Antiphospholipid Syndrome and Kidney Damage: Treatment
Last reviewed: 23.04.2024
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Treatment of kidney damage associated with antiphospholipid syndrome is not clearly defined, since there are no large controlled comparative studies to date assessing the effectiveness of different regimens for this pathology.
- In the treatment of patients with secondary antiphospholipid syndrome within the framework of systemic lupus erythematosus, glucocorticoids and cytostatic drugs are used in doses determined by the activity of the disease. Suppression of the activity of the underlying disease, as a rule, leads to the disappearance of signs of antiphospholipid syndrome. In the primary antiphospholipid syndrome, glucocorticoids and cytotoxic drugs are not used.
- Despite the fact that treatment with glucocorticoids and cytostatic drugs leads to the normalization of the titre of AFL and the disappearance of lupus anticoagulant in the blood, it does not eliminate hypercoagulation, and prednisolone even strengthens it, which preserves the conditions for recurrence of thromboses in various vascular pools, including in the vascular bed kidney. In this regard, in the treatment of nephropathy associated with antiphospholipid syndrome, it is necessary to appoint anticoagulants in the form of monotherapy or in combination with antiaggregants. Eliminating the cause of kidney ischemia (thrombotic occlusion of the intracranial vessels), anticoagulants are able to restore renal blood flow and lead to improved renal function or inhibit the progression of renal failure, which, however, requires confirmation in studies evaluating the clinical efficacy of both direct and indirect anticoagulants in patients antiphospholipid syndrome-associated nephropathy.
- Patients with acute nephropathy associated with antiphospholipid syndrome, the appointment of unfractionated heparin or low-molecular heparins, but the duration of treatment and dose of the drug has not yet been clearly defined.
- In connection with frequent recurrences of thrombosis in patients with antiphospholipid syndrome (including intra-venous vessels), after the end of treatment with heparin, it is advisable to prescribe indirect anticoagulants for prophylactic purposes. Currently, the drug of choice is considered warfarin, the use of which is also shown in the combination of nephropathy associated with antiphospholipid syndrome, CNS, heart and skin lesions. In the chronic course of nephropathy associated with the antiphospholipid syndrome, with slowly progressing renal failure, warfarin appears to be administered without the previous course of direct anticoagulants. The effectiveness of treatment with warfarin is monitored by an internationally normalized ratio (MHO), whose value should be maintained at 2.5-3.0. The therapeutic dose of drugs, allowing to maintain the target level of MHO, is 2.5-10 mg / day. The duration of the use of warfarin is not defined, and the possibility of lifelong treatment is not ruled out.
- For the treatment of catastrophic antiphospholipid syndrome, regardless of its nature (primary, secondary), intensive care methods are used, including pulse therapy with methylprednisolone and cyclophosphamide, direct anticoagulants (low molecular weight heparins) and plasmapheresis to remove antibodies to phospholipids and mediators of intravascular coagulation .
[Prognosis of antiphospholipid syndrome
The prognosis of antiphospholipid syndrome and kidney damage with it, with natural course is unfavorable: a 10-year renal survival rate is 52%.
Risk factors for the development of chronic renal failure in patients with nephropathy associated with antiphospholipid syndrome in primary and secondary antiphospholipid syndrome are severe arterial hypertension, episodes of transient impairment of kidney function, signs of renal ischemia according to USDG data, and morphological changes in renal biopsy specimens (arteriolosclerosis and interstitial fibrosis). In patients with nephropathy associated with antiphospholipid syndrome, with extrarenal arterial thrombosis in history, chronic renal failure develops more often. The only factor that favorably affects the prognosis of nephropathy associated with antiphospholipid syndrome is the treatment with anticoagulants at any stage of the disease course. Anticoagulant therapy contributes to an increase in 10-year renal survival from 52 to 98%.