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Pelland-Marcotte MC, Tole S, Bouhelier E, Lee S, Halparin J, Mammen C, Lyons K, Amid A. Rivaroxaban for Management of Venous Thromboembolism in Pediatric Nephrotic Syndrome; a Case Report and Review of Literature. Pediatr Hematol Oncol 2022; 40:688-695. [PMID: 36427068 DOI: 10.1080/08880018.2022.2150797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/04/2022] [Accepted: 11/12/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Soumitra Tole
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital, London Health Sciences Centre, London, ON, Canada
| | - Eve Bouhelier
- Research Center of the CHU de Quebec, Quebec City, QC, Canada
| | - Susan Lee
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Jessica Halparin
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Cherry Mammen
- Division of Pediatric Nephrology, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Karen Lyons
- Department of Radiology, BC Children's Hospital, Vancouver, BC, Canada
| | - Ali Amid
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
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2
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Constantinescu AR, Mattoo TK, Smoyer WE, Greenbaum LA, Niu J, Howard N, Muff-Luett M, Benoit EB, Traum A, Annaim AA, Wenderfer SE, Plautz E, Rheault MN, Myette RL, Twombley KE, Kamigaki Y, Wandique-Rapalo B, Kallash M, Vasylyeva TL. Clinical presentation and management of nephrotic syndrome in the first year of life: A report from the Pediatric Nephrology Research Consortium. Front Pediatr 2022; 10:988945. [PMID: 36210940 PMCID: PMC9534228 DOI: 10.3389/fped.2022.988945] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nephrotic syndrome (NS) in the first year of life is called congenital (CNS) if diagnosed between 0-3 months, or infantile (INS) if diagnosed between 3-12 months of age. The aim of this study was to determine if there were clinically meaningful differences between CNS and INS patients, regarding clinical presentation, management and outcomes. DESIGN SETTING PARTICIPANTS AND MEASUREMENTS Eleven Pediatric Nephrology Research Consortium sites participated in the study, using IRB-approved retrospective chart reviews of CNS and INS patients born between 1998 and 2019. Data were collected on patient characteristics, pertinent laboratory tests, provided therapy, timing of unilateral/bilateral nephrectomy and initiation of renal replacement therapy (RRT). RESULTS The study included 69 patients, 49 with CNS and 20 with INS, with a median age at diagnosis of 1 and 6 months, respectively. Management for the two groups was similar regarding nutrition, thyroxin supplementation, immunoglobulin administration, and thrombosis prophylaxis. Within the first 2 months after diagnosis, daily albumin infusions were used more often in CNS vs. INS patients (79 vs. 30%; p = 0.006), while weekly infusions were more common in INS patients (INS vs. CNS: 50 vs. 3%; p = 0.001). During the 6 months preceding RRT, albumin infusions were more frequently prescribed in CNS vs. INS (51 vs. 15%; p = 0.007). Nephrectomy was performed more often in CNS (78%) than in INS (50%; p = 0.02). End-stage kidney disease tended to be more common in children with CNS (80%) vs. INS (60%; p = 0.09). CONCLUSION Compared to INS, patients with CNS had a more severe disease course, requiring more frequent albumin infusions, and earlier nephrectomy and RRT. Despite center-specific variations in patient care, 20-40% of these patients did not require nephrectomy or RRT.
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Affiliation(s)
- Alexandru R Constantinescu
- Integrated Medical Sciences, Charles E Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL, United States.,Pediatric Nephrology, Joe DiMaggio Children's Hospital, Hollywood, FL, United States
| | - Tej K Mattoo
- Pediatrics and Urology, Wayne State University School of Medicine, Detroit, MI, United States
| | - William E Smoyer
- Center for Clinical and Translational Research, The Ohio State University, Columbus, OH, United States
| | | | - Jianli Niu
- Department of Research and Scholarly Activity at Memorial Healthcare System, Hollywood, FL, United States
| | - Noel Howard
- Health Sciences Center School of Medicine, Texas Tech University, Amarillo, TX, United States
| | - Melissa Muff-Luett
- Pediatric Nephrology, Children's Hospital and Medical Center, Omaha, NE, United States
| | | | - Avram Traum
- Pediatric Nephrology, Boston Children's Hospital, Boston, MA, United States
| | - Ali A Annaim
- Pediatric Nephrology, Children's Hospital of Atlanta, Atlanta, GA, United States
| | - Scott E Wenderfer
- Pediatric Nephrology, Texas Children's Hospital, Houston, TX, United States
| | - Emilee Plautz
- University of Minnesota, Minneapolis, MN, United States
| | - Michelle N Rheault
- Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Robert L Myette
- Pediatric Nephrology, Children's Hospital of Eastern Ontario and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Katherine E Twombley
- Pediatric Nephrology, Medical University of South Carolina College of Medicine, Charleston, SC, United States
| | - Yu Kamigaki
- Center for Clinical and Translational Research, The Ohio State University, Columbus, OH, United States
| | | | - Mohammad Kallash
- Pediatric Nephrology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Tetyana L Vasylyeva
- Pediatric Nephrology, Health Sciences Center School of Medicine, Texas Tech University, Amarillo, TX, United States
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3
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 693] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Abstract
Membranous nephropathy (MN) is a glomerular disease that can occur at all ages. In adults, it is the most frequent cause of nephrotic syndrome. In ~80% of patients, there is no underlying cause of MN (primary MN) and the remaining cases are associated with medications or other diseases such as systemic lupus erythematosus, hepatitis virus infection or malignancies. MN is an autoimmune disease characterized by a thickening of the glomerular capillary walls due to immune complex deposition. Identification of the phospholipase A2 receptor (PLA2R) as the major antigen in adults in 2009 induced a paradigm shift in disease diagnosis and monitoring and several other antigens have since been characterized. Disease outcome is difficult to predict and around one-third of patients will undergo spontaneous remission. In those at high risk of progression, immunosuppressive therapy with cyclophosphamide plus corticosteroids has substantially reduced the need for kidney replacement therapy. Owing to carcinogenic risk, other treatments (calcineurin inhibitors and CD20-targeted B cell depletion therapy (rituximab)) have been developed. However, disease relapses are frequent when calcineurin inhibitors are stopped and the remission rate with rituximab is lower than with cyclophosphamide, particularly in patients with high PLA2R antibody titres. Other new drugs are already available and antigen-specific immunotherapies are being developed.
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5
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Uncanin S, Dzemidzic J, Serdarevic N, Muslimovic A, Haskovic D. Idiopathic Membranous Nephropathy and Treatment Related Complications. Med Arch 2021; 74:228-232. [PMID: 32801441 PMCID: PMC7405995 DOI: 10.5455/medarh.2020.74.228-232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: Idiopathic Idiopathic membranous nephropathy (iMN) is an immune-complex mediated renal disease which is usually associated with the nephrotic syndrome (NS). The course of the disease is variable. Some patients maintain normal kidney function with or without a spontaneous remission of proteinuria, while others progress to end-stage renal failure or die from complications related to the nephrotic syndrome. Whether or not to treat a patient with idiopathic membranous nephropathy is still controversial. The controversy is mainly related to the toxicity of the therapy and the variable natural course of the disease-spontaneous remission occurs in 40–50% of patients. Aim: The aim of this study was to describe our experience of treatment of an idiopathic membranous nephropathy (iMN), efficacy and complications rate. Case report: Our patient was older, mail gender, in high-risk group with persistent proteinuria 10,68 g/day and stable renal function. We have taken these factors into consideration, along with age and other comorbidities, that may significantly elevate the risk of treatment. We chose to start with early treatment, following the Ponticelli’s group protocol based on high dose corticosteroids (odd months) alternating with clorambucil (even months) for six months. This treatment was accompanied by the steroid side effects, including hyperglycaemia dependance on insulin therapy and pulmonary thromboembolism despite administered prophylactically low molecular weight heparin. The six-month treatment was successfully completed with the reduction of proteinuria to nephritic values 2,86 g/day, despite many complications. Complete remission of the disease with non-significant proteinuria and with stable renal function was achieved in 14 months which has been maintained for 2 years. Conclusion: We suggest that decisions on the timing of start of therapy, whom to treat, best sequence of the use of the various immunosuppressive drugs must be based on an individualized assessment of risks and benefits.
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Affiliation(s)
- Snezana Uncanin
- Urology Clinic, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina and Clinic of Nephrology, Clinics Center, Sarajevo, Bosnia and Herzegovina.,Faculty of Health Studies, University of Sarajevo, Bosnia and Herzegovina
| | - Jasminka Dzemidzic
- Urology Clinic, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina and Clinic of Nephrology, Clinics Center, Sarajevo, Bosnia and Herzegovina
| | - Nafija Serdarevic
- Faculty of Health Studies, University of Sarajevo, Bosnia and Herzegovina.,Institute for Clinical Biochemistry and Immunology University of Sarajevo, Clinics Center, Sarajevo, Bosnia and Herzegovina
| | - Alma Muslimovic
- Urology Clinic, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina and Clinic of Nephrology, Clinics Center, Sarajevo, Bosnia and Herzegovina
| | - Denis Haskovic
- Institute for Clinical Biochemistry and Immunology University of Sarajevo, Clinics Center, Sarajevo, Bosnia and Herzegovina
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6
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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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Zou P, Li H, Cai J, Li C, Chen Z, Li X. The role of prophylactic use of low molecular weight heparin or aspirin in thromboembolic events in primary membranous nephropathy. Ren Fail 2020; 41:623-628. [PMID: 31269849 PMCID: PMC6609351 DOI: 10.1080/0886022x.2019.1635030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: The aim of this study is to investigate the role of prophylactic anticoagulation regimens based on low molecular weight heparin (LMWH) or aspirin in thromboembolic events in patients with primary membranous nephropathy (PMN). Methods: A total of 717 patients with PMN were consecutively enrolled in this retrospective study. The propensity score matching method was utilized to adjust for the selection bias inherent in an analysis of outcomes, which was stratified by the anticoagulation prophylaxis regimen. Results: According to the anticoagulation prophylaxis regimen, patients were assigned into three groups: only LMWH therapy (L + A−, n = 53), only aspirin therapy (L − A+, n = 97), and no therapy of LMWH or aspirin (L − A−, n = 567). After performing 1:1 match, 37 patients were selected in the L + A − group and the L − A− group, respectively, and 94 patients were selected in the L − A+ group and the L − A− group, respectively. It showed that the prophylactic use of LMWH had no protective effects on arterial thromboembolic events (ATEs) (10.8% vs. 21.6%, p = .21) or venous thromboembolic events (VTEs) (8.1% vs. 10.8%, p = .69). The incidence of VTEs in the L − A+ group was lower than the L − A− group (2.1% vs. 10.6%, p = .02), while there were no significant differences in the incidences of ATEs between the L − A+ group and the L − A− group (5.3% vs. 7.4%, p = .55). Conclusions: The prophylactic use of LMWH showed no benefits on the incidence of ATEs or VTEs in patients with PMN. Aspirin effectively decreased the incidence of VTEs, without effects on the occurrence of ATEs.
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Affiliation(s)
- Peimei Zou
- a Blood Purification Center , Beijing ChaoYang Hospital, Capital Medical University , Beijing , China
| | - Hang Li
- b Department of Nephrology , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jianfang Cai
- b Department of Nephrology , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Chao Li
- b Department of Nephrology , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Zhenjie Chen
- c Department of Nephrology , Dongzhimen Hospital, Beijing University of Chinese Medicine , Beijing , China
| | - Xuewang Li
- b Department of Nephrology , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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8
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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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9
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Rieder SC, Huber LC, Trachsler J, Herberger E. [CME: Nephrotic Syndrome in Adults: Presentation, Diagnosis, Therapy]. PRAXIS 2019; 108:347-355. [PMID: 30940036 DOI: 10.1024/1661-8157/a003223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CME: Nephrotic Syndrome in Adults: Presentation, Diagnosis, Therapy Abstract. The nephrotic syndrome is defined by renal protein loss with hypalbuminaemia and edema. Hyperlipoproteinemia and thrombophilia are not diagnostic criteria, but are frequently associated conditions. Patients with nephrotic syndrome are at higher risk for infections. Primary causes of a nephrotic syndrome are differentiated from secondary glomerulopathies due to systemic diseases. To confirm the diagnosis and for prognostic reasons, a kidney biopsy is performed in most cases. Steroids and other immunosuppressive agents are frontline therapies in primary forms. Secondary forms are treated by addressing the underlying disease. Therapeutic cornerstones include an adequate RAAS blockade with ACE inhibitors or AT-II receptor blockers. Loop diuretics are used to control edemas. In addition, the need for anticoagulation and statin therapy must be evaluated.
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Affiliation(s)
| | - Lars C Huber
- 1 Klinik für Innere Medizin, Stadtspital Triemli Zürich
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10
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Direct-Acting Oral Anticoagulants as Prophylaxis Against Thromboembolism in the Nephrotic Syndrome. Kidney Int Rep 2018; 3:784-793. [PMID: 29989039 PMCID: PMC6035159 DOI: 10.1016/j.ekir.2018.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
We report 2 cases of apixaban use as prophylaxis against thromboembolism in the nephrotic syndrome (NS), and review the existing literature on direct-acting oral anticoagulant (DOAC) use in this scenario. Our cases appear to be the first reported use of apixaban as prophylaxis against thromboembolism in NS. We report our systematic review of the existing literature on direct-acting oral anticoagulant (DOAC) use in NS, and discuss theoretical issues relevant to their therapeutic use in this clinical scenario. We searched electronic databases such as OVID, EMBASE, PubMed, and CENTRAL, DARE. The search to identify studies and the application of inclusion and exclusion criteria was performed in duplicate independently. We identified 1 pilot randomized study, 3 case reports, and 3 conference proceedings abstracts relating to DOAC use in NS. These reports all pertain to the treatment of clinically evident thrombosis in NS with rivaroxaban, edoxaban, and dabigatran rather than prophylaxis against thrombosis. Although the existing literature on DOAC use in NS is limited, initial preliminary experience appears promising.
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Affiliation(s)
- Konstantinos N Aronis
- Division of Cardiology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elaine M Hylek
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
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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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Fraisse C, Nouvier M, Lainez S, Nesme P, Ernesto S, Devouassoux G. [Pulmonary embolism as a presentation of nephrotic syndrome]. Rev Mal Respir 2017; 34:765-769. [PMID: 28844809 DOI: 10.1016/j.rmr.2016.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 12/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nephrotic syndrome (NS) in adults is defined by proteinuria>3g/24h or 50mg/kg/d, hypoproteinemia<60g/24h and hypoalbuminemia<30g/L. The final diagnosis is guided by the histopathology evidence when a renal biopsy is possible. The consequences of NS are multiple: high blood pressure, undernutrition, infections and a hypercoagulable state. OBSERVATION We report the case of a patient presenting with thromboembolic disease, occurring in the absence of other thromboembolic risk factors, which revealed NS with spontaneously favorable evolution. CONCLUSION Thromboembolic disease in NS is frequent but underestimated and may remain underdiagnosed. Thorough investigation - including serum protein levels and testing for proteinuria - are essential in thromboembolism, as is excluding cancer or another cause. The treatment of thromboembolic disease in NS is based on anticoagulation for as long as the NS persists. There is no consensus about primary prophylaxis but an albumin level below 20g/L should be considered as a risk factor of thrombosis and prophylactic anticoagulation should be started.
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Affiliation(s)
- C Fraisse
- Service de pneumologie, bâtiment I, hôpital de la Croix-Rousse, groupement hospitalier nord, hospices civils de Lyon et université Claude-Bernard Lyon 1, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - M Nouvier
- Service de néphrologie hôpital Lyon sud, groupement hospitalier sud, hospices civils de Lyon et université Claude-Bernard Lyon 1, France
| | - S Lainez
- Service de pneumologie, bâtiment I, hôpital de la Croix-Rousse, groupement hospitalier nord, hospices civils de Lyon et université Claude-Bernard Lyon 1, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - P Nesme
- Service de pneumologie, bâtiment I, hôpital de la Croix-Rousse, groupement hospitalier nord, hospices civils de Lyon et université Claude-Bernard Lyon 1, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - S Ernesto
- Service de pneumologie, bâtiment I, hôpital de la Croix-Rousse, groupement hospitalier nord, hospices civils de Lyon et université Claude-Bernard Lyon 1, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - G Devouassoux
- Service de pneumologie, bâtiment I, hôpital de la Croix-Rousse, groupement hospitalier nord, hospices civils de Lyon et université Claude-Bernard Lyon 1, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
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Okada M, Akimoto T, Kawamata M, Imai T, Hishida E, Kohara M, Miki A, Murakami T, Sugase T, Masuda T, Ono Y, Ueda Y, Saito O, Muto S, Nagata D. Retroperitoneal Bleeding: An Experience During Prophylactic Anticoagulation in a Patient With Nephrotic Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547617723317. [PMID: 28811743 PMCID: PMC5542073 DOI: 10.1177/1179547617723317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022]
Abstract
The association between nephrotic syndrome (NS) and a hypercoagulable state has been demonstrated. Controlling the blood clotting activity may therefore be attractive for patients with nephrosis in terms of thromboembolism prophylaxis. We herein report a 75-year-old woman with minimal change disease who developed pains in the right back, groin, and thigh because of retroperitoneal bleeding during prophylactic anticoagulation with unfractionated heparin. Although this procedure has not been accepted as the standard of care for patients with nephrosis, pharmacologic prophylaxis may already be practiced empirically, as in the present patient. We believe that our experience highlights the pitfalls of such a management in patients with nephrosis, implying the need for a diagnostic strategy for identifying those patients with NS who can benefit from prophylactic anticoagulation. Several concerns that emerged in this case are also discussed.
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Affiliation(s)
- Mari Okada
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Mutsumi Kawamata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Erika Hishida
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Marina Kohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Atsushi Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takuya Murakami
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Yuko Ono
- Department of Diagnostic Pathology, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Yoshihiko Ueda
- Department of Diagnostic Pathology, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Osamu Saito
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
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Akimoto T, Yamazaki T, Kusano E, Nagata D. Therapeutic Dilemmas Regarding Anticoagulation: An Experience in a Patient with Nephrotic Syndrome, Pulmonary Embolism, and Traumatic Brain Injury. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2016; 9:103-107. [PMID: 27840582 PMCID: PMC5096764 DOI: 10.4137/ccrep.s40607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/02/2016] [Accepted: 10/04/2016] [Indexed: 11/05/2022]
Abstract
Patients with active bleeding complications who concomitantly develop overt pulmonary embolism (PE) present distinct therapeutic dilemmas, since they are perceived to be at substantial risk for the progression of the embolism in the absence of treatment and for aggravation of the hemorrhagic lesions if treated with anticoagulants. A 76-year-old patient with nephrotic syndrome, which is associated with an increased risk of thromboembolism, concurrently developed acute PE and intracranial bleeding because of traumatic brain injury. In this case, we prioritized the treatment for PE with the intravenous unfractionated heparin followed by warfarinization. Despite the transient hemorrhagic progression of the brain contusion after the institution of anticoagulation, our patient recovered favorably from the disease without any signs of neurological compromise. Several conundrums regarding anticoagulation that emerged in this case are also discussed.
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Affiliation(s)
- Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Tomoyuki Yamazaki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Eiji Kusano
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
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16
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Eneman B, Levtchenko E, van den Heuvel B, Van Geet C, Freson K. Platelet abnormalities in nephrotic syndrome. Pediatr Nephrol 2016; 31:1267-79. [PMID: 26267676 DOI: 10.1007/s00467-015-3173-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 01/08/2023]
Abstract
Nephrotic syndrome (NS) is a common kidney disease associated with a significantly increased risk of thrombotic events. Alterations in plasma levels of pro- and anti-coagulant factors are involved in the pathophysiology of venous thrombosis in NS. However, the fact that the risk of both venous and arterial thrombosis is elevated in NS points to an additional role for blood platelets. Increased platelet counts and platelet hyperactivity have been observed in nephrotic children. Platelet hyperaggregability, increased release of active substances, and elevated surface expression of activation-dependent platelet markers have been documented. The mechanisms underlying those platelet alterations are multifactorial and are probably due to changes in plasma levels of platelet-interfering proteins and lipid changes, as a consequence of nephrosis. The causal relationship between platelet alterations seen in NS and the occurrence of thromboembolic phenomena remains unclear. Moreover, the efficiency of prophylactic treatment using antiplatelet agents for the prevention of thrombotic complications in nephrotic patients is also unknown. Thus, antiplatelet medication is currently not generally recommended for routine prophylactic therapy.
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Affiliation(s)
- Benedicte Eneman
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium.
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium.
| | - Elena Levtchenko
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Bert van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | - Kathleen Freson
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
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17
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Yang Y, Ma L, Wang C, Kong D, Wang Y, Mei C. Effectiveness of sulodexide might be associated with inhibition of complement system in hepatitis B virus-associated membranous nephropathy: An inspiration from a pilot trial. Eur J Intern Med 2016; 32:96-104. [PMID: 27160380 DOI: 10.1016/j.ejim.2016.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/05/2016] [Accepted: 04/15/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The activation of complement system is associated with the development of hepatitis B virus-associated membranous nephropathy (HBV-MN) and heparin could inhibit the activation of complement system. METHODS This was a three-center trial. Seventy-nine patients with HBV-MN participated in the study. The follow-up of the study consisted of two periods: Stage 1 (S1) and Stage 2 (S2). All patients received 0.5mg entecavir plus 150-300mg/day of irbesartan but sulodexide was prescribed during S1. They were randomized into 4 groups according to sulodexide dose: blank (Group 1), 250 lipasemic unit (lsu)/day for 1year (Group 2), 500 lsu/day for 1year (Group 3) and 1000 lsu/day for 6months followed by 250 lsu/day for 6months (Group 4). Major clinical outcomes were valid remission (VR): (1) urine albumin/creatinine ratio (UACR) <150mg/mmol and >50% decline of baseline; (2) albumin >35g/L; (3) glomerular filtration rate (GFR) >90ml/(min*1.73m(2)). RESULTS (1) Groups 3 and 4 had significantly lower UACR and higher albumin than did Groups 1 and 2 at major visits; (2) Groups 3 and 4 achieved more VR compared with Group 1 (42.1% and 60.0% vs. 9.1%, p both<0.05); (3) in Groups 3 and 4, instead of Groups 1 and 2, more C3 deposition in the kidney was observed in those achieving VR; (4) plasma C3a, C5a and C5b-9 decreased significantly in Groups 3 and 4 during S1. CONCLUSIONS (1) The prescription of both sulodexide and entecavir could improve the prognosis of patients with HBV-MN but their mechanisms might be different; (2) the renoprotection of sulodexide in HBV-MN might probably relate to the inhibition of complement system.
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Affiliation(s)
- Yang Yang
- Kidney Institute of PLA, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China; Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Lu Ma
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Chao Wang
- Kidney Therapeutic Center of Traditional Chinese and Western Medicine, Beidaihe Sanatorium of Beijing Military Region, Qinhuangdao, China
| | - Deyang Kong
- Department of Nephrology, First Affiliated Hospital of Haerbin Medical University, Haerbin, China
| | - YaPing Wang
- Department of Nephrology, General Hospital of Beijing Military Region, Beijing, China
| | - Changlin Mei
- Kidney Institute of PLA, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.
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18
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Matsuo K, Moeini A, Machida H, Fullerton ME, Shabalova A, Brunette LL, Roman LD. Significance of venous thromboembolism in women with cervical cancer. Gynecol Oncol 2016; 142:405-12. [PMID: 27350404 DOI: 10.1016/j.ygyno.2016.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/11/2016] [Accepted: 06/14/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To characterize risk factors of venous thromboembolism (VTE) and to examine effects of VTE on survival of women with cervical cancer. METHODS This is a retrospective study examining consecutive stage I-IV cervical cancer cases diagnosed between 2000 and 2014. Cumulative risk of VTE after cervical cancer diagnosis was evaluated by a time-dependent analysis, expressing adjusted-hazard ratio [HR] and 95% confidence interval [CI]. Survival analysis was performed to determine independent risk factors for progression-free survival (PFS) and disease-specific overall survival (OS). RESULTS VTE was recorded in 98 (12.3%, 95%CI 11.6-22.8) out of 798 cases with 1-, 2-, and 5-year cumulative incidences after cervical cancer diagnosis being 8.4%, 11.3%, and 18.7%, respectively. On multivariable analysis, advanced-stage disease (2-year cumulative risk, distant metastatic disease 44.8% [HR 4.13, 95%CI 1.06-10.7, P=0.003], and locally-advanced disease 13.4% [HR 2.46, 95%CI 1.17-4.43, P=0.004]) were independently associated with increased risk of VTE compared to early-stage disease (stage IA1-IB1 4.1%). In addition, low albumin level (HR per unit change, 0.59, 95%CI 0.40-0.85, P=0.005) and chemotherapy treatment (HR 2.46, 95%CI 1.30-4.66, P=0.006) remained independent risk factors associated with increased risk of VTE. On univariate analysis, VTE was significantly associated with decreased PFS (5-year rates, 22.3% versus 68.7%, P<0.001) and OS (5-year rates, 55.1% versus 90.0%, P<0.001). On multivariable analysis, VTE remained an independent prognostic factor associated with decreased PFS (HR 1.95, 95%CI 1.43-2.67, P<0.001) and OS (HR 3.54, 95%CI 2.04-6.13, P<0.001). CONCLUSION VTE represents aggressive tumor behavior and poor patient condition, and is an independent prognostic factor for decreased survival in women with cervical cancer.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Aida Moeini
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Hiroko Machida
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Morgan E Fullerton
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Anastasiya Shabalova
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Laurie L Brunette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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19
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Vitamin K antagonists in children with central venous catheter on chronic haemodialysis: a pilot study. Pediatr Nephrol 2016; 31:827-32. [PMID: 26667238 DOI: 10.1007/s00467-015-3293-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND To date, no study has investigated the use of vitamin K antagonists (VKA) in children undergoing chronic haemodialysis (HD) with a central venous catheter (CVC). METHODS Consecutive patients aged <18 years with a newly placed tunnelled CVC for chronic HD were enrolled over a 3-year period. Children with active nephrotic syndrome or a history of venous thrombosis received warfarin (VKA group) with therapeutic target international normalised ratios of between 2.0 and 3.0. Patients at standard risk of CVC malfunction were not treated with VKA (standard group). The primary end-point was overall CVC survival. RESULTS The VKA group consisted of nine patients (median age 10.6 years; range 1.2-15.3 years) with 11 CVC, and the standard group comprised eight patients (11.8 years; 6.1-17.3 years) with ten CVC. The 6- and 12-month CVC survival was significantly longer in the VKA group than in the standard group (100 vs. 60 % and 83.3 vs. 16.7 %, respectively; p < 0.05), with a median survival of 369 and 195 days, respectively (p < 0.05). None of the CVC in the VKA group required removal due to malfunction, as compared to four in the standard group. No major bleeding episodes occurred in either group. CONCLUSIONS Therapy with VKA would appear to be safe in children on chronic HD and may improve CVC survival in patients at increased risk of CVC thrombosis.
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20
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Adike A, Cherry M, Awar M. Case Report: Acute Cerebellar Thrombosis in an Adult Patient with IgM Nephropathy. Methodist Debakey Cardiovasc J 2016; 11:247-9. [PMID: 27057296 DOI: 10.14797/mdcj-11-4-247] [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: 01/10/2023] Open
Abstract
IgM nephropathy is a relatively rare cause of idiopathic nephrotic syndrome.1 It was initially described by van de Putte,2 then by Cohen and Bhasin in 1978, as a distinctive feature of mesangial proliferative glomerulonephritis.2 It is typically characterized by diffuse IgM deposits on the glomeruli and diffuse mesangial hypercellularity. Little is known about the pathogenesis and treatment of this disease.1,3 We describe a patient who presented with nonspecific symptoms of epigastric pain, nausea, and early satiety. Abdominal imaging and endoscopies were unremarkable. She was found to have significant proteinuria (6.4 g/24 hours), hyperlipidemia, and edema consistent with a diagnosis of nephrotic syndrome. Kidney biopsy was performed and confirmed an IgM nephropathy. Less than 2 weeks after her diagnosis of IgM nephropathy, she presented with an acute cerebellar stroke. Thrombophilia is a well-known complication of nephrotic syndrome, but a review of the literature failed to show an association between IgM nephropathy and acute central nervous system thrombosis.
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21
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Sato R, Akimoto T, Imai T, Nakagawa S, Okada M, Miki A, Takeda S, Yamamoto H, Saito O, Muto S, Kusano E, Nagata D. Minimal Change Nephrotic Syndrome Sequentially Complicated by Acute Kidney Injury and Painful Skin Ulcers due to Calciphylaxis. Intern Med 2016; 55:3315-3320. [PMID: 27853075 PMCID: PMC5173500 DOI: 10.2169/internalmedicine.55.7180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Calciphylaxis is rare cutaneous manifestation associated with painful skin ulceration and necrosis. It primarily occurs in patients with end-stage chronic kidney disease. In this report, we would like to show our experience with a male patient presenting with minimal change nephrotic syndrome that was sequentially complicated by acute kidney injury and painful ulcerative cutaneous lesions due to calciphylaxis. There seemed to be several contributing factors, including a disturbance of the patient's mineral metabolism and the systemic use of glucocorticoids and warfarin. Various concerns regarding the diagnostic and therapeutic conundrums that were encountered in the present case are also discussed.
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Affiliation(s)
- Ryuta Sato
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
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Hale G, Brenner M. Risks and benefits of low molecular-weight heparin and target-specific oral anticoagulant use for thromboprophylaxis in medically ill patients. Am J Cardiovasc Drugs 2015; 15:311-22. [PMID: 25957095 DOI: 10.1007/s40256-015-0122-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Venous thromboembolism is the third most common cardiovascular disease and a major cause of inpatient mortality as over 50 % of deep vein thrombosis and pulmonary embolism are undetected in medically treated patients. Several agents are approved for thromboprophylaxis, including warfarin, unfractionated heparin, low molecular-weight heparins, fondaparinux, and target-specific oral anticoagulants. The purpose of this literature review is to discuss the increased risk of venous thromboembolism in medically ill patients and the literature surrounding the efficacy and tolerability of low molecular-weight heparins and target-specific oral anticoagulants for this indication. PubMed, MEDLINE, EBSCOhost, and clinicaltrials.gov were used as search engines in the literature review. Search limits included articles containing human subjects, scholarly (peer-reviewed) journals written in English, and publication dates from 2004 to 2014. Animal studies, non-English articles, and publications dated prior to 2004 were excluded. Recurrent venous thromboembolism remains an ongoing problem affecting thousands of people in the non-surgical population annually. With limited data, it is not likely that target-specific oral anticoagulants will soon replace low molecular-weight heparins or even be considered an alternative until efficacy and tolerability have been established. Until further evidence is disclosed, low molecular-weight heparins and fondaparinux (in the absence of renal dysfunction and low body weight) should continue to be utilized as first-line agents for thromboprophylaxis in medically ill patients. The use of apixaban and rivaroxaban is discouraged for thromboprophylaxis in medically ill patients.
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Lowe SA, Bowyer L, Lust K, McMahon LP, Morton M, North RA, Paech M, Said JM. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust N Z J Obstet Gynaecol 2015; 55:e1-29. [PMID: 26412014 DOI: 10.1111/ajo.12399] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.
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Affiliation(s)
- Sandra A Lowe
- Department of Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Lucy Bowyer
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetric Medicine and Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Mark Morton
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | - Michael Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Joanne M Said
- Sunshine Hospital and University of Melbourne, Melbourne, Victoria, Australia
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Tian M, Liu C. Heparin calcium treated Henoch–Schönlein purpura nephritis in children through inhibiting hyperfibrinolysis. Ren Fail 2015; 37:1100-4. [DOI: 10.3109/0886022x.2015.1061668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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25
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Dupree LH, Reddy P. Use of rivaroxaban in a patient with history of nephrotic syndrome and hypercoagulability. Ann Pharmacother 2014; 48:1655-8. [PMID: 25169250 DOI: 10.1177/1060028014549349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Hypercoagulability, resulting in thromboembolic events, can be a life-threatening complication of nephrotic syndrome (NS). Conventional anticoagulants, such as warfarin, have been the standard of care for more than 50 years; however, the availability of target-specific oral anticoagulants (TSOACs) have provided additional options for the treatment and prevention of thromboembolic events. Documented use of the TSOACs in patients with NS and hypercoagulability is currently limited. CASE SUMMARY We present the case of an 18-year-old young woman with NS and renal vein thrombosis who was readmitted with bilateral pulmonary emboli on therapeutic doses of warfarin, with a goal international normalized ratio of 2.0 to 3.0. The decision was made to transition the patient from warfarin to rivaroxaban, an oral factor Xa inhibitor. DISCUSSION Rivaroxaban was the first of the emerging TSOACs to be FDA approved for both prevention and treatment of venous thromboembolism. With favorable safety and efficacy data compared with warfarin in addition to a predictable pharmacokinetic profile and the lack of requirement of routine monitoring, rivaroxaban provides a useful alternative in this patient population. SUMMARY While on therapeutic anticoagulation, a patient previously diagnosed with NS and renal vein thrombosis experienced pulmonary emboli on a conventional anticoagulant and was switched to a target-specific oral anticoagulant with documented completion of 6 months of therapy without recurrent thromboembolism.
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Affiliation(s)
- Lori H Dupree
- University of Florida College of Pharmacy, Jacksonville, FL, USA
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26
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The nephrotic syndrome: pathogenesis and treatment of edema formation and secondary complications. Pediatr Nephrol 2014; 29:1159-67. [PMID: 23989393 DOI: 10.1007/s00467-013-2567-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/17/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022]
Abstract
Nephrotic syndrome is an important clinical condition affecting both children and adults. Studies suggest that the pathogenesis of edema in individual patients may occur via widely variable mechanisms, i.e., intravascular volume underfilling versus overfilling. Managing edema should therefore be directed to the underlying pathophysiology. Nephrotic syndrome is also associated with clinically important complications related to urinary loss of proteins other than albumin. This educational review focuses on the pathophysiology and management of edema and secondary complications in patients with nephrotic syndrome.
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27
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Smyth A, Radovic M, Garovic VD. Women, kidney disease, and pregnancy. Adv Chronic Kidney Dis 2013; 20:402-10. [PMID: 23978545 DOI: 10.1053/j.ackd.2013.06.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/12/2013] [Accepted: 06/17/2013] [Indexed: 12/18/2022]
Abstract
Several glomerular diseases may occur in women of childbearing age. Pregnancy in such patients should be planned when the disease has been in remission for a minimum of 6 months to minimize maternal and fetal complications. Immunosuppressive agents should be optimized before conception to include those that are safe for pregnancy. The complexity of medical management when caring for these patients calls for a multidisciplinary team approach consisting of a nephrologist, rheumatologist, obstetrician, and pharmacist. This review will address the physiological changes of pregnancy that may affect glomerular disease presentation, activity, and diagnosis; specific glomerular diseases primary and secondary to systemic diseases in the context of pregnancy; fetal and maternal complications and long-term effects; diagnosis and differential diagnosis; and treatment strategies that are considered relatively safe with respect to fetal intrauterine exposure.
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