemical environment. Regulation of the fibrinolytic system, like that of the coagulation cascade, is accomplished by a wide array of cofactors, receptors, and inhibitors. Fibrinolytic activity can be generated either on the surface of a fibrin-containing thrombus, or on cells that express profibrinolytic receptors. In a widening spectrum of clinical disorders, acquired and congenital defects in fibrinolysis contribute to disease morbidity, and new assays of global fibrinolysis now have potential predictive value in multiple clinical settings. Here, we summarize the basic elements of the fibrinolytic system, points of interaction with the coagulation pathway, and some recent clinical advances.

High dose urokinase against massive pulmonary embolism in nephrotic syndrome

Patients with nephrotic syndrome carry a high risk of pulmonary embolism due to the abnormalities in coagulation and fibrinolysis. Thrombolytic therapy for critical pulmonary embolism in nephrotic syndrome patients was rarely reported and remains controversial in the regimen selection so far. We reported a case of fatal pulmonary embolism, complicating in hepatitis B virus-associated nephrotic syndrome. The patient presented with chest pain, hemoptysis and shortness of breath on admission and his initial vital signs showed a high risk of developing hypotension. Urgent radiological examinations confirmed massive embolisms in bilateral pulmonary arteries. Prompt thrombolytic therapy was performed right after the diagnosis of pulmonary embolism with an intravenous infusion of urokinase (20 000 U/kg) in 2 h. Complete resolution of pulmonary embolism was achieved after urokinase administration and the patient was discharged in good conditions. This report highlighted the efficacy and safety of prompt thrombolytic therapy with urokinase for nephrotic syndrome patients presented with massive pulmonary embolism. In this study, we also briefly discuss the recent findings on the current state of urokinase in the clinical practice of thrombolysis.

Thrombotic microangiopathy secondary to steroid pulse therapy administered for refractory nephrotic syndrome

A 79-year-old woman with familial hyperlipidemia was treated with low-density lipoprotein apheresis. She was hospitalized due to fatigue and edema, and massive proteinuria was discovered. Renal biopsy revealed no distinct abnormalities, thus suggesting a diagnosis of minimal change nephrotic syndrome. She developed acute kidney injury and hemodialysis was initiated. Two series of steroid pulse therapy were given, but the proteinuria did not decrease. Thereafter, she developed thrombocytopenia and fell into a stupor. Thrombotic microangiopathy (TMA) was the most likely diagnosis. Plasma exchange was initiated, resulting in improvements in platelet counts and in her level of consciousness. Clinicians should therefore be aware that TMA can occur as a result of steroid pulse therapy.

Biomarkers of endothelial dysfunction in patients with primary focal segmental glomerulosclerosis

AIM

Endothelial dysfunction occurs in nephrotic syndrome (NS) and may constitute a link between NS and vascular complications. Focal segmental glomerulosclerosis (FSGS) is a common cause of NS. This study aimed to assess endothelial markers at different stages of FSGS and define whether they were associated with thromboembolic complications and disease activity.

METHODS

Forty-four patients with nephrotic-range proteinuria and biopsy-proven primary FSGS were included in this study. Nine of them had concurrent thromboembolisms. Thirty-two sex- and age- matched healthy volunteers served as controls. Endothelial markers including circulating endothelial cells (CECs), soluble thrombomodulin (sTM), von Willebrand factor (vWf), soluble vascular cell adhesion molecule-1 (sVCAM-1) and sE-selectin were assessed at the commencement of the study in all participants and were repeated at 2, 6 and 12 months of follow-up in patients without thromboembolisms.

RESULTS

Patients with FSGS during active stage showed significantly higher levels of CECs, sTM, vWf, sVCAM-1 and sE-selectin when compared with controls. Moreover, patients with thromboembolisms had higher CECs and vWf than those without thromboembolisms. In patients without thromboembolisms, endothelial markers except sE-selectin had inverse correlations with serum albumin and were positively related to cholesterol. Multiple analyses showed that cholesterol and serum albumin were independent predictors of CECs and sTM, and vWf and sVCAM-1, respectively. At follow-up, these markers systematically decreased as the disease went into remission, but the increase in vWf and sVCAM-1 persisted even in patients obtaining complete remission for nearly a year. In patients with no response, levels of endothelial markers exhibited no obvious change.

CONCLUSION

Patients with FSGS had elevated markers of endothelial dysfunction, which were largely related to the activity of the disease. Meanwhile, levels of CECs and vWf were higher in patients concurrent with thromboembolisms.

Plasma tissue factor and tissue factor pathway inhibitor in patients with primary glomerulonephritis

OBJECTIVE

Nephrotic syndrome (NS) is associated with numerous blood coagulation abnormalities and a marked predisposition to thromboembolism. Fibrin formation within the glomeruli occurs in various forms of human and experimental glomerulonephritis and may play an important role in progressive glomerular injury. The aim of this study was to measure the plasma concentrations of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) and intravascular thrombin generation markers and to analyze their relationships in patients with primary glomerulonephritis.

MATERIAL AND METHODS

The study population comprised 57 patients (mean age 35.2 years; range 18-63 years) with primary glomerulonephritis: 36 with NS (NS group) and 21 without (non-NS group). The control group consisted of 24 sex- and age-matched healthy volunteers. TF and TFPI antigen, prothrombin fragment F 1+2 (PF 1+2) and thrombin-antithrombin III complex (TAT) concentrations in plasma were estimated using commercially available kits.

RESULTS

Serum TF and TFPI concentrations in both the NS and non-NS groups were higher than those observed in the control group. Moreover, there were significant differences in TF and TFPI concentrations between the NS and non-NS groups. TF:TFPI ratios in both the examined groups were constant and significantly higher than those in the control group. Positive correlations between TF and both PF 1+2 and TAT concentrations in the total cohort of patients were shown. Furthermore, a positive correlation between TF and TFPI concentrations was observed.

CONCLUSIONS

Our data support the hypothesis concerning activation of coagulation pathways in patients with primary glomerulonephritis. An inadequate TFPI concentration as a result of an elevated TF:TFPI ratio characterizes not only patients with clinical manifestations of NS but also patients with mild proteinuria.

Markers of endothelial dysfunction in children with idiopathic nephrotic syndrome

Endothelial function impairment may constitute a link between nephrotic syndrome and atherosclerosis. We assessed changes in plasma thrombomodulin, von Willebrand factor and plasminogen activator inhibitor-1 at different stages of idiopathic nephrotic syndrome in children and correlated them with clinical and biochemical parameters. The study group included 132 nephrotic children (aged 2-18 years) divided into four groups, i.e. in acute phase of the disease with proteinuria, during steroid-induced remission, steroid-free remission, and in long-term, steroid-free remission. Forty-one healthy children served as controls. Plasma thrombomodulin, plasminogen activator inhibitor-1 and von Willebrand factor activity were increased in children with early nephrotic relapse. They systematically decreased in later stages of the disease but the increase in von Willebrand factor persisted in drug-free remission. These disturbances were dependent on the degree of proteinuria and serum albumin concentration. The study revealed that nephrotic children show markers of endothelial dysfunction that are dependent on the disease activity. This leads to the hypothesis that children with severe clinical course of nephrotic syndrome may be at high risk of accelerated atherogenesis.

Molecular analysis of the human thrombin-activatable fibrinolysis inhibitor gene promoter

Thrombin-activatable fibrinolysis inhibitor (TAFI) is a carboxypeptidase B-like pro-enzyme that, once activated, attenuates fibrinolysis. Little is presently known of the factors that regulate expression of CPB2, the gene encoding TAFI. This study identified 10 potential transcription factor binding sites (denoted A-J) within the proximal promoter region of CPB2, spanning nucleotides -425 to +21; two of these represent previously-described binding sites for CCAAT/enhancer binding protein and glucocorticoid receptor. We identified additional transcription factors that bind within the proximal CPB2 promoter, namely, nuclear factor-Y (NF-Y) and hepatocyte nuclear factor-1alpha (HNF-1alpha). Binding of NF-Y to the region between nucleotides -76 to -59 (Site B) is important for basal CPB2 promoter activity; NF-Y may be a key factor for the recruitment of the transcriptional machinery to the TAFI gene promoter. HNF-1alpha binds at the interface between Sites C and B. Transient transfections of CPB2 promoter-reporter constructs showed that HNF-1alpha binding is essential for the activity of this promoter in HepG2 cells, indicating that HNF-1alpha is involved in the liver-specific expression of CPB2.

Curiouser and curiouser: recent advances in measurement of thrombin-activatable fibrinolysis inhibitor (TAFI) and in understanding its molecular genetics, gene regulation, and biological roles

The thrombin-activatable fibrinolysis inhibitor (TAFI) pathway defines a novel molecular connection between blood coagulation and both fibrinolysis and inflammation. TAFI is a plasma zymogen that can be activated by thrombin, the thrombin-thrombomodulin complex, or plasmin. The activated form of TAFI (TAFIa) attenuates fibrinolysis by removing the carboxyl-terminal lysine residues from partially degraded fibrin that mediate positive feedback in the fibrinolytic cascade. A role for TAFIa in modulating inflammation is suggested by the ability of this enzyme to down-regulate pericellular plasminogen activation and to inactivate the inflammatory peptides bradykinin and the anaphylatoxins C3a and C5a. The focus of this review is on recent advances in the clinical measurement of the TAFI pathway in human subjects and what this has revealed in terms of the molecular genetics of TAFI, the biological variation in plasma TAFI antigen levels, potential regulators of expression of the gene encoding TAFI, and the TAFI pathway as a risk factor for the development of vascular diseases. Although this field is in its infancy, much recent progress has been made and the available data suggest that the TAFI pathway is an intriguing new player in a variety of physiological and pathophysiological contexts.

Low protein Z levels in children with nephrotic syndrome

Acquired deficiency of anticoagulant proteins, due to loss in the urine, has been proposed as one of the major thrombogenic alterations in nephrotic syndrome (NS). Protein Z (PZ) is a single-chain vitamin K-dependent glycoprotein. Low PZ levels are reported to be a risk factor for thrombosis. The aim of this study was to investigate protein Z and other natural anticoagulant levels in children with NS. Thirty children aged between 1.5 and 12 years with NS (Groups I and II) and 19 age-and-sex-matched healthy controls (Group III) were enrolled into the study. Patients were divided into two groups: Group I (proteinuria >40 mg/m2/hr) and Group II (patients in remission). Plasma PZ levels in Group I were significantly lower than Group II (p=0.009) and group III (p=0.018). Plasma levels of AT III for Group I were significantly lower than for Groups II and III (p=0.009, p=0.005, respectively). Protein C levels in Group I were higher than in Group II and Group III (p=0.002, p=0.000, respectively). Protein Z levels positively correlated with serum total protein and albumin levels (p=0.003, p=0.003, respectively) and negatively with the degree of proteinuria (p=0.000). Protein Z levels were positively correlated with AT III (r=0.037, p=0.04). Along with the other coagulation abnormalities, decreased protein Z may contribute to increased risk of thromboembolic complications in children with NS. The negative correlation between proteinuria and PZ level suggests the possibility of renal PZ loss. Further studies are needed to investigate the mechanism and role of decreased PZ in NS.

Thrombin Activatable Fibrinolysis Inhibitor in Hypertensive Kidney Transplant Recipients

Kidney transplant recipients are prone to hypertension, dyslipidemia, and cardiovascular death. Hypertension is associated with hemostatic abnormalities. Thrombin activatable fibrinolysis inhibitor (TAFI) is a glycoprotein that links coagulation and fibrinolysis. The purpose of this study was to assess TAFI concentrations in renal transplant recipients in relation to blood pressure. Additionally, we evaluated thrombin activity (thrombin-antithrombin complex [TAT], prothrombin fragments 1+2 [F1+2]), thrombomodulin (TM), and the degree of plasmin generation (plasmin-antiplasmin complex [PAP]) using commercially available kits. The studies were performed on 86 renal allograft recipients (48 women, 38 men) at age range 26 to 73 years. The immunosuppressive regimen consisted of cyclosporine (CsA), prednisone, and azathioprine (n = 58) or mycophenolate mofetil (MMF; n = 28). All patients maintained sufficient and stable graft function, showing no clinical signs of rejection. In patients with hypertension (n = 68), we observed significantly higher concentrations of TAFI and of markers of thrombin generation (F1+2, TAT), and of thrombomodulin with significantly prolonged euglobulin clot lysis time (ECLT), which reflects overall fibrinolytic activity and lower fibrinolytic activity index (FAI). Both groups did not differ with respect to age, creatinine clearance, body mass index, time after transplantation, albumin, fibrinogen, and PAP. Diastolic blood pressure correlated significantly with TAFI concentrations, uric acid, and prednisone dose, whereas systolic blood pressure correlated with urea, uric acid, creatinine clearance, and MCV. Elevated TAFI concentrations and enhanced thrombin generation in hypertensive kidney transplant recipients may contribute to the hypofibrinolysis and progressive atherosclerosis in this population. Blood pressure was related to kidney function, maintenance prednisone dose, and TAFI concentration.

Intermittent pneumatic foot compression can activate blood fibrinolysis without changes in blood coagulability and platelet activation

BACKGROUND

Intermittent pneumatic foot compression (IPC) is a useful technique for prophylaxis of peri-operative venous thromboembolism. The aim of this study was to determine the effect of IPC on blood coagulation/fibrinolysis and platelet function using a blood viscometer (Sonoclot) and a platelet aggregation monitor (WBA analyzer(TM)), respectively. Using the same blood samples, serum levels of tissue-type plasminogen activator (t-PA), thrombomodulin (TM) and activated protein C (APC) were also measured.

METHODS

The soles and legs of each subject (n = 8) were compressed for 3 s (130 mmHg) at a 0.3-Hz interval using an IPC device. Parameters were measured 2 min before and at the end of 60-min compression.

RESULTS

Parameters of the Sonoclot time-to-peak were shortened and clot retraction rate was increased significantly by IPC, whereas the other parameters did not change. These results indicate that IPC can activate blood fibrinolysis but not coagulability. A parameter of the WBA analyzer PATI (platelet aggregatory threshold index) did not change, indicating that IPC cannot activate platelet function per se. The concentration of t-PA decreased slightly but significantly. A decrease in the concentration of t-PA can lead to activation of fibrinolysis. Other humoral parameters did not change, indicating that IPC has no effect on endothelial function. Although neither blood coagulability nor platelet function were affected by IPC, fibrinolytic activity increased slightly, probably by activation of t-PA function.

CONCLUSION

IPC is useful for prophylaxis for thromboembolism by activation of blood fibrinolysis as well as inhibition of blood stasis.

Thrombin-activatable fibrinolysis inhibitor in kidney transplant recipient with dyslipidemia

Kidney transplant recipients are not only prone to dyslipidemia but also have a high risk of cardiovascular death. Impairment of the fibrinolytic system is thought to be one factor playing a role in development of thrombotic complications. Thrombin-activatable fibrinolysis inhibitor (TAFI) is a glycoprotein, linking coagulation and fibrinolysis. The purpose of this study was to assess TAFI concentrations and activities in renal transplant recipients stratified based upon serum cholesterol values above 220 mg/dL or below 200 mg/dL. The groups did not differ regarding age, creatinine clearance, BMI, time after transplantation, albumin, fibrinogen, thrombomodulin, or PAP. Additionally, we evaluated thrombin activity (thrombin-antithrombin complex TAT, prothrombin fragments 1 + 2); TAFI activator; thrombomodulin (TM), catalyzer of TAFI activation; and the degree of plasmin generation (plasmin-antiplasmin complex PAP) using commercially available kits. In patients with hyperlipidemia significantly higher TAFI concentrations and activities may contribute to prolonged ECLT and lowered fibrinolytic activity index (FAI). Increased levels of F1 + 2 and TAT were observed in hypercholesterolemic patients, indicating enhanced thrombin generation. Elevated TAFI concentration, and activities and enhanced thrombin generation observed in hypercholesterolemic kidney transplant recipients may contribute to hypofibrinolysis and progression of atherosclerosis in this group of patients.

Some aspects of hemostasis in kidney transplant recipients maintained on cyclosporine, azathioprine, and prednisone in comparison to patients treated with cyclosporine and prednisone

Cyclosporine (CyA) has been implicated to increase cardiovascular morbidity and mortality after renal transplantation. Impairment of the fibrinolytic system is one factor involved in the development of thrombotic complications. The aim of this study was to compare hematological and hemostatic parameters among patients on CyA, azathioprine, and prednisone (n = 31) versus CyA and steroids (n = 14). Using commercially available kits we evaluated thrombin activity as thrombin-antithrombin complexes (TAT), prothrombin fragments (1 + 2), thrombin activatable fibrinolysis inhibitor-(TAFI), TAFI activator, thrombomodulin (TM)-a marker for endothelial cell injury,-plasmin generation (plasmin-antiplasmin complex PAP), a glycoprotein linking coagulation and fibrinolysis. We observed that patients not treated with azathioprine displayed longer prothrombin times and activated partial thromboplastin times; higher fibrinogen, platelet counts and fibrinolytic activity index (FAI); shorter euglobulin clot lysis time; as well as lower thrombin generation markers namely, prothrombin fragments 1 + 2 and thrombin-antithrombin complexes. Although patients in the non-AZA group tended to have been engrafted for a longer time (P =.086), the groups did not differ with regard to age, BMI, erythrocyte count, hematocrit, leukocyte count, creatinine clearance, alanine and asparagine aminotransferase activities mean arterial blood pressure, fibrinogen, TAFI, thrombomodulin, or plasmin-antiplasmin complexes. These findings suggest that kidney transplant recipients on triple therapy are at greater risk of cardiovascular disease than those without azathioprine treatment, despite the lower fibrinolytic activity.