Nephrotic syndrome (NS), especially when associated with severe hypoalbuminia, confers a high risk of venous thromboembolism (VTE). While low-molecular-weight heparin and warfarin are recommended by some guidelines for thromboprophylaxis in high risk patients, data supporting the use of direct oral anticoagulants for primary prophylaxis in NS remain limited and largely observational. We conducted a prospective multicentric cohort study across eight tertiary centers in India, enrolling adults (≥18 years) with NS and severe hypoalbuminia (albumin <2.4 g/dL for Membranous nephropathy; <2.0 g/dL for other etiologies). All patients received apixaban 5 mg once daily as primary VTE prophylaxis until albumin levels improved beyond 2.4 g/dL. The primary composite outcome included VTE occurrence and major or clinically significant bleeding events. Patients were followed until anticoagulation discontinuation. A total of 212 patients were analyzed (mean age 36.9 ± 14.0 years, 52% male). Median proteinuria was 9.0 g/day and mean serum albumin 1.68 ± 0.49 g/dL; mean serum creatinine was 1.5 ± 0.54 mg/dL. Most patients were categorized as low (80%) or intermediate (20%) bleeding risk by GN tool. Membranous nephropathy was the most common etiology (45%). Immunosuppressive therapy included corticosteroids (81%), rituximab (25.9%), and cyclophosphamide (28.3%). The median duration of apixaban therapy was 90 days (IQR: 27–115 days). No venous or arterial thromboembolic events occurred, and minor bleeding was observed in 4 patients (3.5%), all resolving without transfusion or hospitalization. Overall apixaban was well tolerated. In this large multicenter prospective cohort of patients with NS and severe hypoalbuminemia, apixaban use for primaryVTE was associated with a low incidence of thromboembolic and bleeding events. While these findings provide important real-world safety and feasibility data, randomized controlled trials are required to establish efficacy, optimal dosing, and patient selection for DOAC-based VTE in NS. Not applicable. People with nephrotic syndrome (NS) have very low levels of the protein albumin in their blood and lose large amounts of protein in their urine. This puts them at a much higher risk of developing blood clots in the legs, lungs, or other parts of the body. Preventing these clots is important because they can be life-threatening. Traditionally, doctors have used medications such as warfarin (a vitamin K antagonist), but these require frequent blood tests, dose adjustments, and careful monitoring, which can be difficult in routine practice. In this study, we looked at the safety and effectiveness of a newer type of blood thinner called apixaban, which belongs to a group of medicines known as direct oral anticoagulants (DOACs). We followed 212 adults with severe NS across eight hospitals in India. All patients received apixaban to prevent blood clots until their albumin levels improved. We found that none of the patients developed a blood clot while taking apixaban. Only 4 patients (3.5%) experienced minor bleeding, and all recovered without needing hospital care or blood transfusion. These results suggest that apixaban may be a safe and practical option to prevent blood clots in high-risk patients with NS. Larger studies are still needed, but this research provides reassuring real-world evidence for its use.
Meena et al. (Tue,) studied this question.
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