Management of anticoagulation and antiplatelet therapy in patients with primary membranous nephropathy

Abstract

BackgroundIt 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 methodsWe 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.ResultsIt 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.ConclusionThe 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.

Platelets

“…The optimal strategy of antiplatelet and anticoagulation therapy following TAVR for stroke risk reduction and prevention or treatment of leaflet thrombosis also remains a point of debate. Antiplatelet therapies developed to help prevent thrombotic events ( 51 ) are not yet known because of wide variations in clinical practice and heterogeneous trial populations. It is also not known whether thromboembolic complications and leaflet thrombosis following TAVR occur predominantly because of platelet- or thrombin-mediated clot formation, which could also alter the strategy of anticoagulation post-procedure ( 52 ).…”

Advances in Pathogenesis of Idiopathic Membranous Nephropathy

“…Already in the early 1980s it was noted that the risk of a venous thrombotic event (VTE) and associated pulmonary embolism was particularly high in patients with nephrotic syndrome (NS) due to primary MN. VTEs including deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are recognized as early complications of primary MN that carry significant morbidity and mortality [76, 77]. A European study [78] has found that clinically apparent venous thromboembolic events occur in about 7% of patients with MN.…”

“…Next to VTE, patients with NS might also be at risk of arterial thrombotic events (ATEs). The primary cardiovascular events (CVEs) included acute coronary syndrome and ischemic stroke [76, 77]. In the study by Lee et al, the morbidity of CVEs was 4.4, 5.4, 8.2, and 8.8% at 1, 2, 3, and 5 years, respectively, in a primary MN cohort [81].…”

“…In view of the potential prothrombotic effects of corticosteroids, it is important that the decision to start immunosuppressive therapy (often including high dose of prednisone) should not lead to postponement of the start of aspirin. Recently, Zou et al [77] identified 65 primary studies addressing prophylactic and therapeutic anticoagulation therapy in primary MN and found that personalized prophylactic aspirin or warfarin could be considered to prevent ATEs and VTEs in primary MN patients with serum albumin <3.2 g/dL. Moreover, the treatment regimen of thromboembolic complications in primary MN patients was similar to that in the general population with thromboembolic events.…”

Salvianolate Ameliorates Renal Damage Induced by C-BSA in Membranous Nephropathy Rats Through Inhibiting Hypercoagulable State and Alleviating Podocyte Injury

“…MN is often accompanied by the existence of hypercoagulability and hyperviscosity, which is prone to thrombosis, embolism, and other complications, promoting microcirculation disorders and accelerating the occurrence of glomerulosclerosis and renal fibrosis. Therefore, some experts have suggested that promoting blood circulation, removing stasis, and anticoagulation should be considered throughout the treatment of MN (Zou et al, 2019).…”