Prophylactic anticoagulation in patients with nephrotic syndrome in the Cure Glomerulonephropathy (CureGN) cohort.

Background: Adult and paediatric patients with nephrotic syndrome (NS) due to different glomerular diseases are at a higher risk of thromboembolic events than the general population, but the use of prophylactic anticoagulation (PAC) among them has not been well described. Although the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines offer an algorithm to guide the management of PAC, the degree of implementation in practice is unknown.

Methods: We evaluated thromboprophylaxis management in patients with NS secondary to membranous nephropathy, focal segmental glomerulosclerosis, minimal change disease and C1q nephropathy enrolled in the Cure Glomerulonephropathy (CureGN) cohort study (diagnosed 2010-2023) and assessed the concordance or discordance with the 2021 KDIGO guidelines practice points in adults. We also analysed thrombotic and bleeding events.

Results: Among 374 adult and 263 paediatric NS episodes, PAC was prescribed in 21 (6%) and 11 (4%) episodes, respectively. In adults, PAC prescription was associated with a history of prior thrombosis, lower serum albumin and higher proteinuria, with coumarins and direct oral anticoagulants (DOACs) being equally the most prescribed agents. In adults, anticoagulation management was concordant with guidelines in 180 (48%) episodes, discordant in 59 (16%) and indeterminate in 135 (36%). Most (92%) guideline-discordant episodes were cases with a high thrombotic risk and low bleeding risk where PAC was not prescribed. In children, PAC prescription was associated with lower albuminaemia and worse kidney function, with heparins being the only agent used. Thrombotic events occurred during 5 (1.3%) and 4 (1.5%) of all adult and paediatric NS episodes, respectively.

Conclusions: PAC was used more conservatively than guidelines suggest and was mainly driven by hypoalbuminaemia severity in both adults and children. Although not included in the guidelines practice points, DOACs were used as often as coumarins in adults.