48-year-old man presents with acute onset right flank pain and nephrotic syndrome

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Published on Oct 28, 2021
CC - A 48-year-old man presents with acute onset right flank pain and recent diagnosis of nephrotic syndrome.

HPI - He was recently diagnosed with nephrotic syndrome (8 g of protein per 24 hours and serum albumin 1.6 g/dl) due to biopsy-proven idiopathic membranous nephropathy (EM figure 1A) diagnosed 5 weeks ago during evaluation of worsening lower extremity edema and weight gain and sob secondary to bilateral pleural effusion.

LABS - creatinine was 3.9 mg/dl (baseline, 0.9 mg/dl 4 weeks ago). Urinalysis demonstrated 1+ blood and 4+ protein, whereas urine microscopy revealed 40 isomorphic RBC/HPF.

IMAING - A CT angiogram of the abdomen (Figure 1B) showed extensive B/L renal vein thrombus (RVT) (arrow) extending into IVC on venous phase imaging.

What is the next step in management of this patient?

A) percutaneous catheter thrombectomy
B) Local thrombolytic therapy with recombinant tissue plasminogen activator
C) Heparin drip, transitioning to life long warfarin.
D) percutaneous catheter thrombectomy plus Local thrombolytic therapy with recombinant TPA, transitioning to LMW heparin/warfarin till albumin >3.0.
E) percutaneous catheter thrombectomy plus Local thrombolytic therapy with recombinant TPA, transitioning to direct oral anticoagulants (DOACs)till albumin >3.0.

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https://renal.medcase.com/free_cme/48-year-old-man-presents-with-acute-onset-right-flank-pain-and-nephrotic-syndrome/