American Board of Internal Medicine (ABIM) Certification Practice Exam

Which condition is associated with the highest propensity for thromboembolic events in nephrotic syndrome?

1. Focal segmental glomerulosclerosis

2. Minimal change disease

3. Membranous glomerulopathy

4. Lupus nephritis

The correct answer is: Membranous glomerulopathy

Membranous glomerulopathy is associated with the highest propensity for thromboembolic events in nephrotic syndrome due to several underlying pathophysiological mechanisms. In nephrotic syndrome, there is significant proteinuria leading to hypoalbuminemia, which in turn decreases plasma oncotic pressure. This results in intravascular volume contraction and a compensatory hypercoagulable state. Membranous glomerulopathy is particularly noted for causing a marked increase in the risk of thrombosis compared to other types of nephrotic syndrome. The presence of nephrotic syndrome leads to changes in the coagulation cascade, including increased levels of factors that promote coagulation (such as factor V and fibrinogen) as well as decreased levels of natural anticoagulants (like antithrombin III). This hypercoagulability is further exacerbated by the renal loss of anticoagulants, a phenomenon especially relevant in membranous glomerulopathy. In this context, while other conditions like focal segmental glomerulosclerosis, minimal change disease, and lupus nephritis can also lead to nephrotic syndrome and may carry some risk for thromboembolic events, they do not exhibit the same level of risk seen with membr