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DOAC Pharmacokinetics Nephrotic Syndrome — ESENeph MCQ

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HardGlomerulonephritisDOAC Pharmacokinetics Nephrotic SyndromeESENeph

A 30-year-old woman with nephrotic syndrome from minimal change disease is found to have a DVT. She has albumin 13 g/L. She is started on anticoagulation. What choice of anticoagulant requires special consideration in nephrotic syndrome?

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Correct answer: B — DOACs may have altered pharmacokinetics due to protein binding changes in severe hypoalbuminaemia

In severe nephrotic syndrome with hypoalbuminaemia, the pharmacokinetics of protein-bound drugs (including DOACs, particularly Rivaroxaban and Apixaban which are >85% protein-bound) may be altered. Reduced albumin can increase the free fraction of drug, potentially altering efficacy and safety. While DOACs are increasingly used, LMWH or Warfarin with INR monitoring may be preferred in severe hypoalbuminaemia (albumin <20 g/L). This remains an area of active research and clinical uncertainty.

Reference: KDIGO 2021 – GN Guideline (Thrombosis chapter); Sexton et al 2018