Prophylactic anticoagulation in nephrotic syndrome prevents thromboembolic complications

Abstract

Background An increased incidence of thromboembolic events (TE) are reported in nephrotic syndrome (NS) leading to recommendations for prophylactic anticoagulation (PAC). However, as no randomized clinical trial has established the efficacy or risks associated with PAC, guidelines are empiric or substantiated only by estimates of risks and benefits. This study evaluates the risk of TE and hemorrhagic complications in patients with NS treated with PAC and compares to patients not receiving PAC. Methods We included patients diagnosed with NS from two Danish nephrology departments with different practices for the use of PAC. Patients were included if presenting with NS from September 2006 to January 2012, a P-albumin < 30 g/L, and renal biopsy confirming non-diabetic, glomerular disease. Patients aged < 16 years, on renal replacement therapy, or administered anticoagulants at the onset of NS were excluded. Bleeding episodes and/or TE were identified from patient records. Bleeding episodes were divided into minor and major bleeding. Results Of the 79 patients included, 44 patients received PAC either as low or high dose low-molecular-weight heparin (LMWH) or as warfarin with or without LMWH as bridging, while 35 did not receive PAC. P-albumin was significant lower in the PAC group compared to those not receiving PAC. Significantly more TEs was observed in the non-PAC group compared to the PAC group (4 versus 0 episodes, P = 0.035). The TEs observed included one patient with pulmonary embolism (PE), one with PE and deep vein thrombosis, one with PE and renal vein thrombosis, and one with a stroke. Five patients with bleeding episodes were identified among those receiving PAC, of which two were major and three were minor, while two patients in the non-PAC group experienced a minor bleeding episode ( P = 0.45 between groups). The major bleeding episodes only occurred in patients receiving PAC in combination with low dose aspirin. Conclusions In patients with NS the use of PAC was associated with a decreased risk of clinically significant TE, but may also be associated with more bleeding episodes although not statistically significant. Only patients treated with PAC in combination with anti-platelet therapy had major bleeding episodes.

Role of direct oral anticoagulants in patients with kidney disease

“…54 Another observational study compared 44 patients receiving prophylactic LMWH or warfarin with 35 control patients. 55 Four VTEs were observed in the control group compared with none in the prophylaxis group. Two major bleeding events were reported in patients in the prophylaxis group, and both of these patients were taking concomitant aspirin.…”

Thromboembolic complications in nephrotic syndrome

“…Обычная антикоагулянтная терапия с последовательным введением гепарина высокой или низкой молекулярной массы и перорального варфарина остается стандартной терапией при лечении ВТ у пациентов НС [74]. Продолжительность лечения, необходимого для предотвращения повторных событий, неизвестна, но, вероятно, равна продолжительности существования НС как такового [75].…”

“…ретроспективно изучили эффекты проводимой антикоагулянтной терапии у 79 пациентов НС в отсутствие сахарного диабета (35 больных с БМИ, 19 -с МН и 7 -с ФСГС). Это единственное исследование, сравни-вающее исходы между группой пациентов, получающих профилактическую антикоагулянтную терапию варфарином или низкомолекулярным гепарином (НМГ), и контрольной группой больных без антикоагулянтной терапии [74]. У 44 пациентов, которым проводилась профилактика тромботических осложнений, ни одного случая тромбоза не зафиксировано, в то время как в контрольной группе у 4 (11%) из 35 лиц развились тромбоэмболические осложнения.…”

Nephrotic Syndrome-Associated Hypercoagulopathy is Alleviated by Nuclear Receptor Agonist Therapy with both Pioglitazone and Glucocorticoids

“…1,[5][6][7] However, the indications for anticoagulant prophylaxis in the setting of NS remain ill-defined and controversial. [8][9][10][11] Moreover, there is no consensus on when it is safe to discontinue anticoagulation. We have previously demonstrated, in animal models of NS, that disease severity (proteinuria and hypoalbuminemia) is tightly correlated with endogenous thrombin potential (ETP), a global measure of hypercoagulopathy that is predictive of VTE-risk, but not yet widely available for clinical use.…”