1
|
Liu Y, Tang Y, Le WB, Chen D, Liang D, Xu F, Liang S, Zhong Y, Zeng C. The correlation between anti-phospholipase A2 receptor antibodies and hypercoagulability in patients with idiopathic membranous nephropathy. Ren Fail 2024; 46:2374448. [PMID: 38973428 PMCID: PMC11232635 DOI: 10.1080/0886022x.2024.2374448] [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: 04/16/2024] [Accepted: 06/25/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Patients with idiopathic membranous nephropathy (IMN) are more likely to be complicated by venous thromboembolism (VTE). The aim of the study was to investigate the potential association between anti-phospholipase A2 receptor (PLA2R) antibodies and hypercoagulability in patients with IMN. METHODS A total of 168 patients with biopsy-proven IMN and 36 patients with biopsy-proven minimal change disease (MCD) were enrolled in this study. The clinical data, serum anti-PLA2R antibodies and coagulation-related indices of the patients were retrospectively analyzed. RESULTS Patients with IMN were categorized into glomerular PLA2R staining-positive (GAg+) IMN group and glomerular PLA2R staining-negative (GAg-) IMN group in the study. Patients with IMN who were GAg + had lower PT, APTT and R time than patients with IMN who were GAg-, while the CI value was higher in patients with IMN who were GAg+. Patients with IMN who were GAg + were divided into the SAb+/GAg + group and the SAb-/GAg + group. Patients with IMN who were SAb+/GAg + had higher Fib and MA values than patients with IMN who were SAb-/GAg+. Correlation analysis showed that serum anti-PLA2R antibodies were positively correlated with fibrinogen, D-dimer, K time, CI value, α-angle, and MA value. Multiple linear regression analysis indicated that anti-PLA2R antibodies were independently correlated with fibrinogen and MA value. CONCLUSION Our study provides a new perspective on the underlying mechanisms of hypercoagulability in patients with IMN. Anti-PLA2R antibodies are associated with hypercoagulability in patients with IMN and may affect coagulation in patients with IMN by affecting platelet aggregation function and fibrinogen counts.
Collapse
Affiliation(s)
- Yunyun Liu
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yujie Tang
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei-Bo Le
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dacheng Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yongzhong Zhong
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Nephrology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Caihong Zeng
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
2
|
Chebotareva NV, Kharionovskaya EA, Biryukova EA, Berns SA, Vuimo TA. [Comparison of thrombodynamic methods and routine hemostasis tests in the evaluation of hypercoagulable syndrome in chronic glomerulonephritis]. TERAPEVT ARKH 2024; 96:565-570. [PMID: 39106496 DOI: 10.26442/00403660.2024.06.202723] [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: 07/06/2024] [Accepted: 07/06/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Nephrotic syndrome (NS) is associated with a high risk of thrombotic complications. In this group of patients, routine local tests for assessing hemostasis do not accurately reflect hypercoagulable state. Global functional tests for assessing hemostasis, including thrombodynamics (TD), are considered promising for assessing disorders in the blood coagulation system of these patients. AIM To compare the rate of hypercoagulability according to routine hemostatic tests and TD and to evaluate the factors associated with increased risk of thrombotic complications in patients with chronic glomerulonephritis (CGN). MATERIALS AND METHODS The study included 94 patients with active CGN who were not receiving anticoagulant therapy; 63 (80.3%) patients had NS, and 31 (19.7%) had active CGN without NS. Hemostasis parameters were assessed using local coagulation tests and TD test. Using logistic regression analysis, factors associated with the risk of thrombosis were assessed. RESULTS Of the 94 patients with active CGN in 63 without preventive anticoagulant therapy, hypercoagulability according to routine tests was detected in 6 (9.5%) patients with NS and in 3 (9.7%) patients without NS (p<0.05). Hypercoagulability according to the TD test was detected in 24 (53.9%) patients with NS and in 5 (32.2%) without NS (p<0.05). The formation of spontaneous clots was observed in 29 (30.9%) of patients with CGN, most of them 24 (83%) with NS. 10.6% of patients in our cohort experienced thromboembolic events. The risk of thromboembolic events according to the univariate regression analysis was associated with older age, higher lipid levels, use of glucocorticosteroids and detection of spontaneous clots by the TD test. No association of thromboembolic events with abnormalities in routine hemostasis tests was obtained. CONCLUSION In patients with CGN with nephrotic syndrome, hypercoagulability is detected in 9.5% of cases with routine coagulation tests and in 53.9% of cases with TD test. Detection of spontaneous clots by TD test is associated with a risk of thromboembolic events.
Collapse
Affiliation(s)
- N V Chebotareva
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - E A Biryukova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S A Berns
- National Medical Research Center for Therapy and Preventive Medicine
| | - T A Vuimo
- Center for Theoretical Problems of Physico-Chemical Pharmacology
| |
Collapse
|
3
|
Wang F, Xu J, Wang F, Yang X, Xia Y, Zhou H, Yi N, Jiao C, Su X, Zhang B, Zhou H, Wang Y. A dynamic online nomogram for predicting renal outcomes of idiopathic membranous nephropathy. BMC Med Inform Decis Mak 2024; 24:173. [PMID: 38898472 PMCID: PMC11186104 DOI: 10.1186/s12911-024-02568-2] [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: 08/12/2023] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Because spontaneous remission is common in IMN, and there are adverse effects of immunosuppressive therapy, it is important to assess the risk of progressive loss of renal function before deciding whether and when to initiate immunosuppressive therapy. Therefore, this study aimed to establish a risk prediction model to predict patient prognosis and treatment response to help clinicians evaluate patient prognosis and decide on the best treatment regimen. METHODS From September 2019 to December 2020, a total of 232 newly diagnosed IMN patients from three hospitals in Liaoning Province were enrolled. Logistic regression analysis selected the risk factors affecting the prognosis, and a dynamic online nomogram prognostic model was constructed based on extreme gradient boost, random forest, logistic regression machine learning algorithms. Receiver operating characteristic and calibration curves and decision curve analysis were utilized to assess the performance and clinical utility of the developed model. RESULTS A total of 130 patients were in the training cohort and 102 patients in the validation cohort. Logistic regression analysis identified four risk factors: course ≥ 6 months, UTP, D-dimer and sPLA2R-Ab. The random forest algorithm showed the best performance with the highest AUROC (0.869). The nomogram had excellent discrimination ability, calibration ability and clinical practicability in both the training cohort and the validation cohort. CONCLUSIONS The dynamic online nomogram model can effectively assess the prognosis and treatment response of IMN patients. This will help clinicians assess the patient's prognosis more accurately, communicate with the patient in advance, and jointly select the most appropriate treatment plan.
Collapse
Affiliation(s)
- Feng Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Jiayi Xu
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Fumei Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Xu Yang
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Yang Xia
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Hongli Zhou
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Na Yi
- Department of Nephrology, The General Hospital of Angang Group, Anshan, Liaoning, People's Republic of China
| | - Congcong Jiao
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Xuesong Su
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Beiru Zhang
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Hua Zhou
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Yanqiu Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China.
| |
Collapse
|
4
|
Sun Z, Wang H, Jiang H, Shen Y, Shi Z, Wang Q, Wang H, Jiang W, Du X. A new notable compression source of left renal vein entrapment: right renal artery. World J Urol 2024; 42:360. [PMID: 38811391 PMCID: PMC11136829 DOI: 10.1007/s00345-024-05053-7] [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: 03/20/2024] [Accepted: 05/06/2024] [Indexed: 05/31/2024] Open
Abstract
PURPOSE To estimate the incidences of left renal vein (LRV) entrapment by right renal artery (RRA), a phenomenon primarily reported as case reports. METHODS The cross-sectional study consecutively screened renal vessel CT data of 38 (Renal) patients with nephropathy and 305 (Non-renal) patients with peripheral arterial diseases in a teaching hospital in northeast China between November 2018 and March 2023. The LRV compression by adjacent anatomical structures, including but not limited to RRA and multiple compression-related parameters, were investigated through multiplanar analysis of the CT data. RESULTS The overall LRV entrapment rates by adjacent structures were 41.93% (12/31) and 24.00% (6/25), the rates of RRA-sourced LRV compression 22.58% (7/31) and 20.00% (5/25), and the rates of compression by superior mesenteric artery (SMA) 16.13% (5/31) and 4.00% (1/25) in the Renal and Non-renal groups, respectively, with no significance. The venous segments distal to the RRA-compressed site had a significantly larger transectional lumen area than those of the non-compressed veins in both groups (3.09 ± 1.29 vs. 1.82 ± 0.23, p < 0.001 and 4.30 ± 2.65 vs. 2.12 ± 0.55, p = 0.006; maximum-to-minimum area ratios in Renal and Non-renal groups, respectively). Nearly 80% of RRAs were found arising anteriorly rightwards instead of passing straight to the right. CONCLUSION RRA-sourced LRV compression was not rare, and its incidence was higher than that of the compression by SMA in both patient cohorts. RRA could be a more common compression source than SMA concerning LRV entrapment. Further investigations involving different populations, including healthy individuals, are needed.
Collapse
Affiliation(s)
- Zhanfeng Sun
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Haitao Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Huijie Jiang
- Department of Radiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yongbin Shen
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ziming Shi
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qingxiao Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
- Department of Pediatric Orthopaedics, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Han Wang
- Department of Biostatistics, Kun Tuo Medical Research and Development (Beijing) Co., Ltd, Beijing, China
| | - Weiliang Jiang
- Department of Vascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xuanyi Du
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin, 150086, Heilongjiang, China.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Abdelghani E, Waller AP, Wolfgang KJ, Stanek JR, Parikh SV, Rovin BH, Smoyer WE, Kerlin BA. Exploring the Role of Antithrombin in Nephrotic Syndrome-Associated Hypercoagulopathy: A Multi-Cohort Study and Meta-Analysis. Clin J Am Soc Nephrol 2023; 18:234-244. [PMID: 36754010 PMCID: PMC10103265 DOI: 10.2215/cjn.0000000000000047] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/01/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Nephrotic syndrome is associated with an acquired hypercoagulopathy that is thought to drive its predisposition for venous thromboembolism. Previous studies have suggested that urinary antithrombin (AT) loss leading to acquired AT deficiency is the primary mechanism underlying this hypercoagulopathy, but this hypothesis has not been directly tested. The objectives of this study were to test the influence of AT levels on hypercoagulopathy in nephrotic syndrome patient samples and perform meta-analyses to evaluate the likelihood of AT deficiency in patients with nephrotic syndrome. METHODS Samples from three independent nephrotic syndrome cohorts were analyzed. AT antigen and activity assays were performed using ELISA and amidolytic assays, respectively. Plasma thrombin generation, albumin, and urine protein-to-creatinine ratios were determined using established methods. Meta-analyses were performed by combining these new data with previously published data. RESULTS AT levels were not consistently related to either plasma albumin or proteinuria. AT was quantitatively related to hypercoagulopathy in adult nephrotic syndrome, whereas AT activity was inconsistently associated with hypercoagulopathy in childhood nephrotic syndrome. Notably, hypercoagulopathy did not differ between patients with normal AT levels and those with levels below the threshold used to define clinical AT deficiency (<70%). Moreover, ex vivo AT supplementation did not significantly alter hypercoagulopathy in AT-deficient plasma samples. The meta-analyses demonstrated that AT deficiency was not a uniform feature of nephrotic syndrome and was more common in children than adults. CONCLUSIONS These data suggest that AT deficiency plays only a limited role in the mechanisms underlying the acquired hypercoagulopathy of nephrotic syndrome. Moreover, AT deficiency was not present in all patients with nephrotic syndrome and was more likely in children than adults despite the higher risk for venous thromboembolism in adults than children.
Collapse
Affiliation(s)
- Eman Abdelghani
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Division of Pediatric Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Amanda P. Waller
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Katelyn J. Wolfgang
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R. Stanek
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
| | - Samir V. Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Brad H. Rovin
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - William E. Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Division of Nephrology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Bryce A. Kerlin
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Division of Pediatric Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| |
Collapse
|
8
|
Wang P, Wang S, Huang B, Liu Y, Liu Y, Chen H, Zhang J. Clinicopathological features and prognosis of idiopathic membranous nephropathy with thyroid dysfunction. Front Endocrinol (Lausanne) 2023; 14:1133521. [PMID: 37008916 PMCID: PMC10060953 DOI: 10.3389/fendo.2023.1133521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Thyroid dysfunction is common in patients with kidney disease. However, the relationship between thyroid dysfunction and idiopathic membranous nephropathy (IMN) remains unclear. This retrospective study aimed to investigate the clinicopathological characteristics and prognosis of patients with IMN and thyroid dysfunction compared to patients with IMN and without thyroid dysfunction. METHODS A total of 1052 patients with IMN diagnosed by renal biopsy were enrolled in this study, including 736 (70%) with normal thyroid function and 316 (30%) with abnormal thyroid function. We analyzed the clinicopathological features and prognostic data between the two groups, using propensity score matching (PSM) to reduce the bias. Logistic regression analysis was performed to investigate the risk factors for IMN combined with thyroid dysfunction. Kaplan-Meier curves and Cox regression analysis were used to evaluate the association between thyroid dysfunction and IMN. RESULTS Patients with IMN and thyroid dysfunction exhibited more severe clinical features. Female sex, lower albumin level, higher D-dimer level, severe proteinuria, and decreased estimated glomerular filtration rate were predictors of thyroid dysfunction in patients with IMN. After PSM, 282 pairs were successfully matched. Results from the Kaplan-Meier curves indicated that the thyroid dysfunction group had a lower complete remission rate (P = 0.044), higher relapse rate (P < 0.001), and lower renal survival rate (P = 0.004). The multivariate Cox regression analysis revealed that thyroid dysfunction was an independent risk factor for complete remission [hazard ratio (HR) = 0.810, P = 0.045], relapse (HR = 1.721, P = 0.001), and composite endpoint event (HR = 2.113, P = 0.014) in IMN. CONCLUSIONS Thyroid dysfunction is relatively common in patients with IMN, and the clinical indicators are more severe in these patients. Thyroid dysfunction is an independent risk factor for poor prognosis in patients with IMN. More attention should be paid to thyroid function in patients with IMN.
Collapse
Affiliation(s)
- Peiheng Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Shulei Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Bo Huang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Yiming Liu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Yingchun Liu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Huiming Chen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Junjun Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
- *Correspondence: Junjun Zhang,
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Vestergaard SV, Birn H, Darvalics B, Nitsch D, Sørensen HT, Christiansen CF. Risk of Arterial Thromboembolism, Venous Thromboembolism, and Bleeding in Patients with Nephrotic Syndrome: A Population-Based Cohort Study. Am J Med 2022; 135:615-625.e9. [PMID: 34979093 DOI: 10.1016/j.amjmed.2021.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although venous thromboembolism is a well-known complication of nephrotic syndrome, the long-term absolute and relative risks of arterial thromboembolism, venous thromboembolism, and bleeding in adults with nephrotic syndrome remain unclarified. METHODS In this matched cohort study, we identified every adult with first-time recorded nephrotic syndrome from admissions, outpatient clinics, or emergency department visits in Denmark during 1995-2018. Each patient was matched by age and sex with 10 individuals from the general population. We estimated the 10-year cumulative risks of recorded arterial thromboembolism, venous thromboembolism, and bleeding accounting for the competing risk of death. Using Cox models, we computed crude and adjusted hazard ratios (HRs) of the outcomes in patients with nephrotic syndrome versus comparators. RESULTS Among 3967 adults with first-time nephrotic syndrome, the 1-year risk of arterial thromboembolism was 4.2% (95% confidence interval [CI] 3.6-4.8), of venous thromboembolism was 2.8% (95% CI 2.3-3.3), and of bleeding was 5.2% (95% CI 4.5-5.9). The 10-year risk of arterial thromboembolism was 14.0% (95% CI 12.8-15.2), of venous thromboembolism 7.7% (95% CI 6.8-8.6), and of bleeding 17.0% (95% CI 15.7-18.3), with highest risks of ischemic stroke (8.1%), myocardial infarction (6.0%), and gastrointestinal bleeding (8.2%). During the first year, patients with nephrotic syndrome had increased rates of both arterial thromboembolism (adjusted HR [HRadj] = 3.11 [95% CI 2.60-3.73]), venous thromboembolism (HRadj = 7.11 [5.49-9.19]), and bleeding (HRadj = 4.02 [3.40-4.75]) compared with the general population comparators after adjusting for confounders. CONCLUSION Adults with nephrotic syndrome have a high risk of arterial thromboembolism, venous thromboembolism, and bleeding compared with the general population. The mechanisms and consequences of this needs to be clarified.
Collapse
Affiliation(s)
- Søren Viborg Vestergaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Henrik Birn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus , Denmark
| | - Bianka Darvalics
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Wu HHL, Alozai A, Li JWC, Elmowafy A, Ponnusamy A, Woywodt A, Jeyalan V. Risk Factors of Venous Thromboembolism in Anti-PLA2R positive and negative Primary Membranous Nephropathy. Clin Kidney J 2022; 15:1636-1638. [PMID: 35892019 PMCID: PMC9308090 DOI: 10.1093/ckj/sfac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Henry H L Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Abdur Alozai
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Jennifer W C Li
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Ahmed Elmowafy
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Arvind Ponnusamy
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Vishnu Jeyalan
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| |
Collapse
|
13
|
Bankole AA, Nwaonu JN. The Shifting Landscape of Lupus Nephritis Management: A Review. Cureus 2022; 14:e20950. [PMID: 35154930 PMCID: PMC8815326 DOI: 10.7759/cureus.20950] [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] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is commonly the first autoimmune disease that comes to mind for most people when rheumatology is mentioned. It remains an enigma that many of us, including patients and healthcare providers, do not fully understand. Although an ancient disease, it still remains difficult to both diagnose and treat. Historically, there has always been a paucity of therapeutic interventions for SLE as a whole. One of the most distressing manifestations for the patient and diagnostic and therapeutically challenging aspects of SLE is lupus nephritis (LN). There has historically been some difficultly in the development of LN drugs that provide significant therapeutic benefits while having an acceptable side-effect profile. This difficulty led to decades in which no drugs were approved for LN. With a better understanding of the pathogenesis of SLE and LN and improvement in trial design, great therapeutic strides have recently been made. The immunosuppressive landscape of LN has changed recently with the approval of two newer agents as well as a number of promising trials in LN. With the increased number of therapeutic agents (both immunosuppressive and non-immunosuppressive), the clinical question is how and when to use these medications, and, more importantly, which agents to use first. With the increased number of agents, the answers to these questions are becoming more difficult to answer. The purpose of the paper is to review updates in LN diagnosis and management.
Collapse
|
14
|
Liu M, Yang Q, Hua Q, Liu J, He W, Niu D, Liu X. Chinese medicinal herbs for idiopathic membranous nephropathy in adults with nephrotic syndrome: A systematic review of effectiveness and safety. Medicine (Baltimore) 2021; 100:e27953. [PMID: 34918644 PMCID: PMC8677963 DOI: 10.1097/md.0000000000027953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT To assess the benefits and harms of Chinese medicinal herbs formulae for the treatment of idiopathic membranous nephropathy in adult patients with primary nephrotic syndrome.Only randomized controlled trials were included. We searched the Cochrane Central Register of Controlled Trials database, PubMed, EMBASE, Chinese National Knowledge Internet, Chinese Biomedicine Database, and VIP. All studies were analyzed using the criteria of the Cochrane Handbook and were assessed in terms of quality and the risk of bias. Review Manager ver. 5.3.5 software was used for the data analysis, and GRADE profiler software was employed to evaluate quality.Two studies were included (n = 126 Chinese participants). We found that compared with against conventional treatment, one Chinese medicinal herbs formula plus conventional treatment reduced 24-hours urinary total protein (mean differences -3.16 g/24 h, 95% confidence intervals -4.03 to -2.29), and two Chinese medicinal herbs formulae increased serum albumin levels (mean differences 3.18 g/L, 95% confidence intervals 1.12 to 5.52; I2 = 0%).Chinese medicinal herbs formulae may reduce 24-hours urinary total protein and increase serum levels of albumin. However, larger and multicenter studies with high methodological quality are still needed.
Collapse
Affiliation(s)
- Meifang Liu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Department of Nephrology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qianchun Yang
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Second Outpatient Department, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiaoli Hua
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jialing Liu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weifeng He
- Department of Oncology, the Second People's Hospital of Hunan Province, Changsha, China
| | - Di Niu
- School of Basic Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xusheng Liu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- Department of Nephrology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, Guangzhou, China
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Leslom AN, Alrawiah ZMS, Al-Asmari AMA, Alqashaneen MDA, Alahmari AOT, Al-Ahmari HOBT. Prevalence of pulmonary thromboembolism in nephrotic syndrome patients: A systematic review and meta-analysis. J Family Med Prim Care 2020; 9:497-501. [PMID: 32318371 PMCID: PMC7113925 DOI: 10.4103/jfmpc.jfmpc_1076_19] [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: 11/29/2019] [Revised: 01/23/2020] [Accepted: 02/03/2020] [Indexed: 11/26/2022] Open
Abstract
This study was aimed to assess the prevalence of pulmonary thromboembolism in patients with nephrotic syndrome. An electronic search was conducted through nine electronic databases for selection of relevant articles reporting the prevalence of pulmonary thromboembolism in patients with nephrotic syndrome. National Institute of Health was used to assess the quality of each study. Meta-analysis was used to pool the results. Of total 2267 reports screened, we finally included 11 studies including five retrospective cohorts, four prospective cohorts, and two case series studies. Out of these, ten articles were eligible for meta-analysis. The overall prevalence was 7.93% with 95% CI of 4.27 to 14.73. However, a significant heterogeneity (P < 0.001) was observed with I2= 96% and τ2= 0.899. Moreover, Egger's regression test showed a significant risk of bias (P = 0.006). Patients with nephrotic syndrome are prone to pulmonary embolism, therefore early management is critical to decreasing mortality burden.
Collapse
|
19
|
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.
Collapse
|
20
|
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.
Collapse
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.
| |
Collapse
|
21
|
Li J, Cui Z, Long J, Huang W, Wang J, Zhang H, Wang H, Zhang L, Ronco P, Zhao MH. Primary glomerular nephropathy among hospitalized patients in a national database in China. Nephrol Dial Transplant 2019; 33:2173-2181. [PMID: 29509919 DOI: 10.1093/ndt/gfy022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 01/11/2018] [Indexed: 01/10/2023] Open
Abstract
Background Primary glomerular nephropathy (PGN) is a leading cause of end-stage renal disease in developing countries, however, nationwide studies investigating the spectrum of PGN are limited. Methods To evaluate the composition of various pathological types of PGN in a comprehensive geographic coverage in China, a national inpatient database covering 43.7 million patients was used in this analysis. Diagnoses were extracted from the discharge diagnoses. Results The percentage of patients with PGN in hospitalized patients decreased from 0.80% in 2010 to 0.67% in 2015. Among hospitalized patients with PGN, a decreasing trend of immunoglobulin A nephropathy (from 19.0% in 2010 to 10.6% in 2015) and an increasing trend of idiopathic membranous nephropathy (from 4.5% in 2010 to 8.8% in 2015) were revealed. A positive association between the percentage of idiopathic membranous nephropathy (iMN) and the exposure of particulate matter with a diameter < 2.5 μm was observed north of the Yangtze River (P < 0.001, R2 = 0.828). South of the Yangtze River, the proportion of the Zhuang population was positively correlated to the frequency of iMN (P = 0.012, r = 0.697). Conclusions In conclusion, a changing spectrum of PGN was observed between 2010 and 2015 in China and both environmental and genetic factors might play pivotal roles in the pathogenesis of iMN in the Chinese population.
Collapse
Affiliation(s)
- Jiannan Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Jianyan Long
- China Standard Medical Information Research Center, Shenzhen, Guangdong, China
| | - Wei Huang
- Department of Occupational and Environmental Health Sciences, Peking University School of Public Health, Beijing, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen, Guangdong, China.,Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Peking University, Center for Data Science in Health and Medicine, Beijing, China
| | - Pierre Ronco
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM UMR_S 1155, Paris, France.,AP-HP, Service de Néphrologie et Dialyses, Hôpital Tenon, Paris, France
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| |
Collapse
|
22
|
Ma F, Zhou K, Hua Y, Liu X, Duan H, Li Y, Wang C. Chronic thromboembolic pulmonary hypertension as the first manifestation of nephrotic syndrome in a 12-year-old child. Medicine (Baltimore) 2018; 97:e12349. [PMID: 30313030 PMCID: PMC6203542 DOI: 10.1097/md.0000000000012349] [Citation(s) in RCA: 2] [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: 11/25/2022] Open
Abstract
RATIONALE Chronic thromboembolic pulmonary hypertension (CTEPH) is rare in children and determining the underlying etiologies is essential for treatment. Venous thromboembolism, a well-known complication in nephrotic syndrome (NS), always occurrs during the treatment in course of the disease. However, CTEPH as the first manifestation of NS has not been reported till now. PATIENT CONCERNS A 12-year-old boy initially complained of hemoptysis, cough and shortness of breath with exertion, any symptoms regarding NS such as edema were not presented. Due to the identification of P2 enhancement, liver enlargement (2 cm below the rib) and jugular vein distension, pulmonary hypertension (PH) was firstly suspected and ultimately confirmed by detection of enlargement of right atrium (RA) and right ventricle (RV) enlargement (RA = 45mm, RV = 30mm), mild tricuspid valve regurgitation (TR) and elevation of pulmonary arterial pressure (63 mmHg) on echocardiogram. In order to search the underlying causes of PH, series of targeted laboratory evaluation and imaging were conducted, and pulmonary arterial embolism (PE) in inferior lobes of double lungs was found on chest contrast-enhanced computed tomography. DIAGNOSIS NS was unexpectedly discovered by detection of lower serum albumin level (24.4 g/L), severe proteinuria (+++, 4.62 g/24 h) when we were searching for the predisposing factors causing thromboembolism. INTERVENTIONS AND OUTCOMES After treatment of NS, the symptom regarding shortness of breath with exertion gradually became less apparent and was relieved one month later. Proteinuria and microscopic hematuria also disappeared. Encouragingly, RA and RV dilation, and the pulmonary arterial pressure almost returned to a normal range half a year later, with alleviation of MR. LESSONS CTEPH can occur rarely in children and NS is an important predisposing factor. PE could be the first manifestation of NS. When pediatricians encounter children with PE or CTEPH, NS as the underlying etiology should be considered. Except for renal venous thrombosis, the possibility of PE needs to be paid more attention in children with NS.
Collapse
Affiliation(s)
- Fan Ma
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
- West China Medical School of Sichuan University, Chengdu
| | - Kaiyu Zhou
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yimin Hua
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoliang Liu
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
| | - Hongyu Duan
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
| | - Yifei Li
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
| | - Chuan Wang
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University
| |
Collapse
|
23
|
Song Z, Wu H, Cao H, Tang M, Yang S, Qin L. Nephrotic syndrome with acute pulmonary embolism in young adults: Two case reports. Medicine (Baltimore) 2018; 97:e11495. [PMID: 30024529 PMCID: PMC6086462 DOI: 10.1097/md.0000000000011495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pulmonary embolism (PE) is often misdiagnosed, or the diagnosis is delayed because of its diverse clinical manifestations, it may even remain asymptomatic until sudden death. Most risk factors are not associated with young people, and there is a paucity of literature regarding PE in children and young adults. CASE PRESENTATION Patient 1 who died was diagnosed with nephrotic syndrome more than 10 years before. He presented to a clinic with gradually worsening dyspnea, which was initially misdiagnosed as myocarditis. Patient 2 presented with sudden shortness of breath after treatment for nephrotic syndrome. His PE was quickly diagnosed, allowing prompt initiation of anticoagulant therapy. At follow-up 30 days after hospital discharge, his symptoms had disappeared, and his abnormal laboratory results had returned to almost normal. CONCLUSION The diagnosis and treatment of the above 2 patients suggest that the possible occurrence of PE in a young person with nephrotic syndrome should not be ignored. The early diagnosis and delayed diagnosis will have different clinical outcomes.
Collapse
|
24
|
Zhang L, Zhang H, Zhang J, Tian H, Liang J, Liu Z. Rivaroxaban for the treatment of venous thromboembolism in patients with nephrotic syndrome and low AT-III: A pilot study. Exp Ther Med 2017; 15:739-744. [PMID: 29399079 PMCID: PMC5772665 DOI: 10.3892/etm.2017.5471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022] Open
Abstract
The anticoagulation effect of heparin requires adequate serum antithrombin (AT)-III levels. Rivaroxaban, however, exhibits its anticoagulation effects independent of AT-III. The aim of the present study was to evaluate the efficacy and safety of rivaroxaban as a treatment for venous thromboembolism in patients with AT-III deficiency due to nephrotic syndrome. Patients with nephrotic syndrome and low serum concentration and functional activity of AT-III and venous thromboembolism were randomly assigned to the rivaroxaban group (n=8) and low weight molecular heparin group (n=8). The patients were treated for 4 weeks and evaluated at weeks 2 and 4. The primary endpoint was thrombus dissolution or a >90% decrease in thrombus volume in 4 weeks. Secondary endpoints included an increase in the volume of the pre-existing thrombosis and safety assessments. In each of the two groups, 7/8 patients achieved a primary endpoint. At week 2, 5 patients in the rivaroxaban group and 4 in the low weight molecular heparin group had achieved the primary endpoint. Notably, at week 2 the patients whose AT-III levels and functional activity remained low in the low weight molecular heparin group did not achieve the primary endpoint. The adverse effects were similar in both groups, with no severe hemorrhage observed. In conclusion, the results of this pilot study demonstrate that rivaroxaban may be an effective, safe, single-agent approach for treating vein thromboembolism in patients with nephrotic syndrome and low AT-III levels. The potential benefits of rivaroxaban over low weight molecular heparin treatment require further investigation with a larger sample size in order to validate the findings of the present study.
Collapse
Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Jiong Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Hong Tian
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Ju Liang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| |
Collapse
|
25
|
Gyamlani G, Molnar MZ, Lu JL, Sumida K, Kalantar-Zadeh K, Kovesdy CP. Association of serum albumin level and venous thromboembolic events in a large cohort of patients with nephrotic syndrome. Nephrol Dial Transplant 2017; 32:157-164. [PMID: 28391310 DOI: 10.1093/ndt/gfw227] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/04/2016] [Indexed: 11/13/2022] Open
Abstract
Background Prior small studies have suggested an association between low serum albumin and increased risk of venous thromboembolic (VTE) events in patients with nephrotic syndrome (NS). Methods From a nationally representative prospective cohort of over 3 million US veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m 2 , we identified 7037 patients with NS based on ICD-9 codes. Association between serum albumin and risk of incident VTE was assessed using Cox regression analysis with adjustments for age, gender, race, comorbidities, eGFR, body mass index and anticoagulant treatment. Results Mean age was 57 ± 11 years, patients were 96% male, 32% African-American and 60% diabetic. There were a total of 158 VTE events over a median follow-up of 8.1 years; 16 events [absolute event rate (AER) 4.1%, event rate 8.5/1000 patient-years (PY)] in patients with albumin <2.5 g/dL, 18 events (AER 3.4%, event rate 5.7/1000 patient-years) in patients with albumin 2.5-2.99 g/dL, 89 events (AER 2.5%, event rate 3.4/1000 patient-years) in patients with albumin 3-3.99 g/dL and 35 events (AER 1.4%, event rate 1.9/1000 patient-years) in patients with albumin ≥4 g/dL. Compared with patients with albumin ≥4 g/dL, those with albumin levels of 3-3.99 g/dL [adjusted hazard ratio (HR): 1.51, 95% confidence interval (CI): 1.01-2.26], 2.5-2.99 g/dL (HR: 2.24, 95% CI: 1.24-4.05) and <2.5 g/dL (HR: 2.79, 95% CI: 1.45-5.37) experienced a linearly higher risk of VTE events. Conclusions Lower serum albumin is a strong independent predictor for VTE events in NS. The risk increases proportionately with declining albumin levels. Clinical trials are needed to determine benefit of prophylactic anticoagulation in NS patients with moderately lower serum albumin levels.
Collapse
Affiliation(s)
- Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
26
|
Abstract
Membranous nephropathy (MN) is a unique glomerular lesion that is the most common cause of idiopathic nephrotic syndrome in nondiabetic white adults. About 80% of cases are renal limited (primary MN, PMN) and 20% are associated with other systemic diseases or exposures (secondary MN). This review focuses only on PMN. Most cases of PMN have circulating IgG4 autoantibody to the podocyte membrane antigen PLA2R (70%), biopsy evidence PLA2R staining indicating recent immunologic disease activity despite negative serum antibody levels (15%), or serum anti-THSD7A (3%-5%). The remaining 10% without demonstrable anti-PLA2R/THSd7A antibody or antigen likely have PMN probably secondary to a different, still unidentified, anti-podocyte antibody. Considerable clinical and experimental data now suggests these antibodies are pathogenic. Clinically, 80% of patients with PMN present with nephrotic syndrome and 20% with non-nephrotic proteinuria. Untreated, about one third undergo spontaneous remission, especially those with absent or low anti-PLA2R levels, one-third progress to ESRD over 10 years, and the remainder develop nonprogressive CKD. Proteinuria can persist for months after circulating anti-PLA2R/THSD7A antibody is no longer detectable (immunologic remission). All patients with PMN should be treated with supportive care from the time of diagnosis to minimize protein excretion. Patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis, and those who fail to reduce proteinuria to <3.5 g after 6 months of supportive care or have complications of nephrotic syndrome, should be considered for immunosuppressive therapy. Accepted regimens include steroids/cyclophosphamide, calcineurin inhibitors, and B cell depletion. With proper management, only 10% or less will develop ESRD over the subsequent 10 years.
Collapse
Affiliation(s)
- William G Couser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
27
|
Al-Azzawi HF, Obi OC, Safi J, Song M. Nephrotic syndrome-induced thromboembolism in adults. Int J Crit Illn Inj Sci 2016; 6:85-8. [PMID: 27308257 PMCID: PMC4901833 DOI: 10.4103/2229-5151.183019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nephrotic syndrome (NS) is a well-defined syndrome characterized by the presence of nephrotic range of proteinuria, hypoalbuminemia, and hyperlipidemia. Although venous thromboembolism (VTE) is a well-reported complication associated with NS, the incidence, prevalence, risk factors, treatment options, and preventative strategies are not well-established. Thromboembolic phenomena in nephrotic patients are postulated to be a result of the urinary loss of antithrombotic factors by affected kidneys and increased production of prothrombotic factors by the liver. Most cases of VTE associated with NS reported in the literature have a known diagnosis of NS. We report a case of a young female presenting with dyspnea and a pulmonary embolism. She was found to have NS and right renal vein thrombosis. We review the available literature to highlight the best approach for clinicians treating VTE in patients with NS.
Collapse
Affiliation(s)
- Hasan F Al-Azzawi
- Department of Pulmonary and Critical Care, Southern Illinois University (SIU School of Medicine), Springfield, Illinois, USA
| | - Onyekachi C Obi
- Department of Pulmonary and Critical Care, Southern Illinois University (SIU School of Medicine), Springfield, Illinois, USA
| | - Javeryah Safi
- Department of Pulmonary and Critical Care, Southern Illinois University (SIU School of Medicine), Springfield, Illinois, USA
| | - Mingchen Song
- Department of Pulmonary and Critical Care, Southern Illinois University (SIU School of Medicine), Springfield, Illinois, USA
| |
Collapse
|
28
|
Xu J, Hu X, Xie J, Chen N. Management of Membranous Nephropathy in Asia. KIDNEY DISEASES 2015; 1:119-25. [PMID: 27536672 DOI: 10.1159/000437288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/30/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Membranous nephropathy (MN) is the most common cause of nephrotic syndrome (NS) in adults, accounting for about 20.0% of all NS cases. With an increasing prevalence, especially in the elderly, it has received great attention in Asia. SUMMARY Recently, the prevalence of idiopathic MN (IMN) has significantly increased among the elderly people in Asia and other places in the world. Although the exact mechanism of IMN remains unveiled, the identification of new antigens such as PLA2R and THSD7A has greatly enhanced our understanding of its pathogenesis. However, consensus has not yet been reached for the treatment of IMN in Asia. For example, there are many choices of immunosuppressive agents, including corticosteroid monotherapy, corticosteroids combined with cytotoxic agents [such as alkylating agents, calcineurin inhibitors or mycophenolate mofetil (MMF)] or traditional Chinese medicine (triptolide, Shenqi and other Chinese herbal soups). Patients with IMN in Asia often have a favorable prognosis, and progression to end-stage renal disease is relatively uncommon compared to other populations. KEY MESSAGES The prevalence of MN has significantly increased in the last years. The treatment strategies for IMN have not reached consensus in Asia. Traditional Chinese medicine is generally preferred by the Chinese, and compelling results have been reported recently. FACTS FROM EAST AND WEST (1) The prevalence of IMN is increasing worldwide, particularly in elderly patients, and has been reported in 20.0-36.8% of adult-onset NS cases. The presence of anti-PLA2R antibodies in serum or PLA2R on renal biopsy is the most predictive feature for the diagnosis of IMN and is used in both the East and West; however, appropriate screening to rule out secondary causes should still be performed. (2) Several observational (nonrandomized) Asian studies indicate a good response to corticosteroids alone in IMN patients, although no randomized controlled trials have been done in Asian membranous patients at high risk of progression. Corticosteroid monotherapy has failed in randomized controlled trial studies in Western countries and is therefore not recommended. (3) Cyclophosphamide is the most commonly prescribed alkylating agent in Europe and China. Also, chlorambucil is still used in some Western countries, particularly in Europe. In North America, calcineurin inhibitors are the more common first-line treatment. (4) Cyclosporine is predominantly used as monotherapy in North America, although KDIGO (Kidney Disease: Improving Global Outcomes) and Japanese guidelines still recommend a combination with low-dose corticosteroids. Clinical studies both in Asia and Europe showed no or little effects of monotherapy with MMF compared to standard therapies. (5) There are encouraging data from nonrandomized Western studies for the use of rituximab and a few small studies using adrenocorticotropic hormone. Clinical trials are ongoing in North America to confirm these observations. These drugs are rarely used in Asia. (6) A Chinese study reported that 36% of IMN patients suffered from venous thromboembolism versus 7.3% in a North American study. Prophylactic anticoagulation therapy is usually added to IMN patients with a low risk of bleeding in both Eastern and Western countries. (7) The Chinese traditional medicine herb triptolide, which might have podocyte-protective properties, is used in China to treat IMN. An open-label, multicenter, randomized controlled trial showed that Shenqi, a mixture of 13 herbs, was superior to corticosteroids plus cyclophosphamide therapy to restore epidermal growth factor receptor in IMN patients, although proteinuria improvement was equal in the two groups. Importantly, Shenqi treatment induced no severe adverse events while standard therapy did.
Collapse
Affiliation(s)
- Jing Xu
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaofan Hu
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyuan Xie
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
29
|
Li SJ, Tu YM, Zhou CS, Zhang LH, Liu ZH. Risk factors of venous thromboembolism in focal segmental glomerulosclerosis with nephrotic syndrome. Clin Exp Nephrol 2015. [PMID: 26220221 DOI: 10.1007/s10157-015-1149-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is an important and potentially life-threatening complication in focal segmental glomerulosclerosis (FSGS). The aim of this study was to investigate the prevalence and predisposing risk factors of venous thromboembolism in patients with FSGS with nephrotic syndrome. METHODS A total of 120 FSGS patients with nephrotic syndrome were enrolled in this study. Venous thromboembolism was confirmed by contrast-enhanced dual-source computed tomography angiography or magnetic resonance venography. Potential clinical and laboratory risk factors for VTE were screened. RESULTS Venous thrombosis was demonstrated in 12 (10 %) patients. Venous thrombosis occurred during the first episode of nephrotic syndrome in 3 patients and during a relapse in 9 patients. Eight patients had a pulmonary embolism, four had a renal vein thrombosis, three had a lower limb deep vein thrombosis, one had a cerebral sinovenous thrombosis, and one had a portal vein thrombosis. The positive predictive value for the D-dimer level was 22.4 % in the patients with FSGS, and the negative predictive value for the D-dimer level was 100 %. Of the screened risk factors, higher hematocrit and relapse of nephrotic syndrome were risk factors for VTE. Other risk factors, such as proteinuria, hypoalbuminemia, platelet count, fibrinogen level, and antithrombin III level, were not risk factors for VTE in patients with FSGS. CONCLUSION We found that the prevalence of venous thromboembolism is approximately 10 % in FSGS patients with nephrotic syndrome. Most of the patients had a PE. Hemoconcentration and relapse of nephrotic syndrome were risk factors for the development of VTE in FSGS. Negative D-dimer may exclude venous thromboembolism in patients with nephrotic syndrome.
Collapse
Affiliation(s)
- Shi-jun Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China.
| | - Yuan-Mao Tu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China
| | - Chang-sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China
| | - Li-Hua Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China
| | - Zhi-hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China
| |
Collapse
|
30
|
Wang Y, Chen S, Wang W, Liu J, Jin B. Renal vein thrombosis mimicking urinary calculus: a dilemma of diagnosis. BMC Urol 2015; 15:61. [PMID: 26133978 PMCID: PMC4488058 DOI: 10.1186/s12894-015-0054-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/12/2015] [Indexed: 11/29/2022] Open
Abstract
Background Renal vein thrombosis (RVT) with flank pain, and hematuria, is often mistaken with renal colic originating from ureteric or renal calculus. Especially in young and otherwise healthy patients, clinicians are easily misled by clinical presentation and calcified RVT. Case presentation A 38-year-old woman presented with flank pain and hematuria suggestive of renal calculus on ultrasound. She underwent extracorporeal shock wave lithotripsy that failed, leading to the recommendation that percutaneous lithotomy was necessary to remove the renal calculus. In preoperative view of the unusual shape of the calculus without hydronephrosis, noncontrast computed tomography was taken and demonstrated left ureteric calculus. However computed tomography angiography revealed, to our surprise, a calcified RVT that was initially thought to be a urinary calculus. Conclusion This case shows that a calcified RVT might mimic a urinary calculus on conventional ultrasonography and ureteric calculus on noncontrast computed tomography. Subsequent computed tomography angiography disclosed that a calcified RVT caused the imaging findings, thus creating a potentially dangerous clinical pitfall. Hence, it is suggested that the possibility of a RVT needs to be considered in the differential diagnosis whenever one detects an uncommon shape for a urinary calculus.
Collapse
Affiliation(s)
- Yimin Wang
- Department of Urology, the First Affiliated Hospital of Medical College, Zhejiang University, No. 79 Qing Chun Road, 310003, Hangzhou, China.
| | - Shanwen Chen
- Department of Urology, the First Affiliated Hospital of Medical College, Zhejiang University, No. 79 Qing Chun Road, 310003, Hangzhou, China.
| | - Wei Wang
- Department of Urology, the First Affiliated Hospital of Medical College, Zhejiang University, No. 79 Qing Chun Road, 310003, Hangzhou, China.
| | - Jianyong Liu
- Sidney kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 21128, Baltimore, USA.
| | - Baiye Jin
- Department of Urology, the First Affiliated Hospital of Medical College, Zhejiang University, No. 79 Qing Chun Road, 310003, Hangzhou, China.
| |
Collapse
|
31
|
Ismail G, Mircescu G, Ditoiu AV, Tacu BD, Jurubita R, Harza M. Risk factors for predicting venous thromboembolism in patients with nephrotic syndrome: focus on haemostasis-related parameters. Int Urol Nephrol 2015; 46:787-92. [PMID: 24078010 DOI: 10.1007/s11255-013-0574-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/21/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The venous thromboembolic events (VTE) incidence is high in nephrotic syndrome (NS). We aimed to assess prospectively the risk of VTE in a large cohort of NS patients and to identify predictive factors for VTE, especially haemostasis-related parameters. METHODS This is the prospective, observational study conducted in 256 adults with idiopathic NS. VTE were the study outcome. Clinical data, proteinuria, albuminuria, haemostasis and fibrinolysis parameters, and D-dimers were evaluated every 6 months. RESULTS Median follow-up time was 24 [IQR 12–72] months. VTE cumulative and rate incidence were 11 % and 4.4 per 100 patient-years. Baseline higher proteinuria,lower serum albumin, low antithrombin III activity, and,surprisingly, high ionized calcium were VTE independent predictors. Proteinuria and serum albumin cut-offs, and positive and negative predictive values (PPV and NPV) for VTE were 9.0 g/24 h (30 % PPV and 90 % NPV) and 1.5 g/dL (69 % PPV and 93 % NPV). CONCLUSIONS The rate of VTE incidence of 4.4 per 100 patient-years found in this prospective study confirms the idiopathic nephrotic syndrome as a thromboembolism-generating condition. Severe and unremitting proteinuria and hypoalbuminemia,low antithrombin III activity, and, surprisingly, high ionized calcium are independent VTE predictors.
Collapse
|
32
|
Onishi A, Inoue M, Imai T, Takeda SI, Kondo M, Shimada K, Nagata D. Nephrotic syndrome complicated with deep venous thrombosis in the upper extremities. Case Rep Nephrol Dial 2014; 5:1-5. [PMID: 25849667 PMCID: PMC4294448 DOI: 10.1159/000365567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Deep venous thrombosis (DVT) in the upper extremities is a rare but important clinical illness, which leads to severe complications such as pulmonary embolism. Unlike DVT in the lower extremities, which is mainly induced by a hypercoagulable state, DVT in the upper extremities is usually caused by mechanical obstruction or anatomical stenosis in the venous system. We herein report a case in which DVT developed in the left upper limb during treatment of nephrotic syndrome. This is the first case report of upper-extremity DVT in association with nephrotic syndrome in the literature. Our patient was a 56-year-old male with nephrotic syndrome due to idiopathic membranous nephropathy who was treated with 40 mg/day of prednisolone. During corticosteroid therapy, he developed a swelling of the left upper limb. Computed tomography revealed thrombi in the left internal jugular vein and the left subclavian vein without anatomical abnormalities in his venous system. Thus, he was diagnosed with DVT of the upper extremities. After the initiation of warfarin treatment and subsequent regression of nephrotic syndrome, the swelling disappeared and the thrombi significantly diminished. DVT should be considered when upper-extremity edema is observed in patients with nephrotic syndrome.
Collapse
Affiliation(s)
- Akira Onishi
- Division of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke City, Japan
| | - Makoto Inoue
- Division of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke City, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke City, Japan
| | - Shin-Ichi Takeda
- Division of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke City, Japan
| | | | | | - Daisuke Nagata
- Division of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke City, Japan
| |
Collapse
|
33
|
Medjeral-Thomas N, Ziaj S, Condon M, Galliford J, Levy J, Cairns T, Griffith M. Retrospective analysis of a novel regimen for the prevention of venous thromboembolism in nephrotic syndrome. Clin J Am Soc Nephrol 2013; 9:478-83. [PMID: 24334865 DOI: 10.2215/cjn.07190713] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Venous thromboembolism (VTE) occurs in 7%-40% of nephrotic patients. The risk of VTE depends on the severity and underlying cause of nephrotic syndrome. This study investigated the use of low-dose prophylactic anticoagulation to prevent VTE in patients with nephrotic syndrome caused by primary glomerulonephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Since 2006, all patients presenting with nephrotic syndrome to Imperial College Kidney and Transplant Centre have been considered for treatment with a novel anticoagulation prophylaxis regimen. All cases of nephrotic syndrome secondary to primary membranous nephropathy, minimal-change disease, and FSGS over a 5-year period were retrospectively reviewed. Patients with serum albumin<2.0 g/dl received prophylactic-dose low-molecular-weight heparin or low-dose warfarin; patients with albumin levels of 2.0-3.0 g/dl received aspirin, 75 mg once daily. All thrombotic events and bleeding complications were recorded. RESULTS A total of 143 patients received the prophylactic anticoagulation regimen. Median follow-up was 154 weeks (range, 30-298 weeks). The cohort had features associated with a high risk of developing VTE; 40% of the cohort had an underlying diagnosis of membranous nephropathy, and the initial median serum albumin was 1.5 g/dl (range, 0.5-2.9 g/dl). No VTE occurred in patients established on prophylaxis for at least 1 week. VTE was diagnosed in 2 of 143 patients (1.39%) within the first week after presentation and starting prophylaxis. In both cases, it is unclear whether the thrombus had developed before or after the start of prophylaxis. One of 143 (0.69%) patients receiving prophylaxis was admitted urgently with gastrointestinal hemorrhage. Two of 143 patients (1.40%) had elective blood transfusions and procedures to manage occult gastrointestinal bleeding. No other bleeding events occurred in patients receiving prophylaxis. CONCLUSIONS This regimen of prophylactic antiplatelet or anticoagulant therapy appears effective in preventing VTE in nephrotic syndrome, with relatively few hemorrhagic complications.
Collapse
|
34
|
Zhang LJ, Wu X, Yang GF, Tang CX, Luo S, Zhou CS, Ji XM, Lu GM. Three-dimensional contrast-enhanced magnetic resonance venography for detection of renal vein thrombosis: comparison with multidetector CT venography. Acta Radiol 2013; 54:1125-31. [PMID: 23794130 DOI: 10.1177/0284185113490152] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Renal vein thrombosis is not uncommon, however, there have been few reports on the diagnostic accuracy of three-dimensional contrast-enhanced magnetic resonance venography (3D-CE-MRV) in the detection of renal vein thrombosis (RVT). PURPOSE To evaluate the value of 3D-CE-MRV for detecting RVT with multidetector computed tomography (CT) venography as reference standard. MATERIAL AND METHODS Thirty-two patients with nephrotic syndrome underwent renal CT venography and gradient echo pulse sequence (FLASH 3D) 3D-CE-MRV in a clinical 3-T whole-body MR scanner for suspected RVT with time interval of 0-5 days. RVT was recorded on a per-patient and per-vessel (left renal vein, right renal vein, and inferior vena cava) basis. The diagnostic accuracy of 3D-CE-MRV for detection of RVT was calculated with CT venography as reference standard. Inter-reader agreement for RVT detection was evaluated using Kappa statistics. RESULTS Of 32 patients, CT venography detected 22 vessels with thrombosis in 17 patients, including five in right renal veins, 14 in left renal veins, and three in inferior vena cava, while 15 patients had no RVT. 3D-CE-MRV detected 21 vessels (21/96, 21.9%) with thrombosis in 16 patients (6/32, 50%), including five in right renal veins, 13 in left renal veins, and three in inferior vena cava, while 16 patients (16/32, 50%) had no RVT. With CT venography as reference standard, the sensitivities and specificities of 3D-CE-MRV for RVT detection were 94.1%, 100%; 95.5%, 100% on a per-patient and a per-vessel basis, respectively. Excellent inter-reader agreement (Kappa value = 0.969, P < 0.001) was observed for RVT detection. CONCLUSION 3D-CE-MRV has a high diagnostic accuracy in the detection of RVT, which is optimal alternative imaging modality in the detection of RVT.
Collapse
Affiliation(s)
- Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Xinsheng Wu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Gui Fen Yang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Song Luo
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Xue Man Ji
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, PR China
| |
Collapse
|
35
|
Chen G, Liu Y, Xie Y, Li J, Liu H, Sun L, Peng Y, Liu F. High dose urokinase against massive pulmonary embolism in nephrotic syndrome. Blood Coagul Fibrinolysis 2013; 24:439-43. [PMID: 23386277 DOI: 10.1097/mbc.0b013e32835d9b7a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with nephrotic syndrome carry a high risk of pulmonary embolism due to the abnormalities in coagulation and fibrinolysis. Thrombolytic therapy for critical pulmonary embolism in nephrotic syndrome patients was rarely reported and remains controversial in the regimen selection so far. We reported a case of fatal pulmonary embolism, complicating in hepatitis B virus-associated nephrotic syndrome. The patient presented with chest pain, hemoptysis and shortness of breath on admission and his initial vital signs showed a high risk of developing hypotension. Urgent radiological examinations confirmed massive embolisms in bilateral pulmonary arteries. Prompt thrombolytic therapy was performed right after the diagnosis of pulmonary embolism with an intravenous infusion of urokinase (20 000 U/kg) in 2 h. Complete resolution of pulmonary embolism was achieved after urokinase administration and the patient was discharged in good conditions. This report highlighted the efficacy and safety of prompt thrombolytic therapy with urokinase for nephrotic syndrome patients presented with massive pulmonary embolism. In this study, we also briefly discuss the recent findings on the current state of urokinase in the clinical practice of thrombolysis.
Collapse
Affiliation(s)
- Guochun Chen
- Renal Division, the Second Xiangya Hospital of Central South University, Changsha, Hunan, P.R. China.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Zhang LJ, Luo S, Yeh BM, Zhou CS, Tang CX, Zhao Y, Li L, Zheng L, Huang W, Lu GM. Diagnostic accuracy of three-dimensional contrast-enhanced MR angiography at 3-T for acute pulmonary embolism detection: Comparison with multidetector CT angiography. Int J Cardiol 2013; 168:4775-83. [DOI: 10.1016/j.ijcard.2013.07.228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/20/2013] [Accepted: 07/25/2013] [Indexed: 02/03/2023]
|
37
|
Chen G, Liu H, Liu F. A glimpse of the glomerular milieu: from endothelial cell to thrombotic disease in nephrotic syndrome. Microvasc Res 2013; 89:1-6. [PMID: 23851046 DOI: 10.1016/j.mvr.2013.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/23/2013] [Accepted: 06/28/2013] [Indexed: 10/26/2022]
Abstract
Patients with nephrotic syndrome (NS) carry a high risk of venous thromboembolism (VTE) due to the abnormalities in coagulation and fibrinolysis. Although massive urine protein loss is considered to trigger the cascade of hypercoagulation, the exact nature of VTE in NS patients still remains obscure, especially in some cases when VTE occurs far before the presence of nephrotic proteinuria. Recent findings illustrate that loss of local glomerular homeostasis, like disturbance of cytokine profiles in endothelial cells or aberrant cellular crosstalks in glomerulus, is sufficient to initiate the development of thrombotic disease in glomerulonephropathy. Emerging data have highlighted the glomerular endothelial cell as a key regulator of local homeostasis, which might mediate the haemostatic derangement in the beginning of glomerular disease by expression of numerous prothrombotic factors and result in the subsequent predilection of VTE in NS. As the glomerulus-derived circulating factors are all collected and flushed into the renal vein directly, it is reasonable to suggest that increased release of glomerulus-derived thrombotic regulators, particularly from endothelial cells, may play a significant role in the highest proclivity for the renal vein as the site of thrombosis in NS. In this review, we thus discuss the current understandings of thromboembolism in NS with focus on how the glomerular endothelial cell involves in the pathogenesis of VTE, which may help to increase our understandings in the anti-thrombotic therapy for patients with NS.
Collapse
Affiliation(s)
- Guochun Chen
- Renal Division, The Second Xiangya Hospital, Central South University, Changsha, Hunan, PR China.
| | | | | |
Collapse
|
38
|
Pincus KJ, Hynicka LM. Prophylaxis of Thromboembolic Events in Patients with Nephrotic Syndrome. Ann Pharmacother 2013; 47:725-34. [DOI: 10.1345/aph.1r530] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review published literature regarding use of strategies to prevent thrombotic events in patients with nephrotic syndrome (NS). DATA SOURCES The MEDLINE/PubMed, EMBASE, and Cochrane databases were queried from 1980 to December 2012 for articles in English using the search terms nephrotic syndrome, thrombosis, thromboembolism, anticoagulation, warfarin, heparin, low-molecular-weight heparin, enoxaparin, dalteparin, tinzaparin, statin, atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin, aspirin, direct thrombin inhibitor, rivaroxaban, argatroban, lepirudin, bivalirudin, dabigatran, factor Xa inhibitor, fondaparinux, rivaroxaban, clopidogrel, ticlopidine, and prasugrel. STUDY SELECTION AND DATA EXTRACTION All relevant original studies, meta-analyses, systematic reviews, guidelines, and review articles were assessed for inclusion. References from pertinent articles were examined for additional content not found during the initial search. DATA SYNTHESIS NS leads to multiple complications, including hypercoagulability. A small prospective cohort study used enoxaparin for primary prophylaxis and demonstrated successful prevention of thrombotic events with minimal adverse events. Additional information has come in the form of decision analyses, which show potential decreased morbidity and mortality when primary prophylaxis for thrombotic events is used; however, all data have numerous limitations. Other strategies for thrombus prevention, including statins and antiplatelet agents, also have been investigated. CONCLUSIONS When patients with NS are admitted to the hospital, develop an acute medical illness, or acquire an additional thrombotic events risk factor such as surgery, active malignancy, or pregnancy, consideration for primary pharmacologic prophylaxis with appropriately dosed low-molecular-weight heparin or other indicated anticoagulant should include the potential for increased thrombotic events risk in this patient population. Consideration may also be given to the use of primary pharmacologic prophylaxis with low-molecular-weight heparin or oral vitamin K antagonist in patients with membranous nephropathy once the albumin level drops below 2.0–2.5 g/dL. Short-term use of pharmacologic prophylaxis during the first 6 months following diagnosis warrants further investigation.
Collapse
Affiliation(s)
- Kathleen J Pincus
- Kathleen J Pincus PharmD BCPS, Assistant Professor of Pharmacotherapy, School of Pharmacy, University of Maryland, Baltimore
| | - Lauren M Hynicka
- Lauren M Hynicka PharmD BCPS, Assistant Professor of Pharmacotherapy, School of Pharmacy, University of Maryland
| |
Collapse
|
39
|
Sexton DJ, Clarkson MR, Mazur MJ, Plant WD, Eustace JA. Serum D-dimer concentrations in nephrotic syndrome track with albuminuria, not estimated glomerular filtration rate. Am J Nephrol 2012; 36:554-60. [PMID: 23221061 DOI: 10.1159/000345475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 10/26/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The nephrotic syndrome is associated with an increased risk of venous and arterial thrombosis. There are little published data on the distribution, interpretation or determinants of serum D-dimer levels in patients with the nephrotic syndrome. We aimed to describe this relationship. METHODS This was a cross-sectional study of 100 patients with the nephrotic syndrome. Multivariate linear regression was used to evaluate for independent predictors of elevated D-dimer levels. Patients were observed for a period of 2 years after the baseline measurement of D-dimer level to assess for subsequent clinically evident thrombosis. RESULTS On univariate linear regression, D-dimer elevation was associated with age in years β (95% CI) 0.02 (0.016, 0.03), log-transformed urinary protein:creatinine ratio in g/g 0.439 (0.32, 0.558) and inversely with serum albumin in g/l -0.05 (-0.073, -0.035) and estimated glomerular filtration rate (eGFR) in ml/min/1.73 m(2) -0.01 (-0.016, -0.003). On multivariate linear regression, age in years β (95% CI) 0.019 (0.012, 0.026), serum albumin in g/l -0.023 (-0.043, -0.003), and log-transformed urinary protein:creatinine ratio in g/g 0.266 (0.124, 0.408) were independently associated with elevated D-dimer levels. CONCLUSION D-dimer levels are commonly raised in the nephrotic syndrome in the absence of clinically evident thrombosis, and are independently associated with age, degree of proteinuria and serum albumin, but not with eGFR. Baseline levels of D-dimer did not predict subsequent episodes of clinically evident thrombosis after 2 years of follow-up.
Collapse
Affiliation(s)
- D J Sexton
- Cardiac Renal Centre, Department of Renal Medicine, Cork University Hospital, Cork, Ireland.
| | | | | | | | | |
Collapse
|