Atrial fibrillation (AF) is common in patients with kidney disease, with prevalence several times greater than in the general population. Anticoagulation agents are used to prevent thromboembolic events as a consequence of AF. Several randomized trials have established the efficacy of antithrombotic drugs for preventing stroke in patients with AF, with both antiplatelet agents and oral anticoagulants showing benefit. End-stage kidney disease (ESKD) patients have known platelet defects/dysfunction and also receive heparin during their dialysis treatment, which contributes to their overall coagulopathy. Warfarin being vitamin-K antagonist can augment calciphylaxis in patients with ESKD. Taken together, formal anticoagulation use in patients with ESKD may confer additional risk that is not appreciated in patients without kidney disease. In particular, patients on new oral anticoagulants show excess morbidity and mortality from bleeding when compared to warfarin.
Part of the book: Anticoagulant Drugs
Membranous nephropathy (MN) is a glomerular disease that is the leading cause of nephrotic syndrome in non-diabetic Caucasian adults. MN is most often primary (idiopathic) and the remaining is secondary to systemic disease or exposure to infection or drugs. The majority of patients with MN have circulating antibodies to the podocyte antigens phospholipase A2 receptor (PLA2R) (70%) and thrombospondin type-1 domain-containing 7A (THSD7A) (3–5%). Immunologic remission (depletion of PLA2R antibodies) often precedes and may predict clinical remission. Untreated, about one-third of patients undergo spontaneous remission, one-third have persistent proteinuria but maintain kidney function and the remaining one-third will develop end stage kidney failure. All patients with idiopathic MN should be treated with conservative care from the time of diagnosis to minimise proteinuria. Immunosuppressive therapy is traditionally reserved for patients who have persistent nephrotic-range proteinuria despite conservative care. Immunosuppressive agents for primary MN include combination of corticosteroids/alkylating agent or calcineurin inhibitors and rituximab. This chapter will review the epidemiology, diagnosis and treatment of MN, particularly focusing on idiopathic MN.
Part of the book: Glomerulonephritis and Nephrotic Syndrome