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Renal vein thrombosis and hypercoagulable state in nephrotic syndrome

INTRODUCTION

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".)

EPIDEMIOLOGY

The incidences of both venous and arterial thrombosis are much higher in patients with nephrotic syndrome compared to estimates in the general population [7]. This issue was examined in a retrospective study of 298 patients who presented with the nephrotic syndrome and were followed for a mean period of 10 years [7]. In this study, the absolute risk of venous thrombosis was 1.02 percent per year, which is eight times higher than the age- and sex-matched annual incidence reported in the Worcester DVT study [7,8]. (See "Overview of the causes of venous thrombosis", section on 'VTE and atherosclerotic disease'.) The absolute risk of arterial thrombosis was 1.48 percent per year, also approximately eight times that observed in a general population [9]. The risk of both venous and arterial thrombosis was greatest within the first six months of diagnosis (with annual incidences of 9.85 and 5.52 percent, respectively) [7].

The risk of thrombosis varies among the causes of nephrotic syndrome. The risk is highest with membranous nephropathy followed by membranoproliferative glomerulonephritis (MPGN) and minimal change disease [10,11]. The risk of thrombosis may also be related to the severity and duration of the nephrotic state [7,9,10] and appears to be particularly increased with serum albumin concentrations ≤2.0 g/dL (20 g/L) [4,10,12-14].

Renal vein thrombus — There is wide variability in the reported rate of RVT, probably related to the selection of patients for study (eg, degree of nephrotic syndrome, symptomatic or asymptomatic thrombosis, since RVT is often clinically silent) and methods of detection (since the sensitivities of the available tests differ).
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