Venous Thromboembolism in Patients with Membranous Nephropathy

Abstract

SummaryBackground and objectives The aims of this study were to determine the frequency of venous thromboembolic events in a large cohort of patients with idiopathic membranous nephropathy and to identify predisposing risk factors.Design, setting, participants, & measurements We studied patients with biopsy-proven membranous nephropathy from the Glomerular Disease Collaborative Network (n=412) and the Toronto Glomerulonephritis Registry (n=486) inception cohorts. The cohorts were pooled after establishing similar baseline characteristics (total n=898). Clinically apparent and radiologically confirmed venous thromboembolic events were identified. Potential risk factors were evaluated using multivariable logistic regression models.Results Sixty-five (7.2%) subjects had at least one venous thromboembolic event, and this rate did not differ significantly between registries. Most venous thromboembolic events occurred within 2 years of first clinical assessment (median time to VTE = 3.8 months). After adjusting for age, sex, proteinuria, and immunosuppressive therapy, hypoalbuminemia at diagnosis was the only independent predictor of a venous thromboembolic event. Each 1.0 g/dl reduction in serum albumin was associated with a 2.13-fold increased risk of VTE. An albumin level ,2.8 g/dl was the threshold below which risk for a venous thromboembolic event was greatest.Conclusions We conclude that clinically apparent venous thromboembolic events occur in about 7% of patients with membranous nephropathy. Hypoalbuminemia, particularly ,2.8 g/dl, is the most significant independent predictor of venous thrombotic risk.

Risk factors for venous thromboembolism in immunoglobulin light chain amyloidosis

“…The frequency of VTE observed in this study is consistent with what has previously been described in the nephrotic syndrome associated with membranous nephropathy 11,12 and with what has been reported in AL and multiple myeloma. 5,24,25 Interestingly, no renal vein thromboses were documented in this group; this may reflect the often clinically silent nature of these events, which have been observed in as many as 40-50% of patients with nephrotic syndrome, 15 but were not screened for in our population.…”

“…[26][27][28][29] The association between low serum albumin and risk of VTE has been previously described in nephrotic syndrome. 11,12,14,30 Serum albumin is inversely correlated with the degree of urinary protein loss, and may be a surrogate marker for loss of endogenous antithrombotic proteins such as antithrombin III and plasminogen. Serum albumin levels may have direct effects on hemostasis and platelet aggregation 26 and in addition levels may be decreased in critical illness and thus correlate with more advanced disease.…”

“…The nephrotic syndrome, a common presentation of AL, is associated with hypercoagulability and may contribute to the risk of venous thromboembolism (VTE) in this population. [10][11][12][13][14][15] Other potential contributors to thromboembolic risk include monoclonal gammopathy and plasma cell dyscrasia 16 as well as AL treatments, specifically immunomodulatory agents (IMiDs) [17][18][19][20][21][22][23] and those requiring central venous catheters. A means of risk stratification of VTE in this population is needed to guide prophylaxis and treatment strategies.…”

American Society of Nephrology Quiz and Questionnaire 2012

“…Acute renal vein thrombosis is usually characterized by a recent episode of acute flank pain, macroscopic hematuria, flank tenderness at percussion, worsening proteinuria, and deterioration of renal function (45). Hypoalbuminemia, particularly a serum albumin concentration ,2.8 g/dl, is the most significant independent predictor of venous thrombotic risk in patients with MN (46). In view of the above, it is unlikely that our patient had developed acute renal vein thrombosis, although asymptomatic chronic renal vein thrombosis cannot be ruled out.…”

American Society of Nephrology Quiz and Questionnaire 2014

“…Of all of the nephrotic syndrome etiologies, for reasons heretofore unexplained, MN is associated with the greatest risk for clot, with some series citing up to a 35% lifetime risk for clot for patients with MN (16,17). In the largest cohort of patients with MN studied to date combining United States (n=412) and Canadian (n=486) patients, Lionaki et al (17) showed that the risk of thrombotic events in MN increased significantly when serum albumin levels fall below 2.8 g/dl. Therefore, this patient with MN and a serum albumin of 2.6 g/dl would be considered high risk for a clotting complication, but there is no consensus agreement on whether such patients should be offered prophylactic anticoagulation (choice C).…”