Therapeutic Dilemmas regarding Anticoagulation: An Experience in a Patient with Nephrotic Syndrome, Pulmonary Embolism, and Traumatic Brain Injury

Abstract

Patients with active bleeding complications who concomitantly develop overt pulmonary embolism (PE) present distinct therapeutic dilemmas, since they are perceived to be at substantial risk for the progression of the embolism in the absence of treatment and for aggravation of the hemorrhagic lesions if treated with anticoagulants. A 76-year-old patient with nephrotic syndrome, which is associated with an increased risk of thromboembolism, concurrently developed acute PE and intracranial bleeding because of traumatic brain injury. In this case, we prioritized the treatment for PE with the intravenous unfractionated heparin followed by warfarinization. Despite the transient hemorrhagic progression of the brain contusion after the institution of anticoagulation, our patient recovered favorably from the disease without any signs of neurological compromise. Several conundrums regarding anticoagulation that emerged in this case are also discussed.

Management of anticoagulation and antiplatelet therapy in patients with primary membranous nephropathy

“…Of note, D-dimer levels may be affected by proteinuria and may not be an independent predictor of stopping anticoagulant therapy in patients with primary MN with VTEs. Moreover, the reduction of proteinuria and the increase of serum albumin are also important goals for the treatment of primary MN with VTEs [37–39]. It is necessary to continue the previous steroid therapy or to combine it with immunosuppressive agents over the entire treatment period until the primary MN treatment protocol is completed.…”

Systemic Intravenous Thrombolysis for Massive Pulmonary Embolism after Intracranial Surgery for Traumatic Head Injury: When Absolute Becomes Relative!

“…Heparinization followed by warfarinization for PE has been done successfully previously in case of a traumatic brain injury with nephrotic syndrome by Akimoto et al 6 They noticed slight increase in the hemorrhagic contusions with this therapy. Bottinor et al used tPA in case of a massive PE to save life of a 60-year-old who had suffered from hemorrhagic stroke 8 weeks prior.…”

Retroperitoneal Bleeding: An Experience During Prophylactic Anticoagulation in a Patient With Nephrotic Syndrome

“…Finally, the low rate of reported adverse events with anticoagulation as well as our patient’s markedly decreased serum Alb levels encouraged us to pursue heparinization prior to the renal biopsy as practiced empirically. 5 , 26 Because of the significant bleeding risk with the renal biopsy, 27 no one would argue against a periprocedural interruption of anticoagulation. 5 , 26 Although the clinical scenario of the present patient prevents an evaluation of the significance of the prophylaxis, our experience may highlight the pitfalls of such management, implying the need for a way to identify those patients with NS who can best benefit from the prophylactic anticoagulation.…”

“… 5 , 26 Because of the significant bleeding risk with the renal biopsy, 27 no one would argue against a periprocedural interruption of anticoagulation. 5 , 26 Although the clinical scenario of the present patient prevents an evaluation of the significance of the prophylaxis, our experience may highlight the pitfalls of such management, implying the need for a way to identify those patients with NS who can best benefit from the prophylactic anticoagulation. We believe that accumulating experiences from cases similar to ours will aid in establishing the indications and optimum regimen, including the appropriate timing, duration, preferred agent, and dosage, for prophylactic anticoagulation among patients with nephrosis, which remains an unresolved issue in the field of nephrology.…”

“… 1 The pathogenic basis for an association between NS and accelerated clotting activity is poorly understood; however, it is likely to depend on a net shift in the hemostatic balance toward a hypercoagulable state resulting from abnormal processing of prothrombotic and antithrombotic proteins. 2 , 3 Obviously, controlling the blood coagulation system with anticoagulant agents would be a useful therapeutic option for patients with nephrosis with overt thromboembolism, 1 , 4 , 5 and pharmacologic prophylaxis may be an attractive therapeutic option as well for asymptomatic patients who have NS, although the optimum anticoagulant strategy among overall subjects with the disease remains to be clarified. 1 , 4 , 5 We herein report our experience with a case of NS in a female patient who developed retroperitoneal bleeding during prophylactic anticoagulation with unfractionated heparin.…”