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Rare Case of Chronic Limb-Threatening Ischemia in a 32-Year-Old Patient with Nephrotic Syndrome: A Case ReportFunding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Chronic limb-threatening ischemia represents the end stage of peripheral artery disease (PAD), primarily affecting individuals over 60 years old. While quite rare, nephrotic syndrome (NS) is recognized for increasing the susceptibility to arterial thromboembolism (ATE). A 32-year-old male complained of resting pain in his left leg and pain after walking 50 meters with his right leg. He had a 9-year history of NS confirmed through biopsy and was on a daily regimen of 2 × 360 mg mycophenolic acid and 1 × 8 mg methylprednisolone. He had no history of hypertension, diabetes, or smoking. Atrophy and ulcers were observed on his left leg. Laboratory tests revealed elevated D-dimer and borderline high cholesterol levels. The right ankle-brachial index was 0.5, and for the left, it was 0.33. Computed tomography angiography identified occlusion in the left external iliac artery and right superficial femoral artery (SFA). The patient underwent percutaneous transluminal angioplasty with a plain balloon on both legs and an additional drug-eluting stent on the left SFA. He was discharged on rivaroxaban, clopidogrel, aspirin, simvastatin, mycophenolic acid, and methylprednisolone, with no complaints. The mechanism behind NS-caused ATE remains unclear, although it is associated with the loss of anticoagulants in urine, increased procoagulant activity, altered fibrinolytic systems, thrombocytosis, and enhanced platelet activation. Prolonged corticosteroid therapy in NS management also amplifies the risk of thromboembolism by promoting a hypercoagulable state. We suspected NS and the prolonged use of corticosteroids as risk factors for ATE, manifested as PAD in our patient. While optimal NS therapy may reduce the risk of PAD, prolonged corticosteroid use should be closely monitored.
Keywordschronic limb-threatening ischemia - peripheral artery disease - arterial thromboembolism - nephrotic syndrome - corticosteroid - percutaneous transluminal angioplasty - young
Informed consent has been obtained from the patient for publication of the case report and accompanying images.
Article published online:
14 September 2023
© 2023. International College of Angiology. This article is published by Thieme.
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- 1 Conte MS, Bradbury AW, Kolh P. et al; GVG Writing Group. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69 (6S): 3S , e40
- 2 Simon F, Oberhuber A, Floros N, Düppers P, Schelzig H, Duran M. Pathophysiology of chronic limb ischemia. Gefasschirurgie 2018; 23 (1, suppl 1): 13-18
- 3 Conrad N, Verbeke G, Molenberghs G. et al. Autoimmune diseases and cardiovascular risk: a population-based study on 19 autoimmune diseases and 12 cardiovascular diseases in 22 million individuals in the UK. Lancet 2022; 400 (10354): 733-743
- 4 Akinyosoye G, Solarin AU, Dada A. et al. Prevalence and determinants of peripheral arterial disease in children with nephrotic syndrome. PLoS One 2022; 17 (08) e0266432
- 5 Vestergaard SV, Birn H, Darvalics B, Nitsch D, Sørensen HT, Christiansen CF. Risk of arterial thromboembolism, venous thromboembolism, and bleeding in patients with nephrotic syndrome: a population-based cohort study. Am J Med 2022; 135 (05) 615-625.e9
- 6 Mahmoodi BK, ten Kate MK, Waanders F. et al. High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: results from a large retrospective cohort study. Circulation 2008; 117 (02) 224-230
- 7 Boussetta A, Jaber C, Jellouli M, Gargah T. Thromboembolic complications in children with primary nephrotic syndrome: a Tunisian series. Tunis Med 2022; 100 (01) 33-36
- 8 Rastoder E, Sivapalan P, Eklöf J. et al. Systemic corticosteroids and the risk of venous thromboembolism in patients with severe COPD: a nationwide study of 30,473 outpatients. Biomedicines 2021; 9 (08) 874
- 9 Arrab R, Bourrahouate A, Sbihi M, Ait Sab I. Thrombose artérielle du membre inférieur sur un syndrome néphrotique. Nephrol Ther 2017; 13 (04) 248-250
- 10 Singhal R, Brimble KS. Thromboembolic complications in the nephrotic syndrome: pathophysiology and clinical management. Thromb Res 2006; 118 (03) 397-407
- 11 Beckman JA, Schneider PA, Conte MS. Advances in revascularization for peripheral artery disease: revascularization in PAD. Circ Res 2021; 128 (12) 1885-1912
- 12 von Groote TC, Williams G, Au EH. et al. Immunosuppressive treatment for primary membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev [Internet]. 2021. Accessed March 11, 2023 at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004293.pub4/abstract
- 13 Lin R, McDonald G, Jolly T, Batten A, Chacko B. A systematic review of prophylactic anticoagulation in nephrotic syndrome. Kidney Int Rep 2019; 5 (04) 435-447