Kaohsiung Journal of Medical Sciences
Volume 26, Issue 2 , Pages 89-95, February 2010

Nephrotic Syndrome Complicated by Life-Threatening Pulmonary Embolism in an Adult Patient

  • Szu-Chia Chen

      Affiliations

    • Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
    • ,
  • Wan-Chun Liu

      Affiliations

    • Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
    • ,
  • Cheng-Hsueh Lee

      Affiliations

    • Ming-Kang Clinic, Kaohsiung, Taiwan
    • ,
  • Jer-Ming Chang

      Affiliations

    • Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
    • Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
    • Corresponding Author InformationAddress correspondence and reprint requests to: Dr Jer-Ming Chang, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, 482 San-Ming, Hsiao-Kang District, Kaohsiung 812, Taiwan
    • ,
  • Hung-Chun Chen

      Affiliations

    • Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
    • Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Received 2 April 2009; accepted 26 May 2009.

Article Outline

We report a 23-year-old male presenting with edema. He was originally admitted for an elective renal biopsy for diagnosis of renal pathology. Unfortunately, because of acute abdominal pain an exploratory laparotomy was done. Progressive azotemia and oliguria then developed, and he required temporary hemodialysis. However, he suffered from sudden-onset severe respiratory distress, and blood gas analysis showed profound hypoxemia with a marked arterial–alveolar oxygen difference. Assessment of a pulmonary embolism by radioisotope imaging was not possible because of his dependence on mechanical ventilation. Subcutaneous low molecular weight heparin and intravenous methylprednisolone were given to treat the presumed pulmonary embolism and the underlying nephrotic syndrome. His partial oxygen level gradually increased after continuous heparin and steroid administration. Complete obliteration of one major pulmonary artery and partial obliteration of other smaller arteries were revealed by magnetic resonance angiography. He was discharged and followed-up as an outpatient, and was given oral warfarin and prednisolone. Follow-up magnetic resonance angiography 5 months later showed a normal pulmonary tree with no residual lesions.

Key Words:  low molecular weight heparin , nephrotic syndrome , pulmonary arterial thromboembolism

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. Gitlin D , Janeway CA , Farr LE . Studies on the metabolism of plasma proteins in the nephrotic syndrome. I. Albumin, gamma-globulin and iron-binding globulin . J Clin Invest . 1956;35:44–56
  2. Kaysen GA , al Bander H . Metabolism of albumin and immunoglobulins in the nephrotic syndrome . Am J Nephrol . 1990;10(Suppl 1):36–42
  3. Harris RC , Ismail N . Extrarenal complications of the nephrotic syndrome . Am J Kidney Dis . 1994;23:477–497
  4. Cameron JS . Coagulation and thromboembolic complications in the nephrotic syndrome . Adv Nephrol Necker Hosp . 1984;13:75–114
  5. Llach F . Hypercoagulability, renal vein thrombosis, and other thrombotic complications of nephrotic syndrome . Kidney Int . 1985;28:429–439
  6. Rabelink TJ , Zwaginga JJ , Koomans HA , et al.   Thrombosis and hemostasis in renal disease . Kidney Int . 1994;46:287–296
  7. Llach F , Papper S , Massry SG . The clinical spectrum of renal vein thrombosis: acute and chronic . Am J Med . 1980;69:819–827
  8. Abrass CK . Clinical spectrum and complications of the nephrotic syndrome . J Investig Med . 1997;45:143–153
  9. Addis T , Gray H , Barrett E . Food protein effect on plasma specific gravity, plasma protein, and hematocrit value . J Exp Med . 1948;87:353–368
  10. Citak A , Emre S , Sairin A , et al.   Hemostatic problems and thromboembolic complications in nephrotic children . Pediatr Nephrol . 2000;14:138–142
  11. Singhal R , Brimble KS . Thromboembolic complications in the nephrotic syndrome: pathophysiology and clinical management . Thromb Res . 2006;118:397–407
  12. Parag KB , Somers SR , Seedat YK , et al.   Arterial thrombosis in nephrotic syndrome . Am J Kidney Dis . 1990;15:176–177
  13. Tarry WC , Moser AJ , Makhoul RG . Peripheral arterial thrombosis in the nephrotic syndrome . Surgery . 1993;114:618–623
  14. Ahmed K , Saeed E . Nephrotic syndrome and pulmonary artery thrombosis . Am J Nephrol . 1995;15:274–276
  15. Huang J , Yang J , Ding J . Pulmonary embolism associated with nephrotic syndrome in children: a preliminary report of 8 cases . Chin Med J (Engl) . 2000;113:251–253
  16. Rai Mittal B , Singh S , Bhattacharya A , et al.   Lung scintigraphy in the diagnosis and follow-up of pulmonary thromboembolism in children with nephrotic syndrome . Clin Imaging . 2005;29:313–316
  17. Cherng SC , Huang WS , Wang YF , et al.   The role of lung scintigraphy in the diagnosis of nephrotic syndrome with pulmonary embolism . Clin Nucl Med . 2000;25:167–172
  18. al-Mugeiren MM , Gader AM , al-Rasheed SA , et al.   Coagulopathy of childhood nephrotic syndrome— a reappraisal of the role of natural anticoagulants and fibrinolysis . Haemostasis . 1996;26:304–310
  19. Kauffmann RH , Veltkamp JJ , Van Tilburg NH , et al.   Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome . Am J Med . 1978;65:607–613
  20. Vaziri ND , Branson HE , Ness R . Changes of coagulation factors IX, VIII, VII, X, and V in nephrotic syndrome . Am J Med Sci . 1980;280:167–171
  21. Hoyer PF , Gonda S , Barthels M , et al.   Thromboembolic complications in children with nephrotic syndrome. Risk and incidence . Acta Paediatr Scand . 1986;75:804–810
  22. Zwaginga JJ , Koomans HA , Sixma JJ , et al.   Thrombus formation and platelet-vessel wall interaction in the nephrotic syndrome under flow conditions . J Clin Invest . 1994;93:204–211
  23. Mehls O , Andrassy K , Koderisch J , et al.   Hemostasis and thromboembolism in children with nephrotic syndrome: differences from adults . J Pediatr . 1987;110:862–867
  24. Fink C , Thieme S , Ley S , et al.   MRI of pulmonary embolism . Radiologe . 2007;47:708–715
  25. Ley S , Kauczor HU . MR imaging/magnetic resonance angiography of the pulmonary arteries and pulmonary thromboembolic disease . Magn Reson Imaging Clin N Am . 2008;16:263–273
  26. Carson JL , Kelley MA , Duff A , et al.   The clinical course of pulmonary embolism . N Engl J Med . 1992;326:1240–1245
  27. Reid CJ , Segal T . Pulmonary thrombo-embolism in nephrotic syndrome treated with tissue plasminogen activator . Eur J Pediatr . 1997;156:647–649
  28. Storti S , Pagano L , Marra R , et al.   Urokinase and AT-III concentrate treatment in inferior vena cava thrombosis associated with nephrotic syndrome . Blood Coagul Fibrinolysis . 1990;1:743–745
  29. Bellomo R , Atkins RC . Membranous nephropathy and thromboembolism: is prophylactic anticoagulation warranted? . Nephron . 1993;63:249–254
  30. Rostoker G , Durand-Zaleski I , Petit-Phar M , et al.   Prevention of thrombotic complications of the nephrotic syndrome by the low-molecular-weight heparin enoxaparin . Nephron . 1995;69:20–28
  31. Wang IK , Lee CH , Yang BY , et al.   Low-molecular-weight heparin successfully treating a nephrotic patient complicated by renal and ovarian vein thrombosis and pulmonary embolism . Int J Clin Pract . 2005;59(Suppl):72–75

PII: S1607-551X(10)70013-9

doi:10.1016/S1607-551X(10)70013-9

Kaohsiung Journal of Medical Sciences
Volume 26, Issue 2 , Pages 89-95, February 2010

Article Tools