Dr Takuma Konno1, Dr Joshua Choo1, Dr Valli Manickam1
1Townsville University Hospital, Townsville , Australia
Biography:
Takuma Konno is a resident medical officer at Townsville University Hospital with a keen clinical interest in renal medicine.
Background:
Nephrotic syndrome (NS) arising during the peripartum period presents complex diagnostic and therapeutic challenges, compounded by the physiological changes of pregnancy and heightened thrombotic risk. Kidney biopsy remains the gold standard for diagnosing underlying glomerular disease; however concurrent conditions like pulmonary embolism (PE) requiring therapeutic anticoagulation significantly increase procedural risk delaying definitive diagnosis. We present a case of peripartum NS complicated by PE, where therapeutic anticoagulation precluded immediate biopsy, necessitating the empirical initiation of high-dose corticosteroid therapy.
Case Presentation:
A 26-year-old Aboriginal female presented on postpartum day 8 with NS complicated by bilateral PE. Imaging demonstrated a large thrombus in the right pulmonary artery, segmental thrombi in the left pulmonary circulation, and right lower lobe infarction. Laboratory evaluation revealed severe proteinuria (peak urine protein-to-creatinine ratio [uPCR] 3500 mg/mmol), profound hypoalbuminemia (serum albumin 4 g/L), and preserved kidney function (estimated glomerular filtration rate [eGFR]>90 mL/min/1.73m2). Viral serologies and autoimmune markers were negative. Given the elevated bleeding risk from therapeutic anticoagulation for acute PE, kidney biopsy was deferred. Empirical high-dose corticosteroid therapy was initiated with prednisolone at 1 mg/kg daily for 4 weeks followed by gradual tapering upon clinical remission. The treatment plan targeted a total corticosteroid exposure of 16 weeks. The patient demonstrated a favourable clinical response, with resolution of proteinuria and normalisation of serum albumin, consistent with a steroid-sensitive nephrotic syndrome. A presumptive diagnosis of minimal change disease was made.
Conclusion:
This case highlights the diagnostic and therapeutic challenges of managing nephrotic syndrome in the peripartum period complicated by acute PE requiring therapeutic anticoagulation. In such scenarios, empirical corticosteroid therapy guided by clinical presentation and treatment response, can serve as an effective interim strategy.