Prophylactic Anticoagulant Use in Primary Membranous Nephropathy

Background: The risk of venous and arterial thromboembolic events is well documented in patients with nephrotic syndrome (NS). Clinical practice remains variable despite the recommendation to initiate warfarin prophylactically in the 2021 KDIGO guidelines if the risk is tolerable. We sought to describe the current use of anticoagulants, venous thromboembolic events (VTE) and major bleeding events in patients with primary membranous nephropathy (PMN) and NS. Methods: We retrospectively identified 53 patients with biopsy-proven PMN and NS from 2017-2024 in the Cleveland Clinic Kidney Biopsy Registry with at least two years of follow-up data post-biopsy. Baseline data (near index biopsy) was recorded ensuring proteinuria >3.5g/24hr and hypoalbuminemia was present. The medical records were reviewed to identify prescriptions for anticoagulants. VTEs and major bleeding events were also identified and documented. Results: Of the 53 patients with PMN and NS, only 17% (9/53) were prescribed anticoagulation (AC). Among those, only 44% (4/9) were for VTE prevention and prophylactic, the rest were for primary indications. Out of the total AC prescriptions, 67% were on apixaban and 33% were on warfarin. Prior to diagnosis, 98% (52/53) of our cohort had no bleeding history. During our 2-year retrospective chart review, we identified a total of 4 VTEs and 3 bleeding events, none of which were on anticoagulation Conclusion: The rate of prophylactic anticoagulant use in PMN with NS was low, overall at 7.5% in this patient cohort with a relatively low risk of bleeding events. Despite guideline recommendations favoring warfarin, the predominant anticoagulant prescribed was apixaban. Clinicians may prefer direct oral anticoagulants (DOACs) due to advantages in ease of monitoring and reduced overall burden on patients. Given this data, DOACs may be a reasonable alternative to warfarin and may improve the current low rates of prophylactic AC prescriptions in patients with NS.