Poor response to rivaroxaban in nephrotic syndrome with acute deep vein thrombosis

Li, Yan; Chen, Yikuan; Qi, Xiaotong; Hu, Bangqin; Du, Qingqing; Qian, Yan

doi:10.1097/md.0000000000016585

Cited by 7 publications

(5 citation statements)

References 14 publications

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“…However, for this reason, clinicians have been hesitant to use DOACs for PAC in NS due to the unknown effect of hypoalbuminemia on the drug's efficacy. There have only been a few published case reports and two small retrospective reviews detailing the use of DOACs in NS [20][21][22][23]. But looking forward, trials currently underway examining the pharmacokinetics of apixaban in NS would hopefully provide insights into some of these uncertainties [24].…”

Section: Discussionmentioning

confidence: 99%

Longitudinal Analysis of Prophylactic Anticoagulation in Primary Nephrotic Syndrome: Low Incidence of Thromboembolic Complications

McDonnell,

Hartemink,

Ragy

et al. 2023

Glomerular Dis

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Introduction Thromboembolic events (TEEs) are a serious and potentially fatal complication of nephrotic syndrome (NS). Despite this there is a lack of evidence examining the benefits of prophylactic anticoagulation (PAC) in NS. It was our objective to review the risk factors, rates of TEEs and patterns of PAC in patients with primary NS, with the aim to provide a pragmatic approach to PAC in primary NS. Methods This is a retrospective longitudinal cohort study of adult patients with primary NS. Included were: biopsy proven Minimal Change Disease and Focal Segmental Glomerulosclerosis (described as a combined podocytopathy cohort) plus Membranous Nephropathy (MN) over an 8-year period from a single centre. Anticoagulation practice, TEEs and longer-term outcomes were recorded. Results 54 patients with MN and 48 with podocytopathies were included. Baseline demographics and severity of NS was comparable. Those with MN were more likely to develop TEE 12(22%) vs 4(8%) (p=0.027) though this difference was predominantly seen at index diagnosis. Only 2 patients developed TEEs during active incident nephrotic syndrome. Rates of PAC were similar comparing MN (53%) and podocytopathies (58%). Those with a serum albumin < 20 g/L and HAS BLED score <3 were most likely to receive PAC (22/30, 73% in MN vs 21/30, 70% in iNS). Warfarin was the most common agent used in MN cohort 18/26 (69%) vs prophylactic dose low molecular weight heparin in the podocytopathy cohort 12/28 (43%). Discussion/Conclusion PAC practices applied in this cohort of patients were pragmatic and effective, with low TEE rates during active nephrotic syndrome.

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Section: Discussionmentioning

confidence: 99%

Longitudinal Analysis of Prophylactic Anticoagulation in Primary Nephrotic Syndrome: Low Incidence of Thromboembolic Complications

McDonnell,

Hartemink,

Ragy

et al. 2023

Glomerular Dis

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“…Case reports for VTE treatment with DOACs in patients with NS have also produced inconsistent results. [20][21][22][23]25 However, a randomized controlled trial comparing rivaroxaban 15 mg twice daily (n = 8) and dalteparin 5000 units twice daily (n = 8) for VTE treatment in patients with NS and low antithrombin III concentration and functional activity found similar rates of thrombus resolution at 4 weeks (87.5% vs 87.5%) and no occurrence of major bleeding in either cohort. 26 Of note, only 2 patients in each cohort had a histological diagnosis of MN, and rivaroxaban dosing appears to have remained at 30 mg/day throughout the study, which differs from the standard treatment dose of 15 mg twice daily for 21 days, followed by 20 mg daily.…”

Section: Discussionmentioning

confidence: 99%

“…[10][11][12][13][14][15][16][17][18][19] However, evidence for use of DOACs for both VTE treatment and prophylaxis in patients with NS is extremely limited, and rates of bleeding and thromboembolic outcomes vary between studies. 8,[20][21][22][23][24][25][26] Optimal dosing of DOACs in patients with NS has also not been established, and the pharmacokinetic consequences of severe hypoalbuminemia, particularly in patients treated with apixaban and rivaroxaban (87 and 95% protein-bound in plasma, respectively), is not well understood. 27,28 Due to the paucity of comparative data available, the purpose of this study was to compare bleeding and thromboembolic event rates in patients with NS receiving a DOAC versus warfarin for VTE prophylaxis.…”

Section: Introductionmentioning

confidence: 99%

Direct Oral Anticoagulants Versus Warfarin for Venous Thromboembolism Prophylaxis in Patients With Nephrotic Syndrome: A Retrospective Cohort Study

et al. 2022

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Background: Evidence supporting venous thromboembolism (VTE) prophylaxis with direct oral anticoagulants (DOACs) in patients with nephrotic syndrome (NS) is limited to case reports. Objective: The purpose of this study was to compare bleeding and thromboembolic events in this population. Methods: A retrospective cohort study was conducted in adults with NS initiated on a DOAC or warfarin for VTE prophylaxis between January 2013 and July 2021 within the Ochsner Health System. Patients with study drug exposure within the preceding 7 days, acute VTE within the preceding 6 months, or ≤7 days of study drug exposure were excluded. The primary outcome was the composite rate of major bleeding and clinically relevant nonmajor bleeding. Secondary outcomes included time to major bleeding and rate of new thromboembolic events. This study was approved by the Ochsner Health System Institutional Review Board. Results: Twenty-five DOAC and 19 warfarin patients were included. The primary outcome occurred in 8% vs 26.3% ( P = 0.21) of patients treated with a DOAC or warfarin, respectively, and was driven by major bleeding (4% vs 21%, P = 0.25). Other secondary outcomes were similar between cohorts. The study was limited by a small sample size. Conclusion and Relevance: Use of DOACs for VTE prophylaxis resulted in a nonstatistically significant, but clinically relevant lower rate of major bleeding compared to warfarin. This study provides comparative data showing safe and effective use of DOACs in patients with NS. Prospective, randomized studies are needed to confirm results.

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“…3 These disturbances led to coagulation and fibrinolytic system disorders, resulting in thrombosis. 96 During kidney transplantation, physiological factors such as shorter and thinner renal veins, 97 younger ages, and different blood types between recipients and donors may promote graft thrombosis. 98 Prolonged ischemia during transplantation may induce acute tubular necrosis with graft edema, leading to thrombosis.…”

Section: Mycophenolate Mofetil (Antimetabolite)mentioning

confidence: 99%

“…3 These disturbances led to coagulation and fibrinolytic system disorders, resulting in thrombosis. 96…”

Section: Introductionmentioning

confidence: 99%

The Crosstalk between Nephropathy and Coagulation Disorder: Pathogenesis, Treatment, and Dilemmas

Qiu

Pang

Xiang

et al. 2023

JASN

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The interaction between the kidney and the coagulation system greatly impacts each other due to the abundant vessel distribution and blood perfusion in the kidney. Clinically, the risks of complicated thrombosis and bleeding have become important concerns in the treatment of nephropathies, especially nephrotic syndrome, chronic kidney disease, end-stage renal disease, and nephropathy patients undergoing renal replacement therapies. Adverse effects of anticoagulant or procoagulant therapies in nephropathy patients, especially anticoagulation-related nephropathy, heparin-induced thrombocytopenia, and bleeding, seriously worsen the prognosis of patients, which have become challenges for clinicians. Over the decades, the interaction between the kidney and the coagulation system has been widely studied. However, the effects of the kidney on the coagulation system have not been systematically investigated. Although some coagulation-related proteins and signaling pathways have been shown to improve coagulation abnormalities while avoiding additional kidney damage in certain kidney diseases, their potential as anticoagulation targets in nephropathy requires further investigation. Here, we review the progression of research on the crosstalk between the coagulation system and kidney diseases, and systematically analyze the significance and shortcomings of previous studies to provide new sight into future research. In addition, we highlight the status of clinical treatment for coagulation disorder and nephropathy caused by each other, indicating guidance for the formulation of therapeutic strategies or drug development.

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Poor response to rivaroxaban in nephrotic syndrome with acute deep vein thrombosis

Cited by 7 publications

References 14 publications

Longitudinal Analysis of Prophylactic Anticoagulation in Primary Nephrotic Syndrome: Low Incidence of Thromboembolic Complications

Longitudinal Analysis of Prophylactic Anticoagulation in Primary Nephrotic Syndrome: Low Incidence of Thromboembolic Complications

Direct Oral Anticoagulants Versus Warfarin for Venous Thromboembolism Prophylaxis in Patients With Nephrotic Syndrome: A Retrospective Cohort Study

The Crosstalk between Nephropathy and Coagulation Disorder: Pathogenesis, Treatment, and Dilemmas

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