Thrombosis Despite Sub-Nephrotic Proteinuria

While nephrotic syndrome is a recognized hypercoagulable state associated with an elevated risk of venous thromboembolism (VTE), sub-nephrotic proteinuria and resultant hypoalbuminemia have also been associated with a similar increased risk. We report on a 40-year-old patient who initially presented with findings of anasarca and dyspnea and was found to have bilateral lower extremity deep vein thromboses (DVTs) and pulmonary embolism on further testing. In pursuit of a kidney biopsy, the patient's anticoagulation was briefly held, which resulted in the development of new bilateral upper extremity DVTs. Our findings outline the need to consider the increased risk for VTE in patients with sub-nephrotic proteinuria and hypoalbuminuria, as the latter finding may be more indicative of clotting risk in this patient population. A multidisciplinary approach is needed to determine the optimal management strategy for these patients, especially when pursuing procedures requiring temporary discontinuation of pharmacological anticoagulation.