* - Mycophenolate Mofetil dose was 500 mg twice per day
** - prednisolone in reducing dosage
DISCUSSION
In this case report, we present the case of patient with systemic lupus erythematosus with nephrotic syndrome and increased aPTT due to lupus anticoagulant. The observed bleeding could be associated with thrombocytopenia, however it disappeared with decreasing of aPTT despite persisting thrombocytopenia. The immunosuppressive treatment with prednisolone corrected aPTT. In this case the transfusion of serum would not improve aPTT as it was reflected in aPTT mixing study results. Because of increased aPTT we were not able to do the kidney biopsy. Renal biopsy was crucial to diagnose a specific form and stage of lupus nephritis. Kidney biopsy should be done in all patients with lupus nephritis and nephrotic range proteinuria (8). Reduced prednisolone dose with mycophenolate mofetil treatment have the same impact on aPTT than treatment with high dose of prednisolone alone. Proteinuria decreased during the immunosuppressive therapy however no decreased of serum creatine during the follow-up period was observed. New onset atrial fibrillation was observed in the patient during the therapy. Due to the high risk of stroke associated with atrial fibrillation, anticoagulant therapy was necessary. Choice of anticoagulation treatment was limited due to NOAC influence on aPTT assay(9) and concern for the high risk of HIT development(10). The initiated vitamin K antagonist therapy did not interfere with aPTT and did not cause any bleeding during the follow-up period.
CONCLUSION
Bleeding complications although rare have to be taken into account in patients with lupus anticoagulant. Increased aPTT can be observed in those patients combined with other coagulation disorders i.e. thrombocytopenia or acquired factor II deficiency. Anticoagulation treatment in SLE patients might be a challenge because of limited treatment options.
ACKNOWLEDGMENTS
We kindly thank the patient for allowing us to present her case. Written informed consent was obtained to share and publish the case details.
AUTHOR CONTRIBUTIONS
MF, PP, AK were actively involved in the clinical care of the patient. MF wrote the manuscript. PP, AK and DM revised the manuscript.
CONFLICT OF INTEREST
The authors confirm that this article content has no conflict of interest.
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