Personalized prophylactic anticoagulation decision analysis in patients with membranous nephropathy

Taewoo Lee, Andrea K. Biddle, Sofia Lionaki, Vimal K. Derebail, Sean J. Barbour, Sameer Tannous, Michelle A. Hladunewich, Yichun Hu, Caroline J. Poulton, Shannon L. Mahoney, J. Charles Jennette, Susan L. Hogan, Ronald J. Falk, Daniel C. Cattran, Heather N. Reich, Patrick H. Nachman

Research output: Contribution to journalArticlepeer-review

68 Scopus citations


Primary membranous nephropathy is associated with increased risk of venous thromboembolic events, which are inversely correlated with serum albumin levels. To evaluate the potential benefit of prophylactic anticoagulation (venous thromboembolic events prevented) relative to the risk (major bleeds), we constructed a Markov decision model. The venous thromboembolic event risk according to serum albumin was obtained from an inception cohort of 898 patients with primary membranous nephropathy. Risk estimates of hemorrhage were obtained from a systematic literature review. Benefit-to-risk ratios were predicted according to bleeding risk and serum albumin. This ratio increased with worsening hypoalbuminemia from 4.5:1 for an albumin under 3 g/dl to 13.1:1 for an albumin under 2 g/dl in patients at low bleeding risk. Patients at intermediate bleeding risk with an albumin under 2 g/dl have a moderately favorable benefit-to-risk ratio (under 5:1). Patients at high bleeding risk are unlikely to benefit from prophylactic anticoagulation regardless of albuminemia. Probabilistic sensitivity analysis, to account for uncertainty in risk estimates, confirmed these trends. From these data, we constructed a tool to estimate the likelihood of benefit based on an individual's bleeding risk profile, serum albumin level, and acceptable benefit-to-risk ratio ( This tool provides an approach to the decision of prophylactic anticoagulation personalized to the individual's needs and adaptable to dynamic changes in health status and risk profile.

Original languageEnglish (US)
Pages (from-to)1412-1420
Number of pages9
JournalKidney international
Issue number6
StatePublished - Jun 2014
Externally publishedYes

Bibliographical note

Funding Information:
We are indebted to the contribution of the nephrologists of the Greater Toronto Area and of the Glomerular Disease Collaborative Network. This work would not be possible without the contribution of registrars N Ryan and P Ling. TL was supported by the UNC Kidney Center. VKD was funded by the Duke-UNC Clinical Hematology Research Career Development Program 5K12HL087097-05’ PI (Telen). SJB was supported by a fellowship award from the Clinician Investigator Program at the University of British Columbia.


  • anticoagulation
  • membranous nephropathy
  • thrombosis


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