Presentation on theme: "The Hazardous Headache of Nephrotic Syndrome"— Presentation transcript:
1The Hazardous Headache of Nephrotic Syndrome Amy Dickey, MDResident, Department of Internal MedicinePriyanka Duggal MDAttending, Department of Internal MedicineUniversity of Washington, Seattle, WA
2The CaseA 20yo female presented to the hospital with a severe headache. It is a bilateral frontal, throbbing headache, associated with emesis, photophobia, and fatigue.Three months earlier, she was diagnosed with minimal change disease by renal biopsy. Her initial symptoms of lower extremity edema and decreased exercise tolerance improved with immunosuppressive therapy; however, she was then started on a steroid taper. Two weeks prior to presentation, she noticed increased edema and breathlessness with exercise.
3Prior HistoryPast medical history: minimal change disease, onset approximately 4 months prior, diagnosed by renal biopsyMedications:prednisone 20mg po qday,lasix 40mg po tidKCL 20meq po qdayFamily medical history:Great grandfather – Wegener’s granulomatosisGrandmother – migraine headacheFather – hypothyroidismMother – migraine headacheSocial:No history of alcohol, tobacco, or drug useCurrently a college business studentPreviously ran triathlons
4Physical Exam T 36.5 HR 55 BP 116/66 R 18 O2 sat 98% CONSTITUTIONAL/GENERAL APPEARANCE: tired appearing femaleMENTAL STATUS/NEURO: alert and oriented x4, CN II-XII intact, PERRL, strength 5/5 symmetric throughout, reflexes 2+ throughoutEYES: PERRL, significant peri-orbital edemaNECK: trachea midline, edema of neck and jawRESPIRATORY: clear to auscultation bilaterallyCARDIOVASCULAR: normal rate, regular rhythm, no murmursABDOMEN/GI: soft, slight tenderness in epigastric region, no reboundMUSCULOSKELETAL: no joint swelling, ROM preserved, trace LE edemaSKIN: no rashes
5Initial Laboratory Data 2320518.104.22.1682.28522861333.49216320.75136Lipids: Tchol 418, Trig 118, LDL 244, HDL 136Urinalysis: 3+ blood, 3+ proteinProtein/creatinine ratio 19.7LP – Opening pressure of 31mmHg, otherwise normalNon-contrast head CT – slit ventricles, otherwise normal1.027
6CT Venogram – superior sagittal and straight sinus thrombosis and …
7Bilateral transverse sinus thrombosis CT venogram venous thrombosis of the superior sagittal sinus, bilateral transverse sinuses, and the straight sinus.
8The Anticoagulation Obstacle Baseline PTT 27. Started heparin drip at 6pm.430am – PTT 361030am – PTT 36130pm – anti-Xa heparin activity assay 0.05 (therapeutic range )6pm – anti-Xa activity 0.55 – therapeutic!An initial therapeutic heparin drip rate was 1700U/hr. Several days later, this was decreased to 1200U/hr. At that time, her proteinuria had resolved on high dose steroids.
9A Happy Ending!A complete work-up for other predisposing factors contributing to thrombosis was negativeDuplex scans of renal arteries, veins and vessels of the legs and arms all negativeMRI of the brain negative for infarctionHer headache resolved, and she was discharged on subcutaneous enoxaparin with no residual neurological deficits.
10Nephrotic Syndrome and Venous Thrombosis In adults with nephrotic syndrome, there is an absolute risk of venous thromboembolism at 1.02% per year.Risk of VTE is especially great in the first 6 months, approximately 9.85%!With nephrotic syndrome there is increased prothrombotic factors (fibrinogen, factor VII, platelet adhesions), decreased antithrombotic factors (antithrombin, protein C and S levels)Heparin complexes with antithrombin, increasing its inactivation of factors II and X.In nephrotic syndrome, lower circulating antithrombin, results in decreased responsiveness to heparin
11ReferencesGlassock R. Prophylactic Anticoagulation in Nephrotic Syndrome: A Clinical Conundrum. Circulation 2008; 117:224-30Mahmoodi B, et al. High Absolute Risk and Predictors of Venous and Arterial Thromboembolic Events in Patients with Nephrotic Syndrome. J Am Soc Nephrol 2007; 18:Sung S, et al. Central Venous Thrombosis In Patients with Nephrotic Syndrome: Case Reports. The Journal of Vascular Diseases 1999; 50:
14Annual Incidence of Types of Thromboembolism Among Patients with Nephrotic Syndrome The incidence of cerebral venous thrombosis in adults with nephrotic syndrome is extremely low and has not been quantified.
17Other contributors – volume depletion, diuretic or steroid therapy, venous stasis, immobilization, activation of the clotting cascadeIn nephrotic syndrome, LWMH preferred over warfarin because of unreliable kinetic in patient with hypoalbuminemia