Volume 3, Number 16;  October 22, 2004

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 Resident Report 1022/04—Mohit Rastogi

Case: 

25 year old 31 week pregnant hispanic female with swelling and high blood pressure.

History and Physical - 25 year old female presented to outside hospital with increased blood pressure and headache. She is 31 weeks pregnant with her first child. Her history is significant for SLE diagnosed six years earlier, ITP two years earlier and treated with plasmapharesis and rituxan, and subarchanoid hemorrhage one year earlier.  She was continued on her prenatal vitamin, her prednisone was increased from 5mg daily to 60mg daily. She had a CT scan which was negative and her headache resolved. Her blood pressure also normalized.  She then developed severe swelling to her sacrum.  She was transferred to Grady Memorial Hospital for further medical care.

            On physical exam, her blood pressure was mildly elevated at 140’s over 80’s. She had severe +4 pitting edema. Fetal exam was normal.

Differential diagnosis - Third trimester pregnant female with either preeclampsia versus lupus flare. Her labs showed normal transaminases, normal urinary calcium, normal platelets, all of which point against preeclampsia.  Her 24 hour protein was repeated 3 times and showed initially 400mg, then 3grams, then 13 grams (with dropping albumin and increasing edema), high ds-dna, high ana titer, low c3, c4 levels; all of which is consistent with lupus flare.

Clinical Diagnosis – Lupus Nephrosis

Outcome – She was treated with high dose solumedrol and diuretic for swelling.  She developed placenta abruption and had emergent c-section.  Proteinuria improved and blood pressure was controlled with ace inhibitor. Normally, suspected lupus flare involving the kidney would be biopsied prior to treatment, but her pregnancy precluded this.

Clinical Question(s): 

 In patients with known nephrotic syndrome, is prophylactic anticoagulation beneficial?

Readings:

<1>

Unique Identifier:8164448

Authors: Sarasin FP. Schifferli JA.

Institution: Clinique Medicale 1, Hopital Cantonal Universitaire, University of Geneva Medical School, Switzerland.

Title: Prophylactic oral anticoagulation in nephrotic patients with idiopathic membranous nephropathy.

Source: Kidney International. 45(2):578-85, 1994 Feb.

Abstract: Whether the high incidence of thromboembolic events in nephrotic patients with membranous nephropathy justifies prophylactic administration of oral anticoagulants remains controversial. We used a Markov-based decision analysis model, explicitly considering the consequences of recurrent embolic and bleeding events to quantify the risk-benefit trade-offs of: (1) prophylactic therapy, in which oral anticoagulation was started at the time of diagnosis of nephrotic syndrome (before any thromboembolic event); and (2) anticoagulant therapy, in which treatment was started after the first clinical thromboembolic event. We assumed that anticoagulant therapy was discontinued if there was remission of the nephrotic syndrome. The overall number of fatal emboli prevented by prophylactic anticoagulants exceeded the one of fatal bleeding events for all clinically meaningful ranges of the following parameters: nephrotic syndrome duration, incidence of thromboembolic events, likelihood of embolization, and mortality rates of embolic and bleeding events. For a hypothetical 50-year-old patient who remained nephrotic for 2 years, prophylactic anticoagulation yielded a gain representing 2.5 months of quality-adjusted life expectancy. We conclude that for nephrotic patients with membranous nephropathy, the benefits of prophylactic administration or oral anticoagulants outweigh the risks.

<2>

Unique Identifier:8039758

Authors: Ruggeri M. Milan M. La Greca G. Castaman G. Rodeghiero F.

Institution: Department of Hematology, San Bortolo Hospital, Vicenza, Italy.

Title: Adult patients with the nephrotic syndrome: really at high risk for deep venous thromboembolism? Report of a series and review of the literature. [Review] [35 refs]

Source: Haematologica. 78(6 Suppl 2):47-51, 1993 Nov-Dec.

Abstract: BACKGROUND. The reported incidence of thromboembolic episodes in people with nephrotic syndrome (NS) ranges from 6% to 44% and it has been ascribed to the presence of a hypercoagulable state, as suggested by abnormalities of several hemostatic parameters in these patients. However, the results of the studies are often contradictory and fragmented and are rarely based on prospective studies. To assess the incidence of venous thrombosis and the pattern of abnormalities of the hemostatic parameters in NS, we planned a prospective study of a group of patients with NS. PATIENTS AND METHODS. Thirty-six consecutive patients with NS were enrolled during a 9-month period. Every 4-6 months, clinical history was collected and physical examination was carried out. Blood samples for laboratory investigation were taken at entry into the study and 24 months later. A critical review of the literature was also carried out (Medline database and Current Contents). RESULTS. During the follow-up (mean 45.2 months), no thrombotic symptoms were recorded, PTT, PT, TT and mean AT-III levels were within the normal range, whereas fibrinogen, plasminogen, protein C and S, heparin cofactor II levels were significantly higher than normal both at entry into the study and 24 months later. No patient was positive for antiphospholipid antibodies. Slightly decreased levels of AT-III and heparin cofactor II were found in only two cases. CONCLUSIONS. Our study confirms neither the high incidence of thrombotic complications in NS nor the presence of abnormalities of hemostatic parameters commonly associated with venous thromboembolism. [References: 35] 

Resident Report / Department of Medicine & Grady Branch Library

Emory University School of Medicine

2004 Edition

Participating Faculty:  Carlos Del Rio MD  / Joyce Doyle MD / Lorenzo Difrancesco MD /  Monica Adams MD  / Josh Larned MD

Contact: Karl Woodworth