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Pal D, Inamdar N, Kaur P, Singhal M, Lal A, Gorsi U, Nada R, Kohli HS, Kumar V, Ramachandran R. Augmented mannose-binding lectin levels in primary membranous nephropathy: A pilot study. Nephrology (Carlton) 2024; 29:617-621. [PMID: 38511256 DOI: 10.1111/nep.14293] [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: 09/21/2023] [Revised: 01/25/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
There is evidence to suggest that M-type phospholipase A2 (PLA2R) antibodies activate the mannose-binding lectin (MBL) cascade, resulting in glomerular damage and proteinuria in patients with primary membranous nephropathy (PMN). Furthermore, there are few reports indicating that aberrant MBL activation is associated with endothelial dysfunction and accelerated atherosclerosis. While PMN is a common cause of adult nephrotic syndrome, and patients are at increased risk of cardiovascular disease (CVD), there is a lack of research that explores the factors that contribute to this condition. This study aims to determine the MBL levels in PMN and their relation to the clinical activity and endothelial dysfunction in PMN. The MBL levels of 22 biopsy-confirmed PMN patients were assessed at baseline and after 6 months of immunosuppressive therapy. In order to evaluate endothelial dysfunction in PMN patients, flow-mediated vasodilation (FMD) was measured at baseline and after treatment. A total of 22 healthy controls were included in this study to measure MBL levels and FMD. A significant difference was observed between MBL levels in PMN patients and healthy controls (p < .01). MBL levels decreased significantly after immunosuppressive therapy (p = .04). The baseline MBL levels and FMD levels exhibited a strong correlation (Spearman correlation coefficient [ρ] = 0.51: p = .01). In conclusion, the study signals the activation of the MBL cascade and its association with endothelial dysfunction in PMN patients.
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Affiliation(s)
- Deeksha Pal
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeraj Inamdar
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prabhjot Kaur
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Lal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinod Kumar
- Department of Dermatology, Venereology & Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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2
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Ramachandran R, Jha V, Bose B. Key Points in Managing PLA2R-Associated Membranous Nephropathy. Kidney Int Rep 2024; 9:2320-2322. [PMID: 39156140 PMCID: PMC11328565 DOI: 10.1016/j.ekir.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024] Open
Affiliation(s)
- Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- School of Public Health, Imperial College, London, UK
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Kingswood, Australia
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3
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Wang M, Yang J, Fang X, Lin W, Yang Y. Membranous nephropathy: pathogenesis and treatments. MedComm (Beijing) 2024; 5:e614. [PMID: 38948114 PMCID: PMC11214595 DOI: 10.1002/mco2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Membranous nephropathy (MN), an autoimmune disease, can manifest at any age and is among the most common causes of nephrotic syndrome in adults. In 80% of cases, the specific etiology of MN remains unknown, while the remaining cases are linked to drug use or underlying conditions like systemic lupus erythematosus, hepatitis B virus, or malignancy. Although about one-third of patients may achieve spontaneous complete or partial remission with conservative management, another third face an elevated risk of disease progression, potentially leading to end-stage renal disease within 10 years. The identification of phospholipase A2 receptor as the primary target antigen in MN has brought about a significant shift in disease management and monitoring. This review explores recent advancements in the pathophysiology of MN, encompassing pathogenesis, clinical presentations, diagnostic criteria, treatment options, and prognosis, with a focus on emerging developments in pathogenesis and therapeutic strategies aimed at halting disease progression. By synthesizing the latest research findings and clinical insights, this review seeks to contribute to the ongoing efforts to enhance our understanding and management of this challenging autoimmune disorder.
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Affiliation(s)
- Mengqiong Wang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Jingjuan Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Xin Fang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Weiqiang Lin
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Yi Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
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4
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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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5
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Wang SS, Tang H, Ng HY, Lian JJ, Javaid MM. Thromboembolic phenomena in patients with nephrotic syndrome: pathophysiology, risk factors, prophylaxis and treatment. Br J Hosp Med (Lond) 2024; 85:1-10. [PMID: 38300681 DOI: 10.12968/hmed.2023.0354] [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] [Indexed: 02/02/2024]
Abstract
Thromboembolic events resulting from disturbances in the body's balance of thrombotic and antithrombotic abilities are among the most life-threatening complications of nephrotic syndrome. Certain causes of nephrotic syndrome leave the patient particularly susceptible to thromboembolism. The severity of proteinuria and degree of hypoalbuminaemia are other common predictors of risk. Timely initiation of prophylactic therapy can help prevent morbidity and mortality associated with this complication in patients with nephrotic syndrome. The duration of treatment and choice of therapeutic agent depends on several factors, including the degree of hypoalbuminaemia, risk factors for thrombosis and risk of bleeding. This article reviews current understanding of the pathophysiology and risk factors for thromboembolism associated with nephrotic syndrome, and summarises recommendations and strategies for preventing and treating thromboembolic events in patients with nephrotic syndrome.
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Affiliation(s)
- Samuel Sy Wang
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | | | | | | | - Muhammad M Javaid
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
- Monash Rural Health Mildura, Monash University, Victoria, Australia
- Department of Renal Medicine, Woodlands Health, Singapore
- School of Medicine, Deakin University, Victoria, Australia
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6
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Gerstein J, Battu K, Reich HN. Prophylactic Anticoagulation in Nephrotic Syndrome. KIDNEY360 2023; 4:1476-1478. [PMID: 37526679 PMCID: PMC10617801 DOI: 10.34067/kid.0000000000000225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Jonathon Gerstein
- Department of Medicine, University of Toronto, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Kiran Battu
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Heather N. Reich
- Department of Medicine, University of Toronto, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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7
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Sun J, Nan G, Zhang L, Gao Y, Cui M. Endovascular treatment for severe cerebral venous sinus thrombosis in a patient with polycythemia vera and nephrotic syndrome: a case report. Am J Transl Res 2023; 15:5900-5907. [PMID: 37854205 PMCID: PMC10579010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/06/2023] [Indexed: 10/20/2023]
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease that can occur at any age and generally has a good prognosis. Polycythemia vera and nephrotic syndrome are uncommon risk factors for cerebral venous sinus thrombosis. A dilemma exists in the treatment of cerebral venous sinus thrombosis with polycythemia vera and nephrotic syndrome, as some cases are refractory to first-line therapy. Here, we report a patient with CVST who presented with a generalized seizure and was found to have bilateral frontal lobe hemorrhage and subarachnoid hemorrhage. Brain magnetic resonance venography showed extensive cerebral venous sinus thrombosis extending from the superior sagittal sinus to the left internal jugular vein. Further testing revealed that the patient had polycythemia vera and nephrotic syndrome. Anticoagulation therapy had limited effects. He underwent endovascular intervention, including stent thrombectomy, intermediate catheter aspiration, balloon dilatation, and local intravenous thrombolysis, to achieve revascularization. After 9 months of follow-up, the patient had recovered well without any sequelae. This case shows that in patients with critical cerebral venous sinus thrombosis who fail to respond to anticoagulant therapy, stent thrombectomy combined with intermediate catheter aspiration, balloon dilation, and local thrombolysis may be a viable option. This strategy can quickly resolve venous sinus obstruction and improve the prognosis of patients with critical cerebral venous sinus thrombosis.
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Affiliation(s)
- Jing Sun
- Department of Neurology, China-Japan Union Hospital of Jilin UniversityNo. 126 Xiantai Street, Changchun 130031, Jilin, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin UniversityNo. 126 Xiantai Street, Changchun 130031, Jilin, China
| | - Li Zhang
- Department of Neurology, China-Japan Union Hospital of Jilin UniversityNo. 126 Xiantai Street, Changchun 130031, Jilin, China
| | - Yu Gao
- Department of Neurology, China-Japan Union Hospital of Jilin UniversityNo. 126 Xiantai Street, Changchun 130031, Jilin, China
| | - Mingji Cui
- Department of Nephrology, The First Affiliated Hospital of Jilin UniversityNo. 3302 Jilin Road, Changchun 130031, Jilin, China
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8
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Jiang J, Xing F, Luo R, Chen Z, Liu H, Xiang Z, Duan X. Risk factors and prediction model of nomogram for preoperative calf muscle vein thrombosis in geriatric hip fracture patients. Front Med (Lausanne) 2023; 10:1236451. [PMID: 37720507 PMCID: PMC10502724 DOI: 10.3389/fmed.2023.1236451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Calf muscular vein thrombosis (CMVT) is a common complication in geriatric hip fracture patients. Despite its high incidence, prior research on the topic is limited. The occurrence of CMVT in patients will prolong the preoperative waiting time and even lead to serious thromboembolic events, which can be detrimental to the patient's prognosis. Therefore, this study aimed to identify the risk factors for preoperative CMVT in geriatric hip fracture patients and construct a nomogram model to predict the risk of preoperative CMVT in patients. Materials and methods Geriatric hip fracture patients who underwent surgery between January 2019 and January 2022 were included. The patients were categorized into two groups depending on whether they had preoperative CMVT, confirmed through Color Doppler ultrasound or venography examination. Univariate and multivariate logistic regression analyses were used to analyze demographic characteristics, medical history, comorbidities, and laboratory tests. A nomogram was constructed to predict preoperative CMVT in geriatric hip fracture patients based on the results of the multivariate logistic regression. Results Three hundred and eighty-eight geriatric hip fracture patients, including one hundred and thirty-four patients with CMVT and two hundred and fifty-four patients without CMVT, were ultimately included in our study. After multivariable logistic regression analysis, the time from injury to admission, smoking history, serum albumin levels, and D-dimer levels was identified as independent risk factors and was entered into a nomogram model. The nomogram showed robust discrimination, with an area under the receiver operating characteristic curve of 0.805. The calibration curve showed strong agreement between the CMVT probabilities predicted by the nomogram and the actual probabilities. The decision curve analysis illustrates the excellent clinical utility of the model. Conclusion We have constructed a new nomogram prediction model that can effectively predict the risk of preoperative CMVT in geriatric hip fracture patients based on their medical history and blood test results. This model can help clinicians make individualized predictions of CMVT that are tailored to each patient's unique circumstances.
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Affiliation(s)
- Jiabao Jiang
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fei Xing
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rong Luo
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhao Chen
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Liu
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhou Xiang
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Orthopedics Surgery, West China Sanya Hospital, Sichuan University, Sanya, Hainan, China
| | - Xin Duan
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Orthopedic Surgery, The Fifth People's Hospital of Sichuan Province, Chengdu, Sichuan, China
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9
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Parker K, Ragy O, Hamilton P, Thachil J, Kanigicherla D. Thromboembolism in nephrotic syndrome: controversies and uncertainties. Res Pract Thromb Haemost 2023; 7:102162. [PMID: 37680313 PMCID: PMC10480654 DOI: 10.1016/j.rpth.2023.102162] [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: 05/26/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 09/09/2023] Open
Abstract
Thromboembolism is one of the most serious complications of nephrotic syndrome, including both arterial and venous thromboembolic events. Rates of thromboembolism depend on a multitude of factors, including the severity and cause of nephrotic syndrome, with primary membranous nephropathy having the highest reported rates. In relation to arterial thromboembolism, the risk can be as high as 8 times that of an age- and sex-matched population. However, extrapolating risks is challenging, with published studies not being homogeneous, several being single center and retrospective, and including different causes of primary nephrotic syndrome. Determining thromboembolic risk in nephrotic syndrome is essential to enable decision making on preventive strategies. However, lack of proven strategies to help estimate risk-benefit aspects underpins variations in clinical practice. Although the use of anticoagulation following a thrombotic event is clear, this still leaves us with a clinical dilemma as to if, and who, should receive prophylactic anticoagulation, with what agent, and for how long. In the absence of clear evidence to answer these questions, prophylactic anticoagulation strategies for nephrotic syndrome currently rely on expert consensus opinion, such as in the recently published 2021 Kidney Disease Improving Global Outcomes glomerular disease guidelines. In the mainstay, these recommendations relate to patients with membranous nephropathy. Here, we detail the current controversies still faced by clinicians around the risk of thromboembolism in nephrotic syndrome, use of prophylactic anticoagulation in nephrotic syndrome and propose ways of advancing existing knowledge and practice in this field to unravel the conundrum.
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Affiliation(s)
- Kathrine Parker
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Pharmacy and Optometry, the University of Manchester, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Omar Ragy
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Wellcome Trust Centre for Cell Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, Manchester, United Kingdom
| | - Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Wellcome Trust Centre for Cell Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, Manchester, United Kingdom
| | - Jecko Thachil
- Department of Haematology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, the University of Manchester, School of Medical Sciences, Manchester, United Kingdom
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10
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Derebail VK, Zhu J, Crawford ML, Garnier JR, Martin KA, Skinner S, Patel T, Froment A, Sketch MR, Szeto AH, Patel SM, Torrice CD, Tiefenbacher S, Adcock DM, Grant RP, Key NS, Crona DJ. Pharmacokinetics and Pharmacodynamics of Apixaban in Nephrotic Syndrome: Findings From a Phase 1a Trial. Am J Kidney Dis 2023; 81:373-376. [PMID: 36328100 DOI: 10.1053/j.ajkd.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/06/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Jing Zhu
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Julia R Garnier
- Laboratory Corporation of America, Burlington, North Carolina
| | - Karlyn A Martin
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | - Sarah Skinner
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tejendra Patel
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne Froment
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Margaret R Sketch
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andy H Szeto
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sheel M Patel
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Chad D Torrice
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefan Tiefenbacher
- Colorado Coagulation, Laboratory Corporation of America, Englewood, Colorado
| | | | - Russell P Grant
- Laboratory Corporation of America, Burlington, North Carolina
| | - Nigel S Key
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Hematology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniel J Crona
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Pharmacy, UNC Medical Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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11
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Piccini CD, Morillos MB, Formoso CR, Rodrigues MADC, Londero RG. Increased cerebrospinal fluid pressure and nephrotic syndrome: A case report and literature review. Clin Neurol Neurosurg 2023; 225:107567. [PMID: 36592532 DOI: 10.1016/j.clineuro.2022.107567] [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: 10/23/2022] [Revised: 12/09/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To analyze how nephrotic syndrome (NS) correlates to increased intracranial pressure (ICP), and to present a case of an adult patient whose initial manifestation of NS was cephalalgia, with the later identification of raised ICP. METHODS Data were retrospectively retrieved from the patient's record, and a literature search with the keywords "nephrotic syndrome", "intracranial hypertension" and "headache" was conducted in PubMed and Embase. RESULTS This is a rare description of co-occurrence of NS and raised ICP in a 48-year-old man, in which ICP normalizes after NS remits. There is no known cause for the raised ICP of our patient. Ten reports (n = 13) of concomitant occurrence of increased ICP and NS were described in the literature, both in children and adults. Cerebral venous thrombosis (CVT) was the most likely underlying cause for the majority of them. For one patient, the underlying cause was meningoencephalitis. Finally, in one case, the cause is unknown, but CVT was not discarded. CONCLUSION The early suspicion of elevated ICP is warranted in patients with new-onset headache and NS. It is possible that NS could both directly and indirectly lead to increased ICP through yet unknown mechanisms, although this direct causal relationship cannot be currently established.
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Affiliation(s)
- Cristian Daniel Piccini
- Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
| | | | | | | | - Renata Gomes Londero
- Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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12
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Greenberg KI, Choi MJ. Understanding Hypercoagulability with Nephrotic Syndrome: How the Clot Thickens. Clin J Am Soc Nephrol 2023; 18:149-151. [PMID: 36754000 PMCID: PMC10103297 DOI: 10.2215/cjn.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Keiko I Greenberg
- Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington, DC
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13
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Acute on chronic bilateral renal vein thrombosis in the setting of remission of class V lupus nephritis: A case report and literature review. Clin Nephrol Case Stud 2023; 11:39-43. [PMID: 36896139 PMCID: PMC9990424 DOI: 10.5414/cncs110922] [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: 04/14/2022] [Accepted: 01/06/2023] [Indexed: 03/07/2023] Open
Abstract
Renal vein thrombosis (RVT), defined as the presence of a thrombus in the major renal vein or one of its tributaries, can present acutely or go unnoticed resulting in acute kidney injury or chronic kidney disease. RVT is associated with multiple etiologies, including nephrotic syndrome, thrombophilia, autoimmune disorders, and malignancy. Patients with systemic lupus erythematosus (SLE), a multiorgan autoimmune disorder, are predisposed to coagulopathy and thus are at a higher risk of venous and arterial thromboembolism. We describe the case of a 41-year-old man with SLE and biopsy-proven membranous glomerulonephritis (WHO class V lupus nephritis) in clinical remission with no evidence of nephrotic range proteinuria who presented with macroscopic hematuria and was diagnosed with acute-on-chronic bilateral RVT. We discuss the different causes of RVT and compare the clinical presentation, diagnostic imaging findings, and management of acute and chronic RVT.
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14
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Lu H, Cui Z, Xiao TL, Wang SX, Zhao MH. Kidney Histopathology Features of Suspected Intra-Kidney Venous Thromboembolism in Patients with Primary Glomerulonephritis. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:478-486. [PMID: 36590678 PMCID: PMC9798834 DOI: 10.1159/000527009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/04/2022] [Indexed: 11/05/2022]
Abstract
Introduction Renal vein thromboembolism is a severe complication of nephrotic syndrome. Small thrombus in the intra-kidney venous system cannot be recognized by ultrasonography. The current study was to investigate the kidney pathological features of intra-kidney venous thrombus and their values in clinical practice. Methods Kidney pathological features of glomerular capillary dilatation and congestion, peritubular capillary dilatation and congestion, and intraglomerular neutrophil infiltration were screened and scored during kidney biopsy information interpretation. Eighty-four consecutive patients with these features and primary glomerulonephritis were analyzed, comparing to another 84 control patients without these features who were matched according to the pathological types of glomerulonephritis. Results In the patients with pathological features of suspected intra-kidney venous thrombus, the levels of proteinuria (5.2 vs. 3.2 g/24 h, p = 0.005), serum creatinine (80.9 vs. 71.2 μmol/L, p < 0.001), platelet count (274.0 vs. 254.5 ×109/L, p = 0.020), D-dimer (0.2 vs. 0.2 mg/L, p = 0.002), and fibrin degradation products (1.9 vs. 1.0 mg/L, p = 0.003) were significantly higher than those in control patients. The levels of serum albumin (24.2 vs. 28.6 g/L, p = 0.003) and eGFR (92.1 vs. 103.9 mL/min/1.73 m2, p < 0.001) were significantly lower. The scores of these pathological features were positively correlated with the levels of D-dimer (r = 0.21, p = 0.05). During follow-up, 9 (10.7%) patients with pathological features of suspected intra-kidney venous thrombus developed venous thromboembolism, which was significantly more than that of control patients (0%, p = 0.006). Conclusions Kidney pathological features could indicate intra-kidney venous thromboembolism, and their scores represent the possibility of thrombus. The notice of these features may provide clinical alerts for venous thromboembolism possibility.
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Affiliation(s)
- Hui Lu
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease (CKD) Prevention and Treatment, Ministry of Education of China, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China,*Zhao Cui,
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease (CKD) Prevention and Treatment, Ministry of Education of China, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China,*Zhao Cui,
| | - Tang-li Xiao
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Su-xia Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China,**Su-xia Wang,
| | - Ming-hui Zhao
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease (CKD) Prevention and Treatment, Ministry of Education of China, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Casey D, Romero K, Patel R, Ouellette T, Anasseri S, Eftekhari P. Bilateral Renal Vein Thrombosis in Membranous Nephropathy: Hypoalbuminemia Predictive of Venous Thromboembolism in Nephrotic Syndrome. Cureus 2022; 14:e30032. [PMID: 36348912 PMCID: PMC9637375 DOI: 10.7759/cureus.30032] [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: 08/22/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Nephrotic syndrome is a known clinical syndrome in which there is increased permeability in the glomerular basement membrane leading to proteinuria, >3.5g/24h, and hypoalbuminemia. The primary causes of nephrotic syndrome include membranous nephropathy, focal segmental glomerulosclerosis, and minimal change disease. Secondary causes include lupus nephritis, diabetes mellitus, multiple myeloma, amyloidosis, and other systemic conditions. Clinically, nephrotic syndrome presents with edema, hyperlipidemia, and increased risk of thromboembolism, the primary focus of this paper. Nephrotic syndrome is often associated with thromboembolic events, especially in patients with membranous nephropathy. It has been shown that hypoalbuminemia is the most significant independent predictor of venous thromboembolic risk. We present the case of a 32-year-old male who first presented with pleuritic chest pain and was found to have multiple bilateral pulmonary emboli treated with oral anticoagulation. On subsequent visits, prompted by either chest pain or edema, he was found to have increasing pulmonary emboli, as well as downtrending serum albumin levels at each visit. Eventually, bilateral non-occlusive renal vein thrombi were discovered. Lab work indicated membranous nephropathy as the most likely etiology secondary to the patient’s presentation. Serum anti-phospholipase A2 receptor antibody positivity confirmed the diagnosis, and the patient was treated appropriately.
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Sutkowska E, Fułek M, Fułek K, Fortuna P, Madziarska K. Nephrotic Syndrome – Different Risk of Venous Thromboembolism with Different Approaches to Justify Prophylactic Anticoagulation. Angiology 2022; 74:519-525. [DOI: 10.1177/00033197221126248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Edyta Sutkowska
- University Rehabilitation Centre, Wroclaw Medical University, Wroclaw, Poland
| | - Michał Fułek
- Department of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - Katarzyna Fułek
- Lower Silesian Oncology, Pulmonology and Hematology Center, Wroclaw, Poland
| | - Paulina Fortuna
- Department of Biochemistry and Immunochemistry, Wroclaw Medical University, Wroclaw, Poland
| | - Katarzyna Madziarska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
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17
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Kelddal S, Hvas AM, Grove EL, Birn H. Safety and effectiveness of direct oral anticoagulants in patients with nephrotic syndrome: a report of 21 cases. BMC Nephrol 2022; 23:305. [PMID: 36064370 PMCID: PMC9446569 DOI: 10.1186/s12882-022-02929-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/31/2022] [Indexed: 12/02/2022] Open
Abstract
Background Nephrotic syndrome (NS) is associated with increased risk of thromboembolic events (TE) adding to the morbidity and mortality. International guidelines recommend prophylactic anticoagulation in patients with NS and high risk of TE, but no studies have identified the optimal type of anticoagulation in NS. We aimed to assess the effectiveness and safety of direct oral anticoagulant (DOAC) by analyzing the thromboembolic and bleeding events in NS patients prescribed DOAC as primary prophylaxis to prevent TE or as treatment for TE occurring in relation to NS. Methods We performed a single-center, retrospective study including patients with NS, a plasma albumin less than 25 g/L and prophylactic anticoagulation treatment with DOAC at the Department of Renal Medicine at Aarhus University Hospital, Denmark from July 2016 to June 2021. Patients treated with DOAC as thromboprophylaxis for other indications than NS were excluded. Baseline characteristics and outcomes, including TE, bleeding and other adverse effects associated with DOAC were obtained from medical records. Results We identified 268 patients treated with DOAC of which 21 patients with NS were included in the study. Nineteen patients were prescribed DOAC as thromboprophylaxis and two patients received DOAC due to previous TE, which was considered associated with the NS. The type of DOAC prescribed was apixaban (n = 10) and rivaroxaban (n = 11). No patients experienced TE during DOAC treatment, while five patients had a minor bleeding episode. Patients who experienced bleeding episodes were older (median 62 vs 51 years), more often female (80%) and had been on DOAC for a longer period (204 days vs 47 days). Neither the HAS-BLED score nor GN-risk-score predicted the risk of minor bleedings in this population. Conclusions In this case series, no new TE and only minor bleeding complications were observed among adult NS patients treated with DOAC.
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Affiliation(s)
- Sarah Kelddal
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark. .,Department of Biomedicine, Aarhus University Health, Aarhus, Denmark.
| | | | - Erik Lerkevang Grove
- Department of Clinical Medicine, Aarhus University Health, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University Health, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Health, Aarhus, Denmark
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Ahmed S, Massicotte-Azarniouch D, Canney M, Booth C, Blanco P, Hundemer GL. The value of repeat kidney biopsy during an atypical course of membranous nephropathy. BMC Nephrol 2022; 23:240. [PMID: 35799179 PMCID: PMC9260970 DOI: 10.1186/s12882-022-02863-y] [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: 03/08/2021] [Accepted: 06/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background The clinical trajectory for patients with primary membranous nephropathy ranges widely from spontaneous remission to a rapid decline in kidney function. Etiologies for rapid progression with membranous nephropathy include concurrent bilateral renal vein thrombosis, malignant hypertension, and crescentic membranous nephropathy. Given the wide heterogeneity in prognosis, timing of immunosuppressive therapy is often challenging and centers around an individual patient’s perceived risk for rapidly progressive disease. Case presentation Herein, we describe the clinical course of a young patient who initially developed a typical presentation of membranous nephropathy with consistent kidney biopsy findings. Given clinical stability, a six month observation period was undertaken prior to initiating immunosuppression. Within this observation window, the patient developed community acquired pneumonia followed several weeks later by a sudden, rapid decline in kidney function requiring dialysis. Repeat kidney biopsy revealed post-infectious glomerulonephritis superimposed upon a background of membranous nephropathy. Immunosuppressive therapy resulted in a favorable long-term outcome with normalization of kidney function and remission of nephrotic syndrome. To our knowledge, this is the first report of the simultaneous occurrence of these two glomerular disease processes. Conclusion This case illustrates the value of repeat kidney biopsy during an atypical course of membranous nephropathy. Superimposed glomerular disease processes should be considered during a course of rapidly progressive membranous nephropathy. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02863-y.
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Affiliation(s)
- Sumaiya Ahmed
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - David Massicotte-Azarniouch
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada
| | - Mark Canney
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada
| | - Clare Booth
- Deparment of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Paula Blanco
- Deparment of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
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19
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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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Poggiali E, Borio G, Magnacavallo A, Vercelli A, Cervellin G. Acute chest pain and dyspnoea as clinical presentation of primary membranous nephropathy. A case report and literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022216. [PMID: 36300242 PMCID: PMC9686161 DOI: 10.23750/abm.v93i5.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 01/25/2023]
Abstract
Membranous nephropathy (MN) is the commonest cause of nephrotic syndrome (NS) in adult male patients worldwide. Most of the cases (80%) are idiopathic (primary MN, PMN), whereas about 20% are associated with autoimmune diseases, malignancies or exposures (secondary MN). PMN is a kidney-specific autoimmune glomerular disease mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) (85%), thrombospondin type 1 domain containing 7A (THSD7A) (3-5%), or by other still unidentified mechanisms (10%). Most of the patients with PMN present with NS (80%). Clinical course of PMN is characterised by spontaneous remissions (40%) and relapses (15-30%). One third develop end-stage renal disease (ESRD) within 5 to 15 years from the onset. Anti-PLA2R/THSD7A antibodies levels correlate with proteinuria, clinical course, and outcomes. The treatment still remains matter of debate. Hypertension, proteinuria, and hyperlipidaemia must be treated in all patients. Immunosuppressive therapy is indicated in patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis. With proper management, only 10% or less will develop ESRD over the subsequent 10 years. Here we report a case of a 34-year-old male patient with a ten-year history of asymptomatic PMN, treated with ACE-inhibitors, who presented to our emergency room for acute chest pain and exertional dyspnoea due to ESRD that required urgent dialysis. (www.actabiomedica.it).
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Affiliation(s)
- Erika Poggiali
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giorgia Borio
- Emergency Department, San Raffaele Hospital IRCCS, Milan, Italy
| | | | - Andrea Vercelli
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
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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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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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Zhu H, Qi J, Schoepf J, Savage RH, Tang C, Lu M, Zhou C, Lu G, Wang D, Zhang L. Prevalence and Associated Risk Factors of Pulmonary Embolism in Children and Young Adults With Nephrotic Syndrome: A Chinese Large Cohort Study. J Thorac Imaging 2021; 36:326-332. [PMID: 34269751 DOI: 10.1097/rti.0000000000000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Nephrotic syndrome (NS) is highly associated with an increased risk of pulmonary embolism (PE) in children and young adults. However, few studies have specified the risk factors of PE in children and young adults with NS. We sought to determine the prevalence and associated factors of PE confirmed with computed tomography pulmonary angiography in Chinese children and young adults with NS. METHODS Data from 444 children and young adults with NS who had computed tomography pulmonary angiography from December 2010 to October 2018 were retrospectively analyzed. The prevalence of PE was estimated for different age, sex, and histopathologic types of NS. Multivariable logistic regression was used to identify independent risk factors of PE in children and young adults with NS. Models incorporating the independent risk factors were evaluated using receiver operation characteristic curves. Area under the curve was used to determine the best-performing prognosticators for predicting PE. RESULTS There were 444 patients in the study cohort (310 male patients, 134 female patients; mean age 19±3 y; range: 6 to 25 y). PE was present in 24.8% of the participants (110 of 444, 18.2% female). Children and young adult NS patients with PE tend to be older, male, to have a previous thromboembolism history and smoking, and have a higher level of proteinuria, D-dimer, and serum albumin (P<0.05 for all). Children and young adults with membranous nephropathy are likely to have a higher incidence of PE than those with other types of nephropathy. Membranous nephropathy and proteinuria were significant predictors of PE in children and young adults with NS (P<0.05 for all). The area under the curves of each model for the presence of PE in children and young adults with NS based on biochemical parameters and clinical information (model 1), adjusted for proteinuria (model 2), and adjusted for membranous nephropathy (model 3) were 0.578, 0.657, and 0.709, respectively. Compared with model 1, model 2, and model 3 showed statistically significant differences (model 1 vs. model 2, P=0.0336; model 1 vs. model 3, P=0.0268). There was no statistically significant difference between model 2 and model 3 (P=0.2947). CONCLUSION This study identified membranous nephropathy and proteinuria as independent associated factors of PE in children and young adults with NS, which can be noted as a risk factor to guide clinician management in this population.
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Affiliation(s)
- Haitao Zhu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Jianchen Qi
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Rock H Savage
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Chunxiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Mengjie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Changsheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Guangming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Dongqing Wang
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Longjiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
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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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Inaguma Y, Kaito H, Horinouchi T, Ogawa Y, Yoshida M, Yoshikawa N, Tanaka R. An "old and new" complication in a child with nephrotic syndrome: Answers. Pediatr Nephrol 2021; 36:1955-1958. [PMID: 33052450 DOI: 10.1007/s00467-020-04794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Yosuke Inaguma
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Tomoko Horinouchi
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Yoshiharu Ogawa
- Department of Cardiology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Makiko Yoshida
- Department of Diagnostic Pathology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Thrombosis secondary to protein-losing enteropathy (PLE): A case report and review. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Waller AP, Troost JP, Parikh SV, Wolfgang KJ, Rovin BH, Nieman MT, Smoyer WE, Kretzler M, Kerlin BA. Nephrotic syndrome disease activity is proportional to its associated hypercoagulopathy. Thromb Res 2021; 201:50-59. [PMID: 33636573 DOI: 10.1016/j.thromres.2021.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Nephrotic syndrome (NS) is associated with an acquired hypercoagulopathy that drives its strong predilection for life-threatening thrombosis. We previously demonstrated that hypercoagulopathy is proportional to NS disease severity in animal models. Therefore, hypercoagulopathy and disease severity may inform thrombosis risk and better guide therapeutic decision making. The objective of this study was thus to establish the relationship between disease severity and hypercoagulopathy in human NS. MATERIALS AND METHODS Thrombin generation assays (TGA) were performed on biorepository plasma samples from a prospective longitudinal NS cohort study. TGA was also determined on a separate cohort of incident NS patients. Multivariable regression was used to build NS-hypercoagulopathy relationship models. RESULTS Endogenous thrombin potential (ETP) was the TGA parameter most strongly correlated with NS severity and was proportional to conventional measures of NS disease activity including proteinuria, hypercholesterolemia, and hypoalbuminemia. The overall disease activity model was well correlated with ETP (R2 = 0.38). The relationship with disease activity was confirmed in the second cohort. These models further revealed that ETP is related to disease activity in a manner dependent on remission status. CONCLUSION Consistent with our previously reported animal model observations, we found that the combination of proteinuria, hypercholesterolemia, and hypoalbuminemia correlated with ETP-defined hypercoagulopathy. Hypercoagulopathy improved significantly with partial or complete NS remission. These data are expected to inform studies designed to stratify thrombotic risk for patients with NS.
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Affiliation(s)
- Amanda P Waller
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Samir V Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katelyn J Wolfgang
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marvin T Nieman
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Nephrology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthias Kretzler
- Departments of Internal Medicine and Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Zou P, Li H, Cai J, Chen Z, Li C, Li X. Statins can benefit patients with primary membranous nephropathy on venous thromboembolism. Ren Fail 2021; 43:302-306. [PMID: 33583321 PMCID: PMC7889158 DOI: 10.1080/0886022x.2021.1879853] [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] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study was to investigate the role of prophylactic use of statin in venous thromboembolism (VTE) in patients with primary membranous nephropathy (PMN). Methods A total of 734 patients with PMN were consecutively enrolled in this retrospective study. 564 patients had received statins prescription, while 170 patients did not. Kaplan–Meier methods were used for cumulative incidence plots of thromboembolic events and Cox proportional hazards regression models were used to assess risk factors. Finally, the effects of different potency of statins were evaluated. Results In the cohort, 37 patients (5.0%) experienced VTE. In a univariate Cox proportional hazard model, the hazard ratio (HR) for VTE in statin users versus statin non-users was 0.5 (95% CI 0.3–0.8, p = .03). Multivariable model proportional-hazards analysis corrected for co-medications and risk factors revealed that adjusted HR was 0.4 (95% CI 0.1–0.7, p = .03). According to the type and dose, statin users were assigned into 3 groups: high-intensity group (n = 278), moderate-intensity group (n = 186), and low-intensity group (n = 49). In comparison, incidences of VTEs in the three groups were similar (2.9% vs 4.8% vs 2.0%, p = .45). Conclusions The prophylactic use of statins could effectively decrease the occurrence of VTE in patients with PMN, and the benefits have no difference in different potency of statins.
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Affiliation(s)
- Peimei Zou
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hang Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianfang Cai
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenjie Chen
- Department of Nephrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chao Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuewang Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hansrivijit P, Trongtorsak A, Gadhiya KP, Lnu K, Dimech CT, Thongprayoon C, Cheungpasitporn W, Lecker SH. Incidence and risk factors of venous thromboembolism in ANCA-associated vasculitis: a metaanalysis and metaregression. Clin Rheumatol 2021; 40:2843-2853. [PMID: 33452661 DOI: 10.1007/s10067-021-05589-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
The incidence of venous thromboembolism (VTE) in ANCA-associated vasculitis patients varies in different populations. Moreover, the risk factors for VTE in these patients are poorly described due to the small number of events. Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible articles. The inclusion criteria included observational studies that enrolled patients age ≥ 18 years diagnosed with ANCA-associated vasculitis. The incidence of VTE is the outcome of interest. Of 1362 citations, a total of 21 studies (n = 4422) dated from 2006 to 2019 were included in the systematic review. The mean age was 54.2 ± 4.0 years. Most were male (52.0%) and Caucasian (80.9%). With a mean follow-up duration of 5.2 ± 2.8 years, the pooled incidence of VTE in ANCA-associated vasculitis patients was 12.4% (95% CI, 8.8-17.2). Of these, 63.4% (95% CI, 57.3-69.1) had deep vein thrombosis and 26.3% (95% CI, 17.6-37.4) had pulmonary embolism. Recurrent VTE occurred in 10.0% (95% CI, 5.2-18.6). From the metaregression adjusted for age, sex, and ethnicity; positive MPO-ANCA, increasing Birmingham Vasculitis Activity Score at time of vasculitis diagnosis, and presence of renal involvement were positively associated with increased VTE events. Positive PR3-ANCA profile was inversely associated with increased VTE events. Increasing follow-up duration was not associated with increased VTE events. VTE in ANCA-associated vasculitis is common. Positive MPO-ANCA, increasing vasculitis activity, and presence of renal involvement were significant risk factors for VTE while positive PR3-ANCA was inversely associated with increased VTE. Key Points • Venous thromboembolism (VTE) is common in ANCA-associated vasculitis with a pooled incidence of 12.4% • Deep vein thrombosis accounts for two-third of total VTE cases • Positive MPO-ANCA profile, higher disease activity at ANCA-associated vasculitis diagnosis, and renal involvement are risk factors for VTE • Positive PR3-ANCA profile is protective factor for VTE.
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Affiliation(s)
- Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA.
| | - Angkawipa Trongtorsak
- Department of Internal Medicine, Amita Health Saint Francis Hospital, Evaston, IL, 60202, USA
| | - Kinjal P Gadhiya
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Kriti Lnu
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Christina T Dimech
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Stewart H Lecker
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
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Chiba Y, Nagasawa T, Kin S, Takahashi K, Yoshida M, Oe Y, Okamoto K, Sato H, Miyazaki M. Spontaneous remission of minimal change nephrotic syndrome in an elderly man. CEN Case Rep 2021; 10:301-307. [PMID: 33398783 DOI: 10.1007/s13730-020-00554-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/31/2020] [Indexed: 11/29/2022] Open
Abstract
Minimal change nephrotic syndrome (MCNS) cases achieving spontaneous remission without external factors are rarely reported. We report a case of MCNS that achieved spontaneous remission without external factors that triggered its onset. An 82-year-old male patient was admitted to the hospital for close examination of nephrotic syndrome. Renal biopsy was performed and MCNS was diagnosed. Owing to the patient's age and history of foot and microvascular arteriovenous thrombosis, we did not start immunosuppressive drugs, including steroids, and opted for conservative management. After conservative treatment, proteinuria gradually decreased, and the patient achieved complete remission. Given that the patient had a history of urinary protein and thrombosis, recurrence of MCNS was considered again this time. In addition, the involvement of external factors that trigger the onset of MCNS was not found. In conclusion, in elderly-onset MCNS, clinicians generally hesitate to initiate treatment with an immunosuppressive drug, containing steroids, because of its many complications. Thus, our data provide valuable insight into MCNS.
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Affiliation(s)
- Yuki Chiba
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Saori Kin
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kei Takahashi
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mai Yoshida
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yuji Oe
- Department of Community Medical Support Tohoku Medical Megabank Organization, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Koji Okamoto
- Department of Community Medical Support Tohoku Medical Megabank Organization, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Hiroshi Sato
- Japanese Railways Sendai Hospital, Sendai, Miyagi, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Zhang Q, Wang Y, Ma Y, Jin L, Lan L, Ren P, Chen J, Han F. The correlation of anti-β2-glycoprotein I antibody with complement activation in patients with idiopathic membranous nephropathy. Int Urol Nephrol 2021; 53:955-959. [PMID: 33392885 DOI: 10.1007/s11255-020-02698-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/27/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE This study evaluated the correlation of anti-β2-glycoprotein I (anti-β2-GPI) antibodies with complement activation in patients with idiopathic membranous nephropathy (IMN). METHODS Thirty-two IMN patients with positive anti-β2-GPI antibody were enrolled, and 32 age- and sex-matched IMN patients with negative anti-β2-GPI antibody were randomly enrolled as controls. The frozen serum samples of these 64 patients were collected for detection of anti-phospholipase A2 receptor (PLA2R) antibody and the activity of three complement pathways. Paraffin specimens of the kidney tissues of these 64 patients were collected for immunohistochemical staining of C4d. RESULTS IMN patients with positive anti-β2-GPI antibody had a significant decline of the residual complement activity of alternative pathway than those with negative anti-β2-GPI antibody (37.4 ± 21.2% vs 65.7 ± 50.5%, P = 0.021). The positive rate of kidney C4d staining in IMN patients with and without anti-β2-GPI was 65.6 and 81.2%, with no significant difference (P = 0.257). Patients with and without anti-β2-GPI had the same positive rate of anti-PLA2R antibody. CONCLUSION Anti-β2-GPI antibody was associated with alternative complement activation in patients with IMN.
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Affiliation(s)
- Qiankun Zhang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
- Division of Nephrology, Lishui Central Hospital, Lishui Hospital of Zhejiang University, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, People's Republic of China
| | - Yin Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
- Division of Nephrology, Lishui Central Hospital, Lishui Hospital of Zhejiang University, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, People's Republic of China
| | - Yanhong Ma
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
| | - Lie Jin
- Division of Nephrology, Lishui Central Hospital, Lishui Hospital of Zhejiang University, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, People's Republic of China
| | - Lan Lan
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
| | - Pingping Ren
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
| | - Fei Han
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Key Laboratory of Kidney Disease Prevention and Control Technology, Institute of Nephrology, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China.
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Lobbes H, Mainbourg S, Lega JC. Prevention of venous thromboembolism in nephrotic syndrome: the quest towards precision medicine. Nephrol Dial Transplant 2020; 36:gfaa337. [PMID: 33367807 DOI: 10.1093/ndt/gfaa337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Indexed: 12/30/2022] Open
Affiliation(s)
| | - Sabine Mainbourg
- Service de médecine interne et médecine vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
| | - Jean-Christophe Lega
- Service de médecine interne et médecine vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
- Groupe d'Etude Multidisciplinaire en Maladie Thrombotique (GEMMAT), Hospices Civils de Lyon, Lyon, France
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Lantman MVS, van de Logt AE, Thelen M, Wetzels JF, van Berkel M. Measurement of serum albumin in nephrology: we need to improve. Nephrol Dial Transplant 2020; 37:1792-1799. [PMID: 33367921 DOI: 10.1093/ndt/gfaa375] [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: 10/30/2020] [Indexed: 11/14/2022] Open
Abstract
Serum albumin is a widely used biomarker in clinical nephrology. Serum albumin cut-off values are used to define disease, to predict outcome, and to guide patient care. The available commercial assays to measure serum albumin rely on different analytical principles, all with their own (analytical) specifications. This paper provides an overview of the different clinical applications of serum albumin measurements in nephrology, the (dis)advantages of the available assays and the estimates of the effects of the measurement uncertainty between different assays in clinical decision making. This paper concludes that harmonisation of serum albumin assay results are needed.
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Affiliation(s)
- Marith van Schrojenstein Lantman
- Radboud University Medical Centre, Department of Laboratory Medicine, Nijmegen, The Netherlands.,Amphia Hospital, Department of Laboratory for Clinical Chemistry, part of Result Laboratorium, Breda, The Netherlands.,SKML, Organisation for Quality Assurance of Medical Laboratory Diagnostics, Radboud University, Nijmegen, The Netherlands
| | - Anne-Els van de Logt
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Marc Thelen
- Radboud University Medical Centre, Department of Laboratory Medicine, Nijmegen, The Netherlands.,Amphia Hospital, Department of Laboratory for Clinical Chemistry, part of Result Laboratorium, Breda, The Netherlands.,SKML, Organisation for Quality Assurance of Medical Laboratory Diagnostics, Radboud University, Nijmegen, The Netherlands
| | - Jack F Wetzels
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Miranda van Berkel
- Radboud University Medical Centre, Department of Laboratory Medicine, Nijmegen, The Netherlands
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Ischemic Stroke in a Young Patient with Nephrotic Syndrome and Antiphospholipid Syndrome. Case Rep Nephrol 2020; 2020:8828864. [PMID: 33294240 PMCID: PMC7718048 DOI: 10.1155/2020/8828864] [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: 04/19/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 11/18/2022] Open
Abstract
We report a case of a 21-year-old man with underlying nephrotic syndrome (NS) secondary to minimal change disease, who developed an ischemic stroke with left hemiparesis. He received intravenous thrombolysis followed by a mechanical thrombectomy. After mechanical thrombectomy, he developed acute kidney injury which subsequently required haemodialysis. Further workup revealed that he had concomitant antiphospholipid syndrome (APS) and NS. He was started on vitamin K antagonist anticoagulant. This case report illustrates the importance of workup in identifying causes of ischemic stroke in a young patient.
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Abstract
Nephrotic syndrome is one cause of end-stage kidney disease. Because edema is a common presenting feature and hypertension and dyslipidemia are often present in nephrotic syndrome, it is important for the primary care physician to suspect this entity. Common causes in adults include diabetic nephropathy, focal segmental glomerulosclerosis, and membranous nephropathy. In adults, many primary causes are due to an underlying disease. A cause of the nephrotic syndrome should be established with serologic workup and renal consultation. Renal biopsy is necessary in those with an unknown cause to or classify disease. Treatment focuses on symptoms, complications, and the primary cause.
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Affiliation(s)
- Seth Anthony Politano
- Division of GHPGIM, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD 306, Los Angeles, CA 90089, USA.
| | - Gates B Colbert
- Texas A&M College of Medicine, 3417 Gaston Avenue, Suite 875, Dallas, TX 75246, USA
| | - Nida Hamiduzzaman
- Division of GHPGIM, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD 306, Los Angeles, CA 90089, USA
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Xu Z, Chen L, Xiang H, Zhang C, Xiong J. Advances in Pathogenesis of Idiopathic Membranous Nephropathy. KIDNEY DISEASES (BASEL, SWITZERLAND) 2020; 6:330-345. [PMID: 33490113 PMCID: PMC7745661 DOI: 10.1159/000507704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Membranous nephropathy (MN), a major cause of nephrotic syndrome, has attracted people's attention in recent years for its growing prevalence. It is the second or third leading cause of ESRD in patients with primary glomerulonephritis and is the leading glomerulopathy that recurs after kidney transplantation. SUMMARY MN can be classified as idiopathic membranous nephropathy (IMN) and secondary MN. The discovery of the M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A) provides the new diagnostic methods and treatment strategies for IMN on the molecular level. The study on single nucleotide polymorphism of IMN genes, such as the single M-type phospholipase A2 receptor 1 (PLA2R1) gene and human leukocyte antigen (HLA) gene, explains the pathogenesis of the disease from the perspective of genetics and conforms to the trend of the era of precision medicine. KEY MESSAGES This review focuses on advances in the pathogenesis of IMN, including molecular and genetic pathogenesis, as well as discussing the diagnostic and treatment guiding value brought by these new discoveries.
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Affiliation(s)
- Zhifeng Xu
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Chen
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiling Xiang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Xiong
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Waller AP, Agrawal S, Wolfgang KJ, Kino J, Chanley MA, Smoyer WE, Kerlin BA. Nephrotic syndrome-associated hypercoagulopathy is alleviated by both pioglitazone and glucocorticoid which target two different nuclear receptors. Physiol Rep 2020; 8:e14515. [PMID: 32776495 PMCID: PMC7415912 DOI: 10.14814/phy2.14515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Thrombosis is a potentially life-threatening nephrotic syndrome (NS) complication. We have previously demonstrated that hypercoagulopathy is proportional to NS severity in rat models and that pioglitazone (Pio) reduces proteinuria both independently and in combination with methylprednisolone (MP), a glucocorticoid (GC). However, the effect of these treatments on NS-associated hypercoagulopathy remains unknown. We thus sought to determine the ability of Pio and GC to alleviate NS-associated hypercoagulopathy. METHODS Puromycin aminonucleoside-induced rat NS was treated with sham, Low- or High-dose MP, Pio, or combination (Pio + Low-MP) and plasma was collected at day 11. Plasma samples were collected from children with steroid-sensitive NS (SSNS) and steroid-resistant NS (SRNS) upon presentation and after 7 weeks of GC therapy. Plasma endogenous thrombin potential (ETP), antithrombin (AT) activity, and albumin (Alb) were measured using thrombin generation, amidolytic, and colorimetric assays, respectively. RESULTS In a rat model of NS, both High-MP and Pio improved proteinuria and corrected hypoalbuminemia, ETP and AT activity (p < .05). Proteinuria (p = .005) and hypoalbuminemia (p < .001) were correlated with ETP. In childhood NS, while ETP was not different at presentation, GC therapy improved proteinuria, hypoalbuminemia, and ETP in children with SSNS (p < .001) but not SRNS (p = .330). CONCLUSIONS Both Pio and GC diminish proteinuria and significantly alleviate hypercoagulopathy. Both Pio and MP improved hypercoagulopathy in rats, and successful GC therapy (SSNS) also improved hypercoagulopathy in childhood NS. These data suggest that even a partial reduction in proteinuria may reduce NS-associated thrombotic risk.
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Affiliation(s)
- Amanda P. Waller
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
| | - Shipra Agrawal
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
- Department of PediatricsThe Ohio State University College of MedicineColumbusOHUSA
| | - Katelyn J. Wolfgang
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
| | - Jiro Kino
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
| | - Melinda A. Chanley
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
| | - William E. Smoyer
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
- Department of PediatricsThe Ohio State University College of MedicineColumbusOHUSA
| | - Bryce A. Kerlin
- Center for Clinical & Translational ResearchThe Abigail Wexner Research Institute at Nationwide Children'sColumbusOHUSA
- Department of PediatricsThe Ohio State University College of MedicineColumbusOHUSA
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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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40
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Xie Z, Li Z, Dong W, Chen Y, Li R, Wu Y, Liang H, Ye Z, Liu S, Shi W, Liang X. The impact of coexisting diabetes mellitus on clinical outcomes in patients with idiopathic membranous nephropathy: a retrospective observational study. BMC Nephrol 2020; 21:224. [PMID: 32532223 PMCID: PMC7291707 DOI: 10.1186/s12882-020-01878-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 06/02/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is frequently coexisted with diabetes mellitus (DM). Few researches investigate clinical outcomes in IMN patients coexisting diabetes mellitus (DM), including remission rates, renal survival and complications. Concurrent DM also pose therapeutic challenges to IMN patients due to the influence of glucocorticoids and immunosuppressant on metabolic disorders. We performed this study to investigate the impact of DM on clinical outcomes in IMN and the influence of therapeutic regime on metabolic parameters in diabetic IMN patients. METHODS Two hundred and six adult hospitalized patients diagnosed with biopsy-proven IMN were retrospectively studied, including 42 patients coexisted with DM. Clinical outcomes including remission rates, renal outcome and complications were compared between groups. Impact of cyclophosphamide and ciclosporin on metabolism and complications were analyzed in IMN patients coexisting DM. RESULTS IMN patients coexisted with DM were presented with advanced age, lower level of eGFR and hemoglobin. Patients coexisted with DM experienced worse renal function deterioration and higher incidence of infection. COX regression analysis showed that DM was an independent risk factor for renal function deterioration in IMN patients. There was no significant difference in remission rates and incidence of venous thromboembolism between two groups. Further exploration on the impact of therapeutic regimens on complications and metabolism showed that cyclophosphamide and ciclosporin had no significant difference in incidence of complications including infection and venous thromboembolism, and posed comparable influences on blood glucose, uric acid and blood lipids in IMN patients coexisted with DM. CONCLUSION Coexisting DM was an independent risk factor for renal function deterioration in IMN patients but did not influence the remission of proteinuria. Glucocorticoids in combination with cyclophosphamide or ciclosporine had similar impact on complications and metabolic index including blood glucose, uric acid and blood lipids in IMN patients coexisted with DM.
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Affiliation(s)
- Zhiyong Xie
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zhilian Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Wei Dong
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Yuanhan Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Ruizhao Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Yanhua Wu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Huaban Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Zhiming Ye
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Shuangxin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Wei Shi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Xinling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No.106 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China.
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Serum Albumin at Partial Remission Predicts Outcomes in Membranous Nephropathy. Kidney Int Rep 2020; 5:706-717. [PMID: 32405591 PMCID: PMC7210705 DOI: 10.1016/j.ekir.2020.02.1030] [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: 09/14/2019] [Revised: 02/11/2020] [Accepted: 02/24/2020] [Indexed: 11/21/2022] Open
Abstract
Background In primary membranous nephropathy (MN), partial remission (PR) (≥50% reduction of proteinuria to <3.5 g/d) is associated with a greater risk of relapse and end-stage kidney disease (ESKD) compared with complete remission (CR). We aimed to determine factors associated with relapse or renal failure in patients who attain the standard definition of PR. Methods We captured PR, CR, relapse, and the composite of doubling of serum creatinine or ESKD in a cohort of 267 patients with MN, nephrotic syndrome, and >12 months of follow-up. Characteristics at the time of PR associated with the composite outcome or relapse were evaluated using a time-to-event analysis. Results A total of 192 patients attained PR and 86 attained CR. Serum albumin at PR (hazard ratio [HR]: 1.58 per 0.5 g/dl decrease from 4.0 g/dl; 95% confidence interval [CI]: 1.03-2.43) and duration of nephrotic proteinuria (HR: 1.01 per month increase; 95% CI: 1.00-1.03) were independent risk factors for the composite endpoint. Serum albumin at PR was associated with an increased risk of relapse (HR: 1.58 per 0.5 g/dl decrease below 4.0 g/dl; 95% CI: 1.24-2.01). A cutoff for serum albumin ≤3.5 g/dl at PR performed best in predicting relapse and composite outcome. Conclusions Patients with serum albumin >3.5 g/dl at PR have decreased risk of composite outcome or relapse compared with PR with low albumin. A definition of PR that includes normalization of serum albumin may be a more robust surrogate endpoint in MN than the traditional definition of PR.
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Liu J, Li Y, Dai J, Lin B, Xiao C, Zhang X, Luo L, Wang T, Li X, Yu Y, Chen S, Wu L, Liu Y, Yu X, Qin X. Comprehensive Analyses of the Immunoglobulin Proteome for the Classification of Glomerular Diseases. J Proteome Res 2020; 19:1502-1512. [PMID: 32168457 DOI: 10.1021/acs.jproteome.9b00748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jianhua Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yang Li
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences-Beijing (PHENIX Center), Beijing Institute of Lifeomics, Beijing 102206, China
| | - Jiayu Dai
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences-Beijing (PHENIX Center), Beijing Institute of Lifeomics, Beijing 102206, China
| | - Baoxu Lin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Chunying Xiao
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Xinpeng Zhang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Lin Luo
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Tingting Wang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Xiaoying Li
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yao Yu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Shixiao Chen
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Lina Wu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yong Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Xiaobo Yu
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences-Beijing (PHENIX Center), Beijing Institute of Lifeomics, Beijing 102206, China
| | - Xiaosong Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
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Perazella MA. A Patient with Nephrotic Syndrome and Acute Flank Pain. KIDNEY360 2020; 1:74-75. [PMID: 35372858 PMCID: PMC8808488 DOI: 10.34067/kid.0000482019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut; and
- Veterans Affairs Medical Center, West Haven, Connecticut
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Lu C, Zuo K, Le W, Chen W, Qin W, Zhang F, Liang S, Zeng C, Wang J. Characterization of thromboelastography of patients with different pathological types of nephrotic syndrome. Medicine (Baltimore) 2020; 99:e18960. [PMID: 32000422 PMCID: PMC7004741 DOI: 10.1097/md.0000000000018960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
To investigate the changes in blood coagulability as measured by thromboelastography (TEG) in patients with nephrotic syndrome of different etiologies as well as in patients with venous thromboembolic events (VTE).From January 2013 to October 2017, patients who were diagnosed as idiopathic membranous nephropathy (IMN), minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) were enrolled into this retrospective study in which their clinical characteristics, including TEG variables, were investigated. According to the presence or absence of VTE, the patients with IMN were divided into 2 groups of VTE and non-VTE. The risk factors of VTE were analyzed with logistic regression.Significant differences in TEG parameters were found among the 3 groups of patients with R and K values lower, while the α-angle, maximum amplitude (MA) and confidence interval (CI) values higher, in the IMN group than those in the MCD and FSGS groups (P < .01). Multiple linear regression analysis indicated that the histologic subtype was an independent relevant factor of K time, angle, MA, and CI values. Multivariate logistic regression analysis revealed that serum albumin and CI value were independent risk factors of VTE (P < .05).The results showed that IMN patients may have higher whole blood coagulability than MCD and FSGS patients. The hypercoagulability in IMN patients may be attributed to platelet hyperactivity and the accelerated fibrin-platelet interaction. Hypoproteinemia and increased CI value were independent risk factors of VTE in IMN.
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Affiliation(s)
- Chunlei Lu
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Ke Zuo
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Weibo Le
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Wencui Chen
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Weisong Qin
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Fan Zhang
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Shaoshan Liang
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Caihong Zeng
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
| | - Jinquan Wang
- Department of National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing
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A Case Report of Extensive Cerebral Venous Sinus Thrombosis as a Presenting Sign of Relapsing Nephrotic Syndrome. Case Rep Neurol Med 2019; 2019:6840240. [PMID: 31949961 PMCID: PMC6948327 DOI: 10.1155/2019/6840240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/11/2019] [Accepted: 11/22/2019] [Indexed: 11/29/2022] Open
Abstract
Nephrotic syndrome is defined by three characteristic features including proteinuria of >3 g in 24 hours, hypoalbuminemia of less than 3 g/dL, and peripheral edema. Multiple nephropathies can result in nephrotic syndrome. Most commonly, minimal change disease is seen in children under the age of 10, while adults are more commonly found to have membranous nephropathy. Hypercoagulability and thrombotic sequela can be seen in nephrotic syndrome, regardless of underlying etiology, and thrombosis is most commonly seen in deep veins of the lower extremities and renal veins. Our case identifies an adult with previously diagnosed and treated for minimal change disease who presented with weight gain, peripheral edema, foamy urine, headache but no neurologic deficits. The patient was found to have near to complete occlusion of the entire superior sagittal sinus, near complete occlusion of the left transverse and sigmoid sinuses, and nonocclusive thrombus in the right sigmoid sinus. She was treated with heparin and IV steroids then transitioned to warfarin and PO steroids, respectively, with resolution of symptoms. This case report emphasizes on the importance of recognizing CVST as a potential complication of nephrotic syndrome at both initial presentation and relapse.
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46
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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47
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A Systematic Review of Prophylactic Anticoagulation in Nephrotic Syndrome. Kidney Int Rep 2019; 5:435-447. [PMID: 32274450 PMCID: PMC7136344 DOI: 10.1016/j.ekir.2019.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Nephrotic syndrome is associated with an increased risk of venous and arterial thromboembolism, which can be as high as 40% depending on the severity and underlying cause of nephrotic syndrome. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend prophylactic anticoagulation only in idiopathic membranous nephropathy but acknowledge that existing data are limited and of low quality. There is a need for better identification of vulnerable patients in order to balance the risks of anticoagulation. Methods We undertook a systematic search of the topic in MEDLINE, EMBASE and COCHRANE databases, for relevant articles between 1990 and 2019. Results A total of 2381 articles were screened, with 51 full-text articles reviewed. In all, 28 articles were included in the final review. Conclusion We discuss the key questions of whom to anticoagulate, when to anticoagulate, and how to prophylactically anticoagulate adults with nephrotic syndrome. Using available evidence, we expand upon current KDIGO guidelines and construct a clinical algorithm to aid decision making for prophylactic anticoagulation in nephrotic syndrome.
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48
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Zou H, Li Y, Xu G. Management of anticoagulation and antiplatelet therapy in patients with primary membranous nephropathy. BMC Nephrol 2019; 20:442. [PMID: 31791286 PMCID: PMC6889582 DOI: 10.1186/s12882-019-1637-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023] Open
Abstract
Background It has been recognized that primary membranous nephropathy (MN) is related to an increased risk for thromboembolic complications. However, the current evidence supporting prophylactic and therapeutic anticoagulation is too weak to better meet the clinical needs of this patient population. The present review provides some suggestions to guide the decision on anticoagulant management in primary MN patients with a high risk of thrombosis or with thromboembolic complication. Materials and methods We extracted relevant studies by searching the published literature using the Cochrane Library, Medline, PubMed and Web of Science from March 1968 to March 2018. Eligible publications included guidelines, reviews, case reports, and clinical trial studies that concerned the rational management of anticoagulation therapy in the primary MN population. The evidence was thematically synthesized to contextualize implementation issues. Results It was helpful for clinicians to make a decision for personalized prophylactic aspirin or warfarin in primary MN patients when serum albumin was < 3.2 g/dl to prevent arterial and venous thromboembolic events (VTEs). The treatment regimen for thromboembolic complications (VTEs, acute coronary syndrome and ischemic stroke) in primary MN was almost similar to that for the general population with thromboembolic events. It is noteworthy that patients should continue the previous primary MN treatment protocol during the entire treatment period until they achieve remission, the protocol is complete and the underlying diseases resolve. Conclusion The utility of prophylactic aspirin or warfarin may have clinical benefits for the primary prevention of thromboembolic events in primary MN with hypoalbuminemia. It is necessary to perform large randomized controlled trials and to formulate relevant guidelines to support the present review.
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Affiliation(s)
- Honghong Zou
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, 330006; No. 1, Minde Road, Donghu District,, Nanchang, People's Republic of China
| | - Yebei Li
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, 330006; No. 1, Minde Road, Donghu District,, Nanchang, People's Republic of China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, 330006; No. 1, Minde Road, Donghu District,, Nanchang, People's Republic of China.
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Myers LC, Li MD, Kalva S, Lai PS. Pulmonary Infarction due to Paget-Schroetter Syndrome and Nephrotic Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1679-1683. [PMID: 31727870 PMCID: PMC6870750 DOI: 10.12659/ajcr.919141] [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] [Indexed: 11/29/2022]
Abstract
Patient: Male, 23 Final Diagnosis: Minimal change disease Symptoms: Right arm and neck swelling Medication: — Clinical Procedure: Catheter-directed thrombolysis Specialty: Cardiology
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Affiliation(s)
- Laura C Myers
- Division of Pulmonary/Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew D Li
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjeeva Kalva
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Peggy S Lai
- Division of Pulmonary/Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Gordon-Cappitelli J, Choi MJ. Prophylactic Anticoagulation in Adult Patients with Nephrotic Syndrome. Clin J Am Soc Nephrol 2019; 15:123-125. [PMID: 31575616 PMCID: PMC6946067 DOI: 10.2215/cjn.05250419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Judit Gordon-Cappitelli
- Department of Medicine, Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington, DC
| | - Michael J Choi
- Department of Medicine, Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington, DC
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