Clinical Case 62: Answers and Summary

A 56 YEAR OLD FEMALE PRESENTS WITH NEPHROTIC SYNDROME AND RENAL VEIN THROMBOSIS. BIOPSY CONFIRMS MEMBRANOUS GN. HOW LONG WOULD YOU CONTINUE ANTI-COAGULATION?

6 months minimum    25%

Lifelong   13%

Till the albumin>2g/dl     21%

Till the remission of syndrome   35%

Not sure    3%

There is very low–quality evidence to suggest the use of 

prophylactic anticoagulation with warfarin in patients with 

idiopathic membranous GN and severe nephrotic syndrome. KDIGO recent glomerular disease recommendations suggests that it might be considered when the serum albumin concentration is <2.0–2.5 g/dl  with one or more of the following: proteinuria over 10g/day; BMI  over 35; prior history of thromboembolism; family history of thromboembolism with documented genetic predisposition; NYHA class III or IV congestive heart failure; recent abdominal or orthopedic surgery; prolonged immobilization.  Per recent KDIGO guidelines, the duration of prophylactic anti-coagulation needed for optimal benefit compared to risk is not known, but it seems reasonable to continue therapy for as long as the patient remains nephrotic with a serum albumin <3.0 g/dl.   Per glomerular disease experts " The treatment of overt thrombotic or embolic events in patients with nephrotic syndrome is relatively straightforward. Anticoagulation with sequential high or low molecular weight heparin and oral warfarin is the recommended. The duration of treatment needed to prevent recurrent events is unknown but is probably equal to the duration of the nephrotic state per se. "  Another article suggests that warfarin therapy is given for a minimum of 6 to 12 months. However, most experts feel that warfarin should be continued for as long as the patient remains nephrotic. So the best answer would be till the remission of the syndrome and following that perhaps 6 months minimum. The remission might be quicker than 6 months in some cases.