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Recurrent venous thromboembolism in primary membranous nephropathy despite direct Xa inhibitor therapy

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Abstract

Clinically apparent venous thromboembolism (VTE) occurs in approximately 7% of patients with membranous nephropathy. Hypoalbuminemia at diagnosis is an independent risk factor for VTE, and risk increases significantly as albumin falls. Optimal prophylactic and treatment anticoagulation regimens in the nephrotic syndrome remain unproven but novel oral anti-coagulants have become attractive therapeutic options. We describe a patient diagnosed with anti-phospholipase A2 receptor antibody positive membranous nephropathy and recurrent VTE while on therapeutic dosing of apixaban. A direct factor Xa inhibitor, apixaban has been shown to be non-inferior to warfarin for the treatment of VTE in the general population. However, because it is highly protein-bound, apixaban may have altered pharmacokinetics and pharmacodynamics in patients with nephrotic syndrome and hypoalbuminemia. This case report highlights the need for further studies of direct oral anticoagulants to fully assess their effectiveness in this high-risk population.

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Acknowledgements

VKD is supported in part by Nephrotic Syndrome Study Network Consortium (NEPTUNE) via the National Institutes of Health (NIH)/National Center for Advancing Translational Sciences and NIH/National Institute of Diabetes and Digestive and Kidney Disease (U54DK083912), NephCure Kidney International, and University of Michigan.

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Authors and Affiliations

  1. Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Monica L. Reynolds & Vimal K. Derebail

  2. Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA

    Patrick H. Nachman

  3. Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Micah J. Mooberry

  4. Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Daniel J. Crona

  5. UNC Kidney Center, 7024 Burnett-Womack, CB#7155, Chapel Hill, NC, 27599, USA

    Monica L. Reynolds

Authors
  1. Monica L. Reynolds
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  2. Patrick H. Nachman
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  3. Micah J. Mooberry
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  4. Daniel J. Crona
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  5. Vimal K. Derebail
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Correspondence to Monica L. Reynolds.

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On behalf of all authors, the corresponding author states that there is no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from the individual participant whose case was reported.

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Reynolds, M.L., Nachman, P.H., Mooberry, M.J. et al. Recurrent venous thromboembolism in primary membranous nephropathy despite direct Xa inhibitor therapy. J Nephrol 32, 669–672 (2019). https://doi.org/10.1007/s40620-018-0552-9

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  • DOI: https://doi.org/10.1007/s40620-018-0552-9

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