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Renal Vein Thrombosis

Renal vein thrombosis is a condition characterized by renal dysfunction secondary to a clot blocking the renal vein, which drains blood from the kidney. It is typically seen in patients suffering from nephrotic syndrome, but may also be diagnosed in individuals with renal malignancies, and hypercoagulable states. Clinical symptoms are variable and may be often masked by underlying conditions. Therefore diagnosis is based on clinical suspicion and confirmed with the radiological identification of the blood clot.


Presentation

Renal vein thrombosis (RVT) is a relatively rare condition in which a clot occludes the renal vein draining blood from the kidney and leads to renal vein infarction [1]. The exact reason why there is a predilection of the renal vein for thrombosis in as yet unknown [2]. It occurs most often in patients with nephrotic syndrome but can also affect patients with renal malignancies, anti-glomerular basement membrane disease [3], Behçet syndrome, hypercoagulable states like pregnancy [4], antiphospholipid antibody syndrome and following renal transplantation.

The clinical presentation of RVT in adults is usually insidious and asymptomatic. The first indication of the condition may be when the clot in the renal vein travels to the lungs causing pulmonary embolism with dyspnea and chest pain. Some cases may present with unilateral lower limb swelling. The onset is often sudden in children and some adults with fever, nausea, vomiting, flank pain, oliguria, gross hematuria, and proteinuria which progresses swiftly to renal failure especially in bilateral renal vein thrombosis or in patients with a single kidney [5]. The first symptom is usually flank pain occurring posterior to the lower ribs and in the region of the hips. In patients with renal malignancies, anorexia and weight loss may be predominant while patients with nephrotic syndrome may have anasarca.

Hemophilia A
  • While clotting factor deficiencies are well known causes of hemophilia, their levels should also be measured in the workup of transplant candidates with a history of multiple vascular access thrombosis.[ncbi.nlm.nih.gov]
Vomiting
  • Warfarin can cause rashes, diarrhea, nausea (feeling sick) or vomiting, and hair loss.[en.wikipedia.org]
  • Symptoms of renal failure and sometimes nausea, vomiting, flank pain, gross hematuria, decreased urine output, or systemic manifestations of venous thromboembolism may occur. Diagnosis is by CT, magnetic resonance angiography, or renal venography.[merckmanuals.com]
  • The onset is often sudden in children and some adults with fever, nausea, vomiting, flank pain, oliguria, gross hematuria, and proteinuria which progresses swiftly to renal failure especially in bilateral renal vein thrombosis or in patients with a single[symptoma.com]
  • A 61-year-old woman whose medical history was notable for hypertension and type 2 diabetes reported a two-day history of increasing dull pain in the right flank and nonbloody, bilious vomiting.[nejm.org]
  • However, onset may be acute, causing renal infarction with nausea, vomiting, flank pain, gross hematuria, and decreased urine output.[merckmanuals.com]
Nausea
  • Such patients may be asymptomatic, have minor nonspecific symptoms such as nausea or weakness, or have more specific symptoms such as upper abdominal pain, flank pain, or hematuria.[ncbi.nlm.nih.gov]
  • Symptoms of renal failure and sometimes nausea, vomiting, flank pain, gross hematuria, decreased urine output, or systemic manifestations of venous thromboembolism may occur. Diagnosis is by CT, magnetic resonance angiography, or renal venography.[merckmanuals.com]
  • The onset is often sudden in children and some adults with fever, nausea, vomiting, flank pain, oliguria, gross hematuria, and proteinuria which progresses swiftly to renal failure especially in bilateral renal vein thrombosis or in patients with a single[symptoma.com]
  • However, onset may be acute, causing renal infarction with nausea, vomiting, flank pain, gross hematuria, and decreased urine output.[merckmanuals.com]
  • The person may have fever, nausea, vomiting, less than a normal amount of urine, and blood in the urine.[merck.com]
Hypertension
  • A 61-year-old woman whose medical history was notable for hypertension and type 2 diabetes reported a two-day history of increasing dull pain in the right flank and nonbloody, bilious vomiting.[nejm.org]
  • Most patients (10 of 14) had generalized vague illness and nephrotic syndrome but 4 were initially seen with acute symptoms of flank pain, hematuria or hypertension.[ncbi.nlm.nih.gov]
  • […] artery disease - legs, Peripheral intravenous line - infants, Portacaval shunting, Pulmonary angiography, Pulmonary arteriovenous fistula, Pulmonary embolus, Renal arteriography, Renal cell carcinoma, Renal vein thrombosis, Renal venogram, Renovascular hypertension[ufhealth.org]
  • Characterized by:  Heavy proteinuria ( 3.5g in 24 hours) Hallmark  Hypoalbuminemia ( serum albumin 300mg/dl)  Edema /anasarca  Hypertension  Lipiduria  Hypercoagulabil ity 3.  Renal vein thrombosis (RVT) is common (around 40%) in patient with nephrotic[slideshare.net]
  • In our study, the proportion of subjects with congestive heart failure was greater among the diabetic patients, probably partly as a consequence of hypertension and CHD.[doi.org]
Hematuria
  • CASE PRESENTATION: A 38-year-old woman presented with flank pain and hematuria suggestive of renal calculus on ultrasound.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We report the case of a 43-year-old Caucasian woman, a mother of three sons who presented with left flank pain and hematuria. The clinical investigations did not find any other cause for her thrombophilia.[ncbi.nlm.nih.gov]
  • A 74-year-old male was admitted to our hospital because of gross hematuria with urinary symptoms and intermittent chills.[ncbi.nlm.nih.gov]
  • RVT should always be included in the differential diagnosis of flank pain and hematuria, and because RVT can induce acute renal injury. A 19-year-old man was admitted to our hospital because he complained of right flank pain and oliguria for 3 days.[ncbi.nlm.nih.gov]
  • Abstract A 1-day-old boy born at 37 weeks gestation presented with hematuria, thrombocytopenia, and palpable irregular right flank mass.[ncbi.nlm.nih.gov]
Flank Pain
  • RVT should always be included in the differential diagnosis of flank pain and hematuria, and because RVT can induce acute renal injury. A 19-year-old man was admitted to our hospital because he complained of right flank pain and oliguria for 3 days.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 38-year-old woman presented with flank pain and hematuria suggestive of renal calculus on ultrasound.[ncbi.nlm.nih.gov]
  • However not all the patients with flank pain really suffer for renal colic, although painful somatic irradiation refers to the same areas. CASE REPORT: A seventy years old male patient was admitted from the casualty ward for left renal colic.[ncbi.nlm.nih.gov]
  • We present a patient whose complaint of flank pain led to the diagnosis of a renal vein thrombosis and uncovered massive pulmonary emboli.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We report the case of a 43-year-old Caucasian woman, a mother of three sons who presented with left flank pain and hematuria. The clinical investigations did not find any other cause for her thrombophilia.[ncbi.nlm.nih.gov]
Bladder Distention
  • Here, we report a rare case of RVT that appears to have occurred as a consequence of obstructive uropathy causing massive bladder distention resulting in compression of the renal vein.[ncbi.nlm.nih.gov]
Enlargement of the Prostate
  • Imaging revealed bladder distension, enlargement of the prostate, bilateral hydronephrosis, and left renal vein thrombosis extending into the inferior vena cava.[ncbi.nlm.nih.gov]

Workup

Diagnosis in patients with RVT is difficult as the clinical presentation is often overshadowed by anasarca or weight loss and anemia due to the predisposing conditions like nephrotic syndrome and renal malignancies respectively. Routine laboratory tests like complete blood count, urinalysis, serum blood urea nitrogen (BUN) and creatinine levels may reveal anemia, oliguria/proteinuria, and elevated BUN/ creatinine levels due to renal dysfunction.

The diagnosis of RVT is based on radiological tests. Ultrasonography in the acute stage may reveal renal enlargement with hyperechogenicity [6] and is the first radiological investigation to be performed although it cannot confirm the diagnosis. Computed tomogram with angiography (CTA) is the gold standard investigation with almost 100% sensitivity and specificity [7] as it can detect the occluding thrombus with abnormal renal perfusion [8]. The radiologist can also deduce the presence of a thrombus on CTA indirectly due to signs of renal enlargement, renal vein dilatation, poor renal venous drainage on a nephrogram, delayed corticomedullary differentiation, and renal fascial thickening [7]. Instead of a CTA, magnetic resonance imaging (MRI) is preferred in patients with renal impairment as it can be performed without using nephrotoxic contrast [9]. However, it has a lower sensitivity and specificity as compared to CTA [10].

Escherichia Coli in Blood Culture
  • Urine cultures were positive for Escherichia coli and blood cultures were negative. After 5 days of antibiotic therapy with cefuroxime, inflammatory parameters (CRP level and white blood cell count) remained highly elevated.[ncbi.nlm.nih.gov]

Treatment

  • Abstract Treatment of renal vein thromboses has previously been limited to conventional anticoagulation.[ncbi.nlm.nih.gov]
  • These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.[ncbi.nlm.nih.gov]
  • Evidence-based recommendations on treatment cannot be made at the present time. Cooperative prospective studies that involve multiple centers are needed to elucidate the optimal treatment for neonatal renal vein thrombosis.[ncbi.nlm.nih.gov]
  • Treatment is aimed at prompt relief of venous obstruction and preservation of renal parenchymal function. Interventional radiological procedures, including thrombolysis and thrombectomy, have proven to be valuable in the treatment of RVT.[ncbi.nlm.nih.gov]
  • The aim of this article is to review the published English literature on aetiology, pathology, clinical presentation, diagnostic methods and treatment of renal vein thrombosis.[ncbi.nlm.nih.gov]

Prognosis

  • METHODS: In this report, we describe a fetus with unilateral RVT and summarize the literature regarding prenatal diagnostic criteria and postnatal prognosis.[ncbi.nlm.nih.gov]
  • It carries a grave prognosis for affected kidneys. Anticoagulant and fibrinolytic therapies have been promoted in the past with anecdotal success in some circumstances.[ncbi.nlm.nih.gov]
  • Prognosis Prognosis is determined by the effects on nephrotic syndrome, renal dysfunction or the complications resulting from thromboembolism. Prognosis of any underlying cause is worsened by the onset of acute renal vein thrombosis.[patient.info]
  • With treatment, prognosis is generally good. Treatment is anticoagulation, support of renal function, and treatment of the underlying disorder. Some patients benefit from thrombectomy or nephrectomy. Drugs Mentioned In This Article COUMADIN PANHEPRIN[merckmanuals.com]

Etiology

  • Nephrotic syndrome preceded the hospital admission of the patient and was the etiological cause of renal vein thrombosis.[ncbi.nlm.nih.gov]
  • DISCUSSION: The etiology of fetal RVT is still unclear. Considering the large number of cases with RVT that manifest in the first days of life, prenatal diagnosis of this condition has relevance. 2015 S. Karger AG, Basel.[ncbi.nlm.nih.gov]
  • The etiology is unclear in the majority of cases, although thrombophilia was found in some affected fetuses. Precise ultrasound scan can improve detection rate of neonatal thrombosis due to characteristic findings.[ncbi.nlm.nih.gov]
  • Harrison, Milne, and Steiner (8) recognized 4 etiologic varieties of renal-vein thrombosis: [1] thrombosis of the inferior vena cava and renal veins secondary to extension of thrombi from pelvic or leg veins; [2] thrombotic occlusion of the inferior vena[annals.org]
  • There are numerous etiologies for bland thrombus, but it most commonly occurs in the hypercoagulable nephrotic syndrome .[radiopaedia.org]

Epidemiology

  • Epidemiology The overall prevalence is unknown, as renal vein thrombosis is probably underdiagnosed. it is rare in children and usually due to severe illness, eg asphyxia, severe infection, dehydration.[patient.info]
  • Clinical Investigation and Epidemiology Summary Background: Renal vein thrombosis (RVT) complicating the nephrotic syndrome is associated with a poor prognosis.[link.springer.com]
  • Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands Department of Hematology, Academic Medical Centre, Amsterdam, the Netherlands Search for more papers by this author First published: 15 January 2014 Cited by[doi.org]
  • […] common non–catheter-related thromboembolism in the neonatal period May also be associated with nephrotic syndrome, hypercoagulable states, and oral contraceptive use May present with a clinical triad of flank mass, gross hematuria, and thrombocytopenia Epidemiology[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • Moreover, diffusion-weighted MRI appears to provide important insights into the pathophysiology of delayed graft function and deserves further investigation.[ncbi.nlm.nih.gov]
  • Effective strategies to prevent and treat AD remain elusive despite major efforts to understand its basic biology and clinical pathophysiology. Significant investments in therapeutic ...[doi.org]
  • Supportive treatment includes correction of fluid and electrolyte disturbances and treatment of infection and underlying pathophysiologic abnormalities.[ncbi.nlm.nih.gov]
  • Renal Vein Thrombosis Pathophysiology Blood flow to and away from the kidney is through the renal artery and renal vein respectively. The artery carries oxygen rich blood to the kidney.[healthhype.com]

Prevention

  • A high clinical suspicion and early imaging with computed tomography or magnetic resonance imaging will allow early initiation of therapy and prevention of thrombus extension in patients with RVT.[ncbi.nlm.nih.gov]
  • Peritoneal dialysis is a simple and effective tool to prevent permanent damage to renal function.[ncbi.nlm.nih.gov]
  • Measures aimed at prevention of the disease because of its poor outcome were highlighted.[ncbi.nlm.nih.gov]
  • Fibrinolytic and heparin therapy may play a role in preventing chronic renal failure in neonates with bilateral RVT. However, the use of fibrinolytics early after any major surgery requires tremendous caution.[ncbi.nlm.nih.gov]
  • If you have experienced renal vein thrombosis, call your provider if you have: Decrease in urine output Breathing problems Other new symptoms Prevention In most cases, there is no specific way to prevent renal vein thrombosis.[mountsinai.org]

References

Article

  1. Mansi MK. Postpartum renal infarction secondary to spontaneous renal vein thrombosis. J Urol. 2001;165:893–894.
  2. Harris SL, Smith MP, Laurie A, Darlow BA. Neonatal renal vein thrombosis and prothrombotic risk. Acta Paediatr. 2010 Jul;99(7):1104-7.
  3. Bailey P, Sarfraz F, Ravanan R. Anti-GBM disease and renal vein thrombosis. BMJ Case Rep. 2011 Nov 15;
  4. Mouhsine A, Belkouch A, El Mehdi A et al. Renal vein thrombosis in the postpartum period: a case report. J.Med Case Rep. 2014; 8:462
  5. Harrison CV, Milne MD, Steiner RE. Clinical aspects of renal vein thrombosis. QJ Med. 1956;25:285–301.
  6. Ricci MA, Lloyd DA. Renal venous thrombosis in infants and children. Arch Surg. 1990;125:1195–1199. doi: 10.1001/archsurg.1990.01410210121019.
  7. Alvarez-Castells A, Sebastia CC, Quiroga GS. Computerized tomography angiography of renal vessels. Arch Esp Urol. 2001;54:603–615.
  8. Kawashima A, Sandler CM, Ernst RD, et al. CT evaluation of renovascular disease. Radiographics. 2000;20 (5):1321-40.
  9. Tempany CM, Morton RA, Marshall FF. MRI of the renal veins: assessment of nonneoplastic venous thrombosis. J Comput Assist Tomogr. 1992;16 (6): 929-34.
  10. Hodgson DJ, Jan W, Rankin S, et al. Magnetic resonance renal angiography and venography: an analysis of 111 consecutive scans before donor nephrectomy. BJU Int. 2006;97:584–586.

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Last updated: 2018-06-22 01:11