Almıla ÜYÜK, Murat Yaşar TAŞ, Belda DURSUN, Furkan UFUK

İlk prezentasyonu tromboembolik olaylar ile olan membranöz nefropati olgusu

Venöz tromboembolizm ile prezente olan ve kortikosteroid, siklosporin, uygun antikoagülan tedavi ile başarılı bir şekilde tedavi edilen bir idiyopatik membranöz glomerülonefrit olgusu sunuyoruz. Ayaklarda şişlik, yan ağrısı şikayetleri olan 59 yaşında erkek hastada proteinüri ve vena cava inferiorda tromboz tespit edilmesi sonucu nefroloji bölümümüze sevk edildi. Görüntülemede femoral ven, renal ven ve inferior vena cavada trombüs saptanması üzerine varfarin sodyum tedavisi başlandı. 12 g/gün proteinüri, hipoalbüminemi, hiperlipidemi ve anti fosfolipaz A2 reseptör antikor pozitifliği saptanan hastaya idiyopatik membranöz nefropati tanısı ile tedavi başlandı. Oral steroid, siklosporin ve varfarin sodyum ile taburcu edilen ancak uyumsuzluk nedeniyle başka bir klinikte varfarin sodyum rivaroksaban ile değiştirilen hasta nefes darlığı şikayeti ile tekrar başvurdu. Pulmoner emboli tespit edilmesi üzerine rivaroksaban kesildi ve düşük molekül ağırlıklı heparin tedavisi başlandı. Çok yüksek bir morbidite ve mortalite riski vardı ve uygun tedavi ile klinik durum ve böbrek fonksiyonu stabilize edildi. Sonuç olarak, nefrotik sendromda tromboemboli görülebilmesine rağmen, nefrotik sendromun ilk prezentasyonu olarak nadiren de olsa tromboemboli ile karşılaşılabilinir. Bu durum gözden kaçırılmamalı, uygun tedaviler geciktirilmeden sağlanmalıdır.

Anahtar Kelimeler:

Hipoalbüminemi, Nefrotik Sendrom, Proteinüri, tromboembolizm

A case of thromboembolic events as first manifestation of membranous nephropathy

We present a case of idiopathic membranous glomerulonephritis that presented with venous thromboembolism and was successfully managed with corticosteroid, cyclosporin, appropriate anticoagulant therapy. A 59-year old male patient was referred to our nephrology department who had an outpatient history of swelling in the feet and flank pain was detected proteinuria and thrombosis in the inferior vena cava. Warfarin sodium treatment was started when thrombus was detected in the femoral vein, renal vein and inferior vena cava in the imaging. The patient had 12 g/day proteinuria, hypoalbuminemia, hyperlipidemia and antiphospholipase A2 receptor antibody positivity and treatment was started with the diagnosis of idiopathic membranous nephropathy. The patient who was discharged with oral steroid, cyclosporine and warfarin sodium, but warfarin sodium was changed to rivaroxaban in another clinic due to incompatibility problems, was presented again with dsypnea. Pulmonary embolism was detected. Rivaroxaban was discontinued and low molecular weight heparin treatment was started. There was a very high risk of morbidity and mortality and with appropriate treatment, clinical status and renal function were stabilized. In conclusion, although thromboembolism can be seen in nephrotic syndrome, it may rarely be encountered as the first presentation of nephrotic syndrome. This situation should not be overlooked, appropriate treatments should be provided without delay.

Keywords:

Hypoalbuminemia, Nephrotic Syndrome, Proteinuria, Thromboembolism,

PDF

___

1. Prince S, Naresh K, Tulasi R. Case report on paediatric nephrotic syndrome. EJIFCC. 2020;31:164-8.
2. Al-Azzawi HF, Obi OC, Safi J, Song M. Nephrotic syndrome-induced thromboembolism in adults. Int J Crit Illn Inj Sci. 2016;6:85-88.
3. Hull RP, Goldsmith DJA. Nephrotic syndrome in adults. Bmj. 2008;336:1185-9.
4. Mirrakhimov AE, Ali AM, Barbaryan A, Prueksaritanond S, Hussain N. Primary nephrotic syndrome in adults as a risk factor for pulmonary embolism: An up-to-date review of the literature. Int J Nephrol. 2014;2014:916760.
5. Ambler B, Irvine S, Selvarajah V, Isles C. Nephrotic syndrome presenting as deep vein thrombosis or pulmonary embolism. Emerg Med J. 2008;25:241-2.
6. Madken M, Nagaraju SP, Attur RP, Vankalakunti M. Pulmonary thromboembolism as first presentation of childhood membranous nephropathy. Saudi J Kidney Dis Transpl. 2017;28:1192-5.
7. Ronco P, Beck L, Debiec H, Fervenza FC, Hou FF, Jha V, et al. Membranous nephropathy. Nat Rev Dis Primers. 2021;7:69.
8. Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, et al. KDIGO 2021 clinical practice guideline for the management of glomerular diseases. Kidney Int. 2021;100:1-276.
9. Medjeral-Thomas N, Ziaj S, Condon M, Galliford J, Levy J, Cairns T, et al. Retrospective analysis of a novel regimen for the prevention of venous thromboembolism in nephrotic syndrome. Clin J Am Soc Nephrol. 2014;9:478-83.
10. Kerlin BA, Ayoob R, Smoyer WE. Epidemiology and pathophysiology of nephrotic syndrome-associated thromboembolic disease. Clin J Am Soc Nephrol. 2012;7:513-20.
11. Daher EF, Silva GB, Galdino GS, Eduardo DS, Wanderley TP, Lopes GS. Renal vein thrombosis and membranous nephropathy - report of 2 cases. J Med. 2011;12:73-6.
12. Reynolds ML, Derebail VK. Recurrent venous thromboembolism (VTE) in membranous nephropathy despite direct xa inhibitor therapy. J Am Soc Nephrol. 2017;28:154