A Systematic Review of Prophylactic Anticoagulation in Nephrotic Syndrome

Abstract

Introduction: Nephrotic syndrome is associated with an increased risk of venous and arterial thromboembolism, which can be as high as 40% depending on the severity and underlying cause of nephrotic syndrome. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend prophylactic anticoagulation only in idiopathic membranous nephropathy but acknowledge that existing data are limited and of low quality. There is a need for better identification of vulnerable patients in order to balance the risks of anticoagulation.

Methods: We undertook a systematic search of the topic in MEDLINE, EMBASE and COCHRANE databases, for relevant articles between 1990 and 2019.

Results: A total of 2381 articles were screened, with 51 full-text articles reviewed. In all, 28 articles were included in the final review.

Conclusion: We discuss the key questions of whom to anticoagulate, when to anticoagulate, and how to prophylactically anticoagulate adults with nephrotic syndrome. Using available evidence, we expand upon current KDIGO guidelines and construct a clinical algorithm to aid decision making for prophylactic anticoagulation in nephrotic syndrome.

Keywords: anticoagulation; arterial thromboembolism; nephrotic syndrome; prophylaxis; venous thromboembolism.

Graphical abstract

Figure 1

Search strategy and results. VTE, venous thromboembolism.

Figure 2

Algorithm for suggested approach to thromboembolism prophylaxis in nephrotic syndrome patients. †HAS-BLED scores for bleeding risk: 0−1, low risk; 2, moderate risk; 3−5, high risk; 5+, very high risk (see Supplementary Table S1). ‡Additional risk factors: proteinuria >10 g/d, body mass index >35 kg/m², documented genetic predisposition to venous thromboembolism (VTE), prolonged immobilization, recent abdominal or orthopedic surgery, New York Heart Association Class III to IV congestive heart failure. §Prophylactic anticoagulation first-line therapy: warfarin (international normalized ratio [INR], 2.0−3.0) or enoxaparin 40 mg daily. FSGS, focal segmental glomerulosclerosis; HAS-BLED, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly); MCD, minimal change disease; MGN, membranous glomerulonephritis; MPGN, membranoproliferative glomerulonephritis; SA, serum albumin.