* - 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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