warfarin and Glomerulonephritis--Membranous

40 patients with idiopathic membranous glomerulonephritis were randomized to receive either no treatment or a regime of cyclophosphamide for 6 months, and warfarin and dipyridamole for two years. During the two years of the trial there was no significant deterioration in renal function in either group. A significantly greater improvement in urinary protein excretion was, however, observed at all time points in the treatment group. Plasma albumin was also significantly higher in the treatment group at 18 and 24 months. As progressive deterioration in renal function in membranous glomerulonephritis is associated with persistent heavy proteinuria these results suggest a beneficial effect of treatment.

Topics: Cyclophosphamide; Dipyridamole; Drug Administration Schedule; Drug Therapy, Combination; Female; Glomerulonephritis, Membranous; Humans; Kidney Function Tests; Male; Middle Aged; Nephrotic Syndrome; Time Factors; Warfarin

Patients with membranous nephropathy (MN) are recognized as individuals with high risk of thrombosis. However, prophylactic anticoagulant therapy in this population is still a controversial topic for a lack of high-quality evidence. Subject of Review: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Glomerular Diseases was published in Kidney International in October 2021, and it was updated on the topic of prophylactic anticoagulant therapy in patients with MN. Differing from the previous main concern about the risk of venous thromboembolism (VTE) in MN, it paid attention to the risk of arterial thromboembolism (ATE) as well. Additionally, the risk of ATE was considered to be associated with hypoalbuminemia. A tool for evaluating the risk of bleeding in patients with MN was proposed in the KDIGO 2021 guideline, and individuals with low risk of bleeding as well as high risk of VTE were suggested to use warfarin or low-molecular-weight heparin (LMWH) combined with aspirin, as an alternative regimen for warfarin. Second Opinion: Our analysis shows that no consensuses have been reached on whether the prevention of ATE is necessary for patients with MN or whether the risk of ATE is associated with hypoalbuminemia. The proposed tool is not the only choice of tools for bleeding assessment, and the HAS-BLED risk score might be a better choice from the perspective of general applicability and availability. Furthermore, in our opinion, the suggestion for prophylaxis regimen of LMWH combined with aspirin showed a lack of consideration and might be inappropriate to some degree. In summary, there are still many controversies in the field of prophylactic anticoagulation for MN; as a consequence, more high-quality studies are required to provide guidance.

Topics: Anticoagulants; Aspirin; Glomerulonephritis, Membranous; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Hypoalbuminemia; Kidney; Venous Thromboembolism; Warfarin

To evaluate the technical success and clinical outcome of the percutaneous treatment of acute renal vein thrombosis (RVT).. Retrospective review was conducted of all patients with acute RVT treated with percutaneous catheter-directed thrombectomy with or without thrombolysis at one institution between 2000 and 2004. Demographics, comorbid conditions, and clinical outcomes associated with therapy were assessed.. Seven thrombosed renal veins in six patients (mean age, 51.5 +/- 18.8 years) were treated with percutaneous catheter-directed thrombectomy/thrombolysis. Thrombosed renal veins included two allografts and five native veins, and diagnosis was confirmed in all cases by direct renal venography. Inferior vena cava thrombosis was the cause of RVT in one patient, and glomerulopathy was the cause in the remaining patients. Percutaneous mechanical thrombectomy was performed in all cases, and five renal veins were additionally treated with thrombolysis for a mean duration of 22.1 +/- 21.0 hours. Restoration of flow to renal veins was achieved in all thrombosed renal veins. Clinical improvement occurred in all patients: the mean serum creatinine level improved from a preoperative level of 3.3 +/- 1.92 mg/dL to a postoperative level of 1.92 +/- 1.32 mg/dL (P = .008). Mean glomerular filtration rate improved from a preoperative level of 30.8 +/- 23.0 mL/min per 1.73 m(2) to 64.2 +/- 52.4 mL/min per 1.73 m(2) (P = .04). There were no pulmonary emboli or hemorrhagic complications, and no RVT recurrence was documented during a median follow-up of 22.5 months.. Percutaneous catheter-directed thrombectomy with or without thrombolysis for acute RVT is associated with a rapid improvement in renal function and low incidence of morbidity. It is feasible for native and allograft renal veins and should be considered in patients with acute RVT, particularly in the setting of deteriorating renal function.

Topics: Adult; Aged; Anticoagulants; Glomerulonephritis, Membranous; Heparin; Humans; Magnetic Resonance Angiography; Middle Aged; Radiography; Renal Veins; Retrospective Studies; Thrombectomy; Thrombolytic Therapy; Treatment Outcome; Vena Cava, Inferior; Venous Thrombosis; Warfarin

While the most common clinical feature of nephrotic syndrome is generalized edema, patients are at risk of developing other problems, such as bacterial infections, electrolyte abnormalities, and venous thromboses. Adults with membranous nephropathy appear to be at the greatest risk for developing thromboses, especially renal vein thrombosis. However, the same is not true for children with membranous nephropathy. A review of pediatric membranous nephropathy stated that renal vein thrombosis is unrecorded in childhood-onset membranous nephropathy. We present our experience in managing two children with idiopathic membranous nephropathy who developed venous thromboses. To our knowledge, this is the first report of pediatric patients with membranous nephropathy to develop a thromboembolic complication without evidence of predisposing factors or coagulation abnormalities. This report emphasizes the need for appropriate evaluation of patients with membranous nephropathy who develop signs and symptoms suggestive of arterial or venous occlusion in order to avoid missing this potentially life-threatening medical complication.

Topics: Adolescent; Anticoagulants; Blood Coagulation Tests; Child; Female; Glomerulonephritis, Membranous; Heparin, Low-Molecular-Weight; Humans; Kidney Function Tests; Male; Venous Thrombosis; Warfarin

Thromboembolic events occur with a frequency of 3-5% in children with nephrotic syndrome (NS). Although numerous abnormalities in all phases of coagulation have been described in NS, the pathogenesis of clotting abnormalities remains poorly understood in this group of patients. We describe a child with long-standing NS in whom a severe deep venous thrombosis and pulmonary embolism secondary to acquired protein S deficiency and a strong lupus-type circulating anticoagulant developed. In addition, this patient had a markedly decreased plasma level of C4b binding protein. Although acquired protein S deficiency has been described in various clinical disorders including NS, our patient is unusual in having C4bBP deficiency, and his is the only reported pediatric case of NS complicated by thromboembolism in which a circulating anticoagulant has been implicated, to our knowledge.

Topics: Autoimmune Diseases; Carrier Proteins; Child; Complement Inactivator Proteins; Drug Eruptions; Drug Therapy, Combination; Glomerulonephritis, Membranous; Glycoproteins; Heparin; Humans; Lupus Coagulation Inhibitor; Male; Methylprednisolone; Necrosis; Nephrotic Syndrome; Phospholipids; Prednisone; Protein S; Pulmonary Embolism; Thrombolytic Therapy; Thrombophlebitis; Urokinase-Type Plasminogen Activator; Warfarin

Between 1973 and 1986, 109 patients with membranous nephropathy have been evaluated with respect to clinical presentation, pathological features and factors determining prognosis. Secondary disease was present in 21, and a further 21 were lost or followed for less than 12 months. The remaining 67 with idiopathic membranous nephropathy were allotted to one of three groups. Group 0 (26 patients) received no active treatment, Group 1 (12 patients) a combination of cyclophosphamide, dipyridamole and warfarin, and Group 2 (21 patients) high dose alternate day prednisolone therapy. Eight patients received other treatment or presented with end stage renal disease. No significant difference in outcome could be detected between the groups. Remission rates were equivalent as were numbers of patients judged as having progressive disease. There was no statistical difference with respect to duration of nephrotic syndrome, plasma creatinine at the end of study and change in plasma creatinine. No demonstrable benefit was obtained in predicting the outcome of disease or response to treatment from conventional pathological grading of stages I to IV as approximately equal numbers of each stage fell into good and bad categories of outcome. Similarly unusual histological features such as mesangial proliferation and immunofluorescence for deposits other than IgG and C3 were not helpful. A different approach to treatment of idiopathic membranous nephropathy is strongly recommended.

Topics: Adolescent; Adult; Aged; Biopsy; Cyclophosphamide; Dipyridamole; Drug Therapy, Combination; Female; Follow-Up Studies; Glomerulonephritis, Membranous; Humans; Kidney; Male; Middle Aged; Prednisolone; Warfarin