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Nephrotic syndrome anticoagulation risk — ABIM Board MCQ

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ModerateNephrologyNephrotic syndrome anticoagulation riskABIM Board

A 42-year-old man with membranous nephropathy has worsening edema, a serum albumin level of 1.8 g/dL, protein excretion of 10 g/day, and preserved kidney function. He develops acute pleuritic chest pain and dyspnea. CT pulmonary angiography confirms bilateral pulmonary emboli. His blood pressure is 126/74 mm Hg, oxygen saturation is 95% on room air, and there is no right ventricular dysfunction. He has no active bleeding or other contraindication to anticoagulation. Which of the following is the most appropriate initial management?

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Correct answer: B — Begin therapeutic-dose anticoagulation

The correct answer is B. This patient has confirmed acute pulmonary embolism and no contraindication to anticoagulation, so therapeutic-dose anticoagulation should be started promptly. Membranous nephropathy with severe hypoalbuminemia and heavy proteinuria creates a marked hypercoagulable state and likely explains the event, but it does not alter the need to treat the established PE. Prophylactic dosing is inadequate once thrombosis has occurred. Systemic thrombolysis is generally reserved for PE causing hemodynamic instability or selected patients who deteriorate despite anticoagulation; this patient is stable and has no right ventricular dysfunction. An inferior vena cava filter is principally considered when therapeutic anticoagulation is contraindicated or cannot be administered. Aspirin does not provide adequate treatment for acute venous thromboembolism.

Reference: Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. Anticoagulation Guidance. 2026. https://www.acc.org/Latest-in-Cardiology/Journal-Scans/2026/02/17/14/32/ACC-AHA-Release-First-Ever-Guideline-For-Treatment-and-Management-of-Acute-PE