Renal vein thrombosis and hypercoagulable state in nephrotic syndrome
- Jai Radhakrishnan, MD, MS
Jai Radhakrishnan, MD, MS
- Professor of Medicine
- Columbia University Medical Center
- Section Editors
- Richard J Glassock, MD, MACP
Richard J Glassock, MD, MACP
- Editor-in-Chief — Nephrology
- Section Editor — Glomerular Diseases
- Emeritus Professor
- The David Geffen School of Medicine at UCLA
- Brad H Rovin, MD
Brad H Rovin, MD
- Section Editor — Glomerular Diseases
- Professor of Medicine and Pathology
- The Ohio State University College of Medicine
Patients with the nephrotic syndrome are at increased risk for venous thrombosis, particularly deep vein and renal vein thrombosis (DVT and RVT) [1-4]. Pulmonary embolization (mostly asymptomatic) is relatively common, and there are case reports of cerebral venous thrombosis [1-4]. Arterial thromboses (eg, limb and cerebral) also occur with higher frequency than in the general population [4-7].
This topic will review the epidemiology and pathogenesis of hypercoagulability in the nephrotic syndrome, and the clinical features and treatment of renal vein thrombosis in adults. Overviews of the nephrotic syndrome and causes of venous thrombosis are discussed separately. (See "Overview of heavy proteinuria and the nephrotic syndrome" and "Overview of the causes of venous thrombosis".)
The incidence of both venous and arterial thrombosis are much higher in patients with nephrotic syndrome compared with estimates in the general population. The magnitude of this effect was illustrated in a retrospective study of 298 (predominantly adult) patients who presented with the nephrotic syndrome and were followed for a mean of 10 years . The absolute risk of venous thrombosis was 1.0 percent per year, which is eight times higher than the age- and sex-matched annual incidence reported in the Worcester DVT study . The absolute risk of arterial thrombosis was 1.5 percent per year, also approximately eight times that observed in a general population . The risk of both venous and arterial thrombosis was greatest within the first six months of diagnosis (annual incidence 9.9 and 5.5 percent, respectively) .
An increase in thromboembolic risk is also present in children with the nephrotic syndrome. (See "Complications of nephrotic syndrome in children", section on 'Thromboembolism'.)
Risk factors — The risk of thrombosis varies among the causes of nephrotic syndrome and appears to be highest in patients with membranous nephropathy [4,10-13]. This was illustrated in a cohort of 1313 patients with idiopathic glomerular disease due to membranous nephropathy, focal segmental glomerulosclerosis, or IgA nephropathy . The incidence of venous thromboembolic events was much higher in membranous nephropathy (7.9 percent) and focal segmental glomerulosclerosis (3.0 percent) than in IgA nephropathy (0.4 percent). The histologic diagnosis remained a predictive factor for thrombosis after adjustment for the degree of proteinuria (which was much higher at presentation in membranous nephropathy and focal segmental glomerulosclerosis [median 5.6 and 3.7 g/day versus 1.6 g/day in IgA nephropathy]) and the serum albumin concentration. (See "Treatment of idiopathic membranous nephropathy", section on 'Anticoagulation'.)
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- Risk factors
- Renal vein thrombosis
- Deep vein thrombosis
- Pulmonary embolism
- RENAL VEIN THROMBOSIS
- Clinical features
- - Chronic renal vein thrombosis
- - Acute renal vein thrombosis
- Diagnosis and screening
- Prevention of thromboembolism
- - Prophylactic anticoagulation
- Approach to prophylactic anticoagulation
- - Anticoagulation for asymptomatic RVT
- - Anticoagulation for a thromboembolic event
- - Duration of anticoagulation
- - Inferior vena cava filters
- Direct therapy of RVT
- - Fibrinolytic therapy and catheter thrombectomy
- - Surgery
- SUMMARY AND RECOMMENDATIONS