Kidney disease and venous thromboembolism: Does being woman make the difference?

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

ABSTRACT

The interaction between the kidney and the coagulation system greatly affects each other because of 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, CKD, ESKD, and patients with nephropathy undergoing RRTs. Adverse effects of anticoagulant or procoagulant therapies in patients with nephropathy, 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.

Direct oral anticoagulant successfully used to treat an adult nephrotic patient complicated with portal vein thrombosis

Thromboembolism is a major complication of nephrotic syndrome, with the renal vein being the most frequent site. However, the incidence of portal vein thrombosis (PVT) in patients with nephrotic syndrome is rare. We report a case of a relapsed steroid-dependent minimal change disease with incidental PVT. A 38-year-old man presented with anasarca. Elevated liver enzymes were discovered during routine blood testing within days after commencing treatment. Although drug-induced liver injuries are frequently observed with mild aminotransferase abnormality during therapy with steroid or immune-suppressive agents, imaging revealed a massive thrombus of the portal vein, which was treated by anticoagulant therapy with edoxaban. Treatment with anticoagulant therapy could normalize liver function. Two months after the initiation of treatment with edoxaban, the follow-up CT scan and ultrasound showed the disappearance of PVT. Our case suggests that much attention should be paid to PVT as a cause of liver enzyme elevation when treating patients with nephrotic syndrome.

Updated clinical models for VTE prediction in hospitalized medical patients

Venous thromboembolism (VTE) occurring in hospitalized medical patients is associated with increased length of hospitalization, high rate of acute care hospital transfer, longer inpatient rehabilitation and multiplication of health-care costs. Identification of acutely ill hospitalized medical patients eligible for thromboprophylaxis is a sophisticated process. Global VTE risk stems from the combination of predictors related with the acute medical illness, comorbidities, associated treatments and patients' intrinsic risk factors. Emerging clinical risk factors related to underlying pathologies should be considered when VTE risk is assessed. The Padua Prediction Score (PPS), the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE-RAM) and the Geneva Risk Score are three robust risk assessment models (RAM) which underwent extensive external validation in cohorts of acutely ill hospitalized medical patients. The development of the IMPROVE bleeding risk assessment model and the identification of D-Dimer increase as a biomarker-predictor of VTE are some steps forward for personalized thromboprophylaxis. The beneficial impact of the RAMs in VTE prevention is already seen by the decrease of in-hospital VTE rates when RAMs are incorporated in electronic alert systems.