Carotid Thromboembolism Associated with Nephrotic Syndrome Treated with Dabigatran

Abstract

Nephrotic syndrome (NS) may be complicated by thromboembolism, which occasionally manifests as stroke. Although the optimal, standardized approach to the prophylaxis and management of thromboembolic complications associated with NS has not been established, anticoagulation with heparin and subsequent warfarin is the de facto standard of treatment. Dabigatran, a novel direct thrombin inhibitor, has become a substitute for warfarin and heparin for many indications, including the prophylaxis of stroke associated with nonvalvular atrial fibrillation and postoperative thromboprophylaxis in orthopedic patients. We report a 35-year-old male with NS due to membranous nephropathy (MN) that presented with carotid thromboembolism. Because the patient developed drug-induced hepatitis due to warfarin, we attempted treatment with dabigatran and were successful in continuing the medication without any complications. We also reviewed the literature on stroke associated with NS. Twenty-one prior cases have been reported, and the review of these cases revealed some interesting points. The age of onset ranged from 19 to 59 years. Most of the reported cases sustained a stroke at earlier ages than patients with atherosclerosis and atrial fibrillation, which suggests that NS may independently predispose individuals to arterial and venous thromboses. MN was the most common underlying pathology. Given that a standardized approach to the prophylaxis and management of thrombotic complications associated with NS has not been established, our experience suggests that dabigatran is a valid new treatment option for thrombotic complications of NS.

Acute ischemic stroke associated with nephrotic syndrome: Incidence and significance — Retrospective cohort study

“…Histopathology of NS in the 22 AIS patients previously reported from several countries was membranous nephropathy in 5 cases (22.7%), minimal change in 4 cases (18.2%), MPGN in 3 cases (13.6%), focal segmental sclerosis in 2 cases (9.0%), Ig A nephropathy, undetermined pathology in 6 cases (27.2%), and DN in only 1 case (4.5%) [4] . In our study, DN was clinically apparent for the pathogenesis of NS in 80% of the patients, but could not be confirmed by the renal biopsy.…”

“…On the other hand, the relative risk of arterial thrombosis was low (1.0 to 5.5%), compared to that of venous thrombosis [3] , [21] , [22] . In 2014, Sasaki et al reported an additional case of ischemic stroke with NS, and reviewed 21 prior cases reported in 19 literatures [4] . However, the incidence and the clinical characteristics of AIS patients have still remained unclear [5] , [6] , [7] , [8] , [9] , [10] .…”

“…Hypoalbuminemia and secondary volume depletion, and hyperlipidemia also could play as risk factors for thromboembolism or atherosclerosis. NS may independently predispose individuals to arterial and venous thromboembolism, but the detailed mechanism of the hypercoagulability is not completely understood [1] , [2] , [3] , [4] , [23] , [24] , [25] , [26] , [27] , [28] , [29] . Study subjects had high serum fibrinogen and D-dimer levels, suggesting that AIS patients with NS have a greater degree of hypercoagulability than AIS patients without NS.…”

“…Arterial thromboses are less frequent than venous thromboses and the most common locations are femoral arteries, although other arteries may be involved [1] , [2] , [3] . Stroke associated with NS has rarely been reported in several case reports [4] , [5] , [6] , [7] , [8] , [9] , [10] . We report 10 cases of acute ischemic stroke (AIS) associated with NS and the results of a retrospective cohort study comparing AIS patients with and without NS.…”

Ischemic Stroke of Possible Embolic Etiology Associated With Nephrotic Syndrome

“…The clinical information regarding these cases is summarized in Table 3 . 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 …”