Abstract: PUB266
The Use of Direct Oral Anticoagulants in Membranous Nephropathy
Session Information
Category: Glomerular Diseases
- 1203 Glomerular Diseases: Clinical, Outcomes, and Trials
Authors
- Wills, Maximilian, Royal London Hospital, London, United Kingdom
- Gupta, Sanjana, Royal London Hospital, London, United Kingdom
- Gage, Alice M., Royal London Hospital, London, United Kingdom
- Ashman, Neil, Royal London Hospital, London, United Kingdom
- Forbes, Suzanne H., Royal London Hospital, London, United Kingdom
Group or Team Name
- Nephrology department, The Royal London Hospital
Background
Barts Health has a dedicated membranous nephropathy (MN) service with 15-20 incident cases per year. Nephrotic syndrome secondary to MN in particular is associated with arterial and venous thrombosis. There is little evidence to guide optimum pharmacological prophylaxis. In those considered high risk, options include warfarin, heparin or aspirin. The advent of direct oral anti-coagulants (DOACs) offers an alternative, though evidence of efficacy is isolated to case studies.
All patients with an albumin <25g/L are offered anticoagulation. We describe our use of DOACs in a large single centre MN cohort.
Methods
Retrospective data from MN patients, collected between 2015-2019 was analysed. This included: demographics; frequency, type and timing of thromboembolic and bleeding events; biochemical data at initiation and cessation of agent.
Results
Total number of patients: 26
DOAC treatment courses: 30
Exposure to drug (patient days): 9899
Malignancy was excluded in all cases, with the exception of 1 case of MN secondary to cancer.
There were 3 thromboembolic events in 3 patients; all events occurred on rivaroxaban and in PLA2Rab positive MN.
Thrombotic events were all arterial, with no venous events, 2 cerebral artery infarcts and 1 lower limb arterial thrombosis. These patient’s mean initial presentation PLA2Rab titres were 164 Kunits/L (75-248) and all were nephrotic at the time of the thromboembolic event. Events were 29, 128 and 340 days post DOAC initiation. 2 of these patients had a venous thrombosis prior to DOAC initiation. Event rate: 0.11 per patient year
Safety data also demonstrated 3 bleeds in this patient cohort - all were minor as per ISTH criteria. 2 epistaxes and 1 associated with rectal prolapse, all without a haemoglobin drop.
Conclusion
Our experience is that DOACs are safe and effective in patients with MN and offer a viable anti-coagulant alternative.
Table 1: Cohort demographics
| Gender, n (%) | 19 (65) Male / 7 (35) Female |
| Mean age (range) years | 54.9 (26-76) |
| Mean eGFR (range) ml/min/1.73m2 | 63.5 (17-124) |
| Median albumin (interquartile range) g/L | 23.5 (20-28) |
| Phospholipase A2 receptor antibody (PLA2Rab) positivity, n (%): PLA2Rab seropositive PLA2Rab seronegative, immunohistochemistry positive PLA2Rab seronegative, immunohistochemistry negative PLA2Rab seronegative, immunohistochemistry unknown | - 20 (76) 2 (8) 2 (8) 2 (8) |
| Median DOAC initiation PLA2Rab titre, Kunits/L (interquartile range) | 141 (75-993) |
| DOAC % | Rivaroxaban 80% Apixaban 20% |
| Mean treatment course duration, days (range) | 330 (46-964) |