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Imam AA, Saadeh SA. Evaluation of Proteinuria and Hematuria in Ambulatory Setting. Pediatr Clin North Am 2022; 69:1037-1049. [PMID: 36880921 DOI: 10.1016/j.pcl.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Proteinuria and/or hematuria are common findings in ambulatory settings. Proteinuria can be glomerular and/or tubular in origin and it may be transient, orthostatic, or persistent. Persistent proteinuria may be indicative of a serious kidney pathology. Hematuria, which denotes the presence of an increased number of red blood cells in the urine, can be gross or microscopic. Hematuria can originate from the glomeruli or other sites of the urinary tract. Asymptomatic microscopic hematuria or mild proteinuria in an otherwise healthy child is less likely to be of clinical significance. However, the presence of both requires further workup and careful monitoring.
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Affiliation(s)
- Abubakr A Imam
- Nephrology & Hypertension, Department of Pediatrics, Sidra Medicine, College of Medicine, Qatar University, Weill Cornell Medicine-Qatar, PO Box 26999, Doha, Qatar.
| | - Sermin A Saadeh
- Department of Pediatrics - MBC 58, Pediatric Nephrology, King Faisal Specialist Hospital and Research Center, (KFSH&RC), King Faisal University, PO Box 3354, Riyadh 11211, KSA
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Meyer J, Rother U, Stehr M, Meyer A. Nutcracker syndrome in children: Appearance, diagnostics, and treatment - A systematic review. J Pediatr Surg 2022; 57:716-722. [PMID: 35065803 DOI: 10.1016/j.jpedsurg.2021.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND The nutcracker syndrome (NCS) is defined by compression of the left renal vein (LVR) and may present with a wide variety of symptoms. Due to its rarity in pediatric patients, incidence, diagnostics and performed therapy regimen are widely undefined. To this date, there are only case reports and small collectives of pediatric patients described but comprehensive research is lacking. METHODS A systematic literature research on pediatric NCS was carried out on Medline and Scopus databases according to PRISMA principles using predefined search terms and inclusion criteria. The PROSPERO registered review (CRD42021237415) identified patients' characteristics regarding age, sex, clinical symptoms, applied diagnostic methods and treatment options. RESULTS In total 47 articles were included. Overall, 423 children (218 boys and 205 girls) with diagnosed NCS were included in the analysis. Mean age was 12.0 (boys 12.9, girls 12.0) years. Hematuria was most common presentation (55.5%), followed by proteinuria (49.9%). Classical flank pain was only detected in 19.1% of patients. Sonographic evaluation was the most commonly used diagnostic tool (99%). Invasive diagnostic studies were performed in 97 children. 86.8% patients were treated conservatively and 94.9% showed complete resolution (42.8%) or at least improvement (52.2%) of symptoms. Type of operative treatment comprised of open surgery with transposition of LRV, endovascular stenting and laparoscopy. CONCLUSIONS Overall, data quality regarding NCS in children is poor. However, conservative approach in pediatric patients is recommended and should be regarded first treatment option. Diagnostic and treatment should follow a defined algorithm when NCS is suspected. Sufficient observation and follow-up must be assured in all patients to get significant results in this heterogenous syndrome. LEVEL OF EVIDENCE V-IV.
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Affiliation(s)
- Johannes Meyer
- Department for Pediatric Surgery and Pediatric Urology, Cnopfsche Children´s Hospital, St.-Johannis Mühlgasse 19, Nürnberg 90419, Germany.
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, Erlangen 91054, Germany
| | - Maximilian Stehr
- Department for Pediatric Surgery and Pediatric Urology, Cnopfsche Children´s Hospital, St.-Johannis Mühlgasse 19, Nürnberg 90419, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, Erlangen 91054, Germany
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Proteinuria from first-morning urine in a child due to brace treatment for adolescent idiopathic scoliosis. CEN Case Rep 2022; 11:490-493. [DOI: 10.1007/s13730-022-00708-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/20/2022] [Indexed: 10/18/2022] Open
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Niu XL, Wu Y, Hao S, Wang P, Kang YL, Kuang XY, Zhu GH, Huang WY. Value of micro-proteinuria in combination with ultrasonography of the left renal vein in the diagnosis of orthostatic proteinuria. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:780. [PMID: 32042796 DOI: 10.21037/atm.2019.11.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to evaluate the clinical value of micro-proteinuria in combination with ultrasonography of the left renal vein (LRV) in the diagnosis of orthostatic proteinuria (OP). Methods The patients with suspected OP received West test, upright lordotic position test, Robinson test, ultrasonography of the LRV, and detection of morning urine micro-proteinuria and micro-proteinuria after activity. The sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (PLR and NLR) and Youden's index (YI) for micro-proteinuria, ultrasonography of the LRV and both of them in the diagnosis of OP were analyzed. Results From January 2013 to January 2018, 75 patients (M/F: 38/37) were recruited. Sixty patients were diagnosed with OP (M/F: 29/31, median age at onset: 10.6±2.80 years); 15 patients had no OP (M/F: 9/6, median age at onset: 10.9±3.25 years); the LRV entrapment, urine Alb/Cr, IgG/Cr, and NAG/Cr after activity were significantly different between OP group and non-OP group (Z=-3.55, -4.10, -4.01, -3.04, P<0.05). The area under the curve (AUC) of urine Alb/Cr, IgG/Cr, NAG/Cr, and the ratio of anteroposterior (AP) for LRV in the hilar and narrow portions (a/b) was 0.84, 0.84, 0.76 and 0.58, respectively, and the best cut-off value was 13.2 mg/mmol, 2.52 mg/mmol, 0.64 U/mmol and 4.06, respectively. The combination of ultrasonography of the LRV and elevated micro-proteinuria after activity could achieve the Se, Sp, PPV, NPV, PLR (weighted by prevalence, W), NLR (W) and YI at 93.3% (95% CI: 0.83-0.98), 66.7% (95% CI: 0.39-0.87), 91.8% (95% CI: 0.81-0.97), 71.4% (95% CI: 0.42-0.90), 11.2 (95% CI: 4.82-26.00), 0.40 (95% CI: 0.17-0.97) and 60%, respectively, in the diagnosis of OP. Conclusions The micro-proteinuria in combination of ultrasonography of the LRV is helpful for the preliminary screening of OP in patients with suspected OP.
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Affiliation(s)
- Xiao-Ling Niu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Ying Wu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Sheng Hao
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Ping Wang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Yu-Lin Kang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Xin-Yu Kuang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Guang-Hua Zhu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Wen-Yan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
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Patel PA, Stojanovic J. Diagnosis and Treatment of Renovascular Disease in Children. Semin Roentgenol 2019; 54:367-383. [PMID: 31706370 DOI: 10.1053/j.ro.2019.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Premal A Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital for Children, London, United Kingdom.
| | - Jelena Stojanovic
- Renal Unit, Great Ormond Street Hospital for Children, London, United Kingdom
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Nishizaki N, Obinata K, Nakagawa M, Shimizu T. Orthostatic proteinuria due to smartphone use in bed. Nephrology (Carlton) 2019; 23:797. [PMID: 30920105 DOI: 10.1111/nep.13170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Naoto Nishizaki
- Department of Pediatrics, Juntendo University Urayasu Hospital, Chiba, Japan.,Department of Pediatrics, Tokyo Rinkai Hospital, Tokyo, Japan
| | - Kaoru Obinata
- Department of Pediatrics, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Mayu Nakagawa
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
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Kanai H, Sawanobori E, Kobayashi A, Goto M, Higashida K, Sugita K. Urinary fibrin/fibrinogen degradation products measured using an anti-fibrinogen antibody predict orthostatic proteinuria. Pediatr Int 2018; 60:639-644. [PMID: 29654610 DOI: 10.1111/ped.13576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to assess the diagnostic value of urinary fibrin/fibrinogen degradation products (uFDP) measured using an anti-fibrinogen antibody in patients with orthostatic proteinuria (OP), and their use in differentiating between OP and glomerulonephritis (GN). METHODS uFDP were measured using first urine in the morning (supine) and non-first urine during a hospital visit (upright) and then normalized to urine creatinine (uFDP/Cr, ng/mgCr). We compared (i) OP patients (n = 16); (ii) those in remission from nephrotic syndrome (NS, n = 14) and from GN (IgA nephropathy [IgAN], n = 14; Henoch-Schönlein purpura nephritis [HSPN], n = 12); and (iii) those with active GN (IgAN, n = 12; HSPN, n = 19). RESULTS The uFDP/Cr ratio increased from supine to upright urine in patients with OP (P < 0.001), but decreased in one case. uFDP were excreted in supine urine in 94% of OP patients, with no excretion in NS remission patients or in 92% of GN remission patients (P < 0.001 for both). uFDP/Cr in supine urine was similar between the OP and active GN patients (P = 0.40), whereas proteinuria in supine urine was in the normal range in all OP patients, but was significantly higher in upright urine in the OP patients (P < 0.001). In upright urine, urinary protein/creatinine ratio was significantly lower in patients with OP than in those with active GN (P = 0.005). A uFDP/Cr ratio cut-off of 1,108 ng/mgCr in upright urine correctly differentiated OP from active GN, with a sensitivity of 87.5% and a specificity of 100%. CONCLUSION Comparison of uFDP levels in supine/upright urine can be reliable for diagnosing OP and for differentiating it from active GN.
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Affiliation(s)
- Hiroaki Kanai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Anna Kobayashi
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Miwa Goto
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kosuke Higashida
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kanji Sugita
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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A rare case of nutcracker phenomenon with nephrotic syndrome. Int Urol Nephrol 2015; 48:631-2. [PMID: 26589612 DOI: 10.1007/s11255-015-1158-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
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Yavuz S, Kıyak A, Er A, Korkmaz O. The utility of bioimpedance analysis for monitoring the children with nutcracker syndrome. Eur J Pediatr 2015; 174:1393-7. [PMID: 25922138 DOI: 10.1007/s00431-015-2535-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED We aimed to evaluate anthropometric and bioimpedance analysis (BIA) indices of children with nutcracker syndrome (NCS). Eighteen patients and 20 age-gender matched controls were enrolled. Weight, height, body mass index (BMI), mid-arm circumference (MAC), waist circumference (WC), waist/hip ratio measurements, and BIA results were assessed. Laboratory parameters and Doppler sonographic findings were recorded. The weight, BMI, MAC, WC, body fat z scores, and waist/hip ratio were significantly lower in patients than in controls (p < 0.05). Serum creatinine (Scr), albumin, HDL cholesterol, and urine protein (Up) were significantly increased in NCS patients compared to controls (p < 0.05). On multivariate analysis, body fat z score was independently related to Up and the degree of superior mesenteric artery (SMA) angle (beta = -0.965, p = 0.018 and beta = 0.841, p = 0.04, respectively). CONCLUSION NCS might be considered in slim proteinuric patients with unproven etiology. Serial anthropometric measurements and BIA analysis would estimate the severity of entrapment in LRV. Long-term follow-up of Scr might be required in NCS. WHAT IS KNOWN • Nutcracker syndrome (NCS) is very rare and characterized by the compression of LRV between aorta and SMA. What is new: • Patients with NCS have a slimmer body feature with lower anthropometric and BIA indices. • Fat percentage indicates the degree of LRV entrapment and amount of proteinuria in NCS.
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Affiliation(s)
- Sevgi Yavuz
- Division of Pediatric Nephrology, Kanuni Sultan Suleyman Training and Research Hospital, 34303, Istanbul, Turkey.
| | - Aysel Kıyak
- Division of Pediatric Nephrology, Kanuni Sultan Suleyman Training and Research Hospital, 34303, Istanbul, Turkey.
| | - Ali Er
- Department of Radiology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Orhan Korkmaz
- Department of Radiology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
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Minimal Change Disease as a Secondary and Reversible Event of a Renal Transplant Case with Systemic Lupus Erythematosus. Case Rep Nephrol 2015; 2015:987212. [PMID: 26351598 PMCID: PMC4550805 DOI: 10.1155/2015/987212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/30/2015] [Accepted: 08/02/2015] [Indexed: 11/23/2022] Open
Abstract
Secondary causes of minimal change disease (MCD) account for a minority of cases compared to its primary or idiopathic form and provide ground for consideration of common mechanisms of pathogenesis. In this paper we report a case of a 27-year-old Latina woman, a renal transplant recipient with systemic lupus erythematosus (SLE), who developed nephrotic range proteinuria 6 months after transplantation. The patient had recurrent acute renal failure and multiple biopsies were consistent with MCD. However, she lacked any other features of the typical nephrotic syndrome. An angiogram revealed a right external iliac vein stenosis in the region of renal vein anastomosis, which when restored resulted in normalization of creatinine and relief from proteinuria. We report a rare case of MCD developing secondary to iliac vein stenosis in a renal transplant recipient with SLE. Additionally we suggest that, in the event of biopsy-proven MCD presenting as an atypical nephrotic syndrome, alternative or secondary, potentially reversible, causes should be considered and explored.
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Uehara K, Tominaga N, Shibagaki Y. Adult orthostatic proteinuria. Clin Kidney J 2014; 7:327-8. [PMID: 25852903 PMCID: PMC4377758 DOI: 10.1093/ckj/sfu040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/17/2014] [Indexed: 12/04/2022] Open
Affiliation(s)
- Keita Uehara
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
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Clinical course of children with nutcracker syndrome. Urology 2013; 82:686-90. [PMID: 23735609 DOI: 10.1016/j.urology.2013.03.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/14/2013] [Accepted: 03/25/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the clinical properties of patients with nutcracker syndrome (NCS). MATERIALS AND METHODS The medical records of the patients with NCS were retrospectively investigated, and the patients' sex, age, presenting symptoms, urinalysis findings, associated diseases, and body mass indexes were recorded. RESULTS A total of 23 nonconsanguineous patients (11 male and 12 female patients, mean age 141 ± 36 months). Two patients had posterior NCS. Seventeen patients presented with 1 or >1 symptom. Fatigue and lassitude (n = 1), flank pain (n = 8), abdominal pain (n = 7), varicocele (n = 2), and macroscopic hematuria (n = 9) were the presenting symptoms. Only 6 patients had received a diagnosis of NCS from the urinalysis findings, which revealed microscopic hematuria or non-nephrotic proteinuria. The urinalysis findings disclosed isolated proteinuria in 6, hematuria plus proteinuria in 8, and macroscopic hematuria in 9 patients. Orthostatic proteinuria was detected in 7 patients. In patients with regressed hematuria and proteinuria, the body mass index was markedly increased at the end of the follow-up period relative to at diagnosis (at diagnosis 16.9 ± 4.0 kg/m(2); at the end of the follow-up period 18.6 ± 4.6 kg/m(2); P = .028). CONCLUSION The diagnosis of NCS should be considered in the presence of symptoms such as proteinuria and hematuria and should be absolutely ruled out before attempting renal biopsy. An apparent correlation between an increased body mass index and regression of symptoms was seen.
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Poyraz AK, Firdolas F, Onur MR, Kocakoc E. Evaluation of left renal vein entrapment using multidetector computed tomography. Acta Radiol 2013; 54:144-8. [PMID: 23117197 DOI: 10.1258/ar.2012.120355] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nutcracker syndrome, also called left renal vein entrapment syndrome, is a cause of non-glomerular hematuria with difficulties in diagnosis. Multidetector computed tomography (MDCT) is a powerful tool to prevent unnecessary diagnostic procedures. PURPOSE To retrospectively determine the prevalence of nutcracker phenomenon and nutcracker syndrome seen in MDCT in consecutive patients. MATERIAL AND METHODS The institutional review board approved the study and waived the requirement for informed consent. Abdominal contrast-enhanced MDCT scans were reviewed from 1000 consecutive patients. MDCT scan assessment included renal vein diameter measurements and evaluation for the presence of anterior or posterior left renal vein entrapment. Electronic medical records and urine analysis reports of patients with left renal vein entrapment were reviewed. Student's t test was used to assess differences in renal vein diameter in patients with left renal vein entrapment. RESULTS Left renal vein entrapment was observed in 10.9% (109), retro-aortic left renal vein in 6.5% (65), entrapment of left renal vein between superior mesenteric artery and aorta in 4.1% (41), and circumaortic left renal vein in 0.3% (3) of patients. Mean diameters of right (8.8 ± 1.9 mm) and unentrapped left (8.9 ± 1.8 mm) renal veins were not significantly different (P = 0.1). The mean diameter of anterior entrapped left renal veins (10.3 ± 2 mm) was significantly greater (P = 0.04) than contralateral renal veins (8.6 ± 2.1 mm) in their widest portion. In 8.8% of patients with the left renal vein entrapment, urine analysis showed isomorphic hematuria or proteinuria with no other known cause. Varicocele and pelvic congestion were seen in 5.5% of patients with the left renal vein entrapment. CONCLUSION Left renal vein entrapment is not a rare entity and renal nutcracker phenomenon might be underdiagnosed.
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Affiliation(s)
- Ahmet K Poyraz
- Department of Radiology, Firat University School of Medicine, Elazig
| | - Fatih Firdolas
- Department of Urology, Firat University School of Medicine, Elazig
| | - Mehmet R Onur
- Department of Radiology, Firat University School of Medicine, Elazig
| | - Ercan Kocakoc
- Department of Radiology, Bezmialem Vakif University, School of Medicine, Istanbul, Turkey
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Gong XY, Zheng W, Du H, Lei Y, Xue YH, Xue CH, An XC, Zheng G. Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis: Case report of three cases. ASIAN PAC J TROP MED 2012; 5:923-4. [DOI: 10.1016/s1995-7645(12)60174-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 08/15/2012] [Accepted: 09/15/2012] [Indexed: 11/26/2022] Open
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Newly-identified symptoms of left renal vein entrapment syndrome mimicking orthostatic disturbance. World J Pediatr 2012; 8:116-22. [PMID: 22573421 DOI: 10.1007/s12519-012-0349-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Accepted: 07/04/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND In addition to the urinary abnormalities, symptoms of left renal vein entrapment between the aorta and superior mesenteric artery (left renal vein entrapment syndrome, LRVES) may include abdominal and flank pain as well as chronic fatigue. We investigated various LRVES symptoms in this study. METHODS In 53 pediatric LRVES patients treated at our department, 22 had a score of 5 points or higher on orthostasis. Initial evaluation of LRVES by abdominal ultrasonography showed a stenotic-to-prestenotic vein diameter ratio of 0.2 or less. Definitive diagnosis was made by computed tomography and magnetic resonance angiography. Cortisol, catecholamine (CA), and brain natriuretic peptide (BNP) were also measured. RESULTS The frequency of LRVES was 2.5 times higher in girls than in boys. Low or very low body mass indexes were seen in both sexes. The most common initial finding was urine abnormalities, followed by dizziness and malaise. In 6 patients, orthostasis precluded school attendance. Ten patients had orthostasis scores above 12. Patients unable to attend school had either low levels of plasma or urinary cortisol. Midodrine significantly decreased orthostasis scores. Some patients required treatment with fludrocortisone. Plasma CA, renin, and BNP levels were all normal. CONCLUSIONS Locally excessive venous pressure may cause reversible adrenal dysfunction with transitory Addisonian symptoms. Children with cryptogenic malaise or severe orthostasis should be evaluated for LRVES.
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Ozçakar ZB, Yalçınkaya F, Fitöz S, Cipe G, Soygür T, Ozdemir H, Köksoy C. Nutcracker syndrome manifesting with severe proteinuria: a challenging scenario in a single-kidney patient. Pediatr Nephrol 2011; 26:987-90. [PMID: 21318458 DOI: 10.1007/s00467-011-1793-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 12/08/2010] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
Nutcracker syndrome (NS) refers to compression of the left renal vein between the aorta and the superior mesenteric artery which results in left renal venous hypertension. The typical clinical presenting feature is hematuria. In this report we describe the case of patient with a single kidney who developed severe proteinuria due to NS. She was successfully treated with left renal vein transposition. This case clearly shows the relation between NS and severe proteinuria based on normal biopsy findings and the complete disappearance of proteinuria following surgery.
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Affiliation(s)
- Z Birsin Ozçakar
- Department of Pediatric Nephrology, Ankara University School of Medicine, Cebeci, Ankara, Turkey.
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Sebestyen JF, Alon US. The teenager with asymptomatic proteinuria: think orthostatic first. Clin Pediatr (Phila) 2011; 50:179-82. [PMID: 20837623 DOI: 10.1177/0009922810380904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Judith F Sebestyen
- University of Missouri at Kansas City School of Medicine, Kansas City, MO 64108, USA
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Mohammadi A, Ghasemi-Rad M, Mladkova N, Masudi S. Varicocele and nutcracker syndrome: sonographic findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:1153-1160. [PMID: 20660448 DOI: 10.7863/jum.2010.29.8.1153] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome. METHODS A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured. RESULTS A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both). CONCLUSIONS Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.
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Affiliation(s)
- Afshin Mohammadi
- Department of Radiology, Urmia University of Medical Sciences, Urmia, West-Azerbaijan, Iran
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Mazzoni MBM, Kottanatu L, Simonetti GD, Ragazzi M, Bianchetti MG, Fossali EF, Milani GP. Renal vein obstruction and orthostatic proteinuria: a review. Nephrol Dial Transplant 2010; 26:562-5. [PMID: 20656752 DOI: 10.1093/ndt/gfq444] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The cause of orthostatic proteinuria is not clear but may often relate to obstruction of the left renal vein in the fork between the aorta and the superior mesenteric artery (=renal nutcracker). However, reports dealing with proteinuria only marginally refer to this possible cause of orthostatic proteinuria. We analysed the corresponding literature. RESULTS Five reports addressed the frequency of renal nutcracker in 229 subjects with orthostatic proteinuria. Their age ranged between 5.2 and 17 years (female-to-male ratio: 0.96:1.00). Imaging studies demonstrated renal nutcracker in 156 (68%) subjects. Renal nutcracker was also demonstrated in 9 anecdotal reports for a total of 53 subjects with postural proteinuria. Very recently, 13 Italian subjects with orthostatic proteinuria associated with renal nutcracker were reassessed 6 years after the initial diagnosis: in nine subjects, both orthostatic proteinuria and renal nutcracker had disappeared; in three, both orthostatic proteinuria and renal nutcracker had persisted; and in one, orthostatic proteinuria had persisted unassociated with renal nutcracker. CONCLUSIONS These data provide substantial support for renal nutcracker as a common cause of orthostatic proteinuria.
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Affiliation(s)
- Marta B M Mazzoni
- Emergency Unit, Clinica Pediatrica De Marchi, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Milani GP, Mazzoni MB, Burdick L, Bianchetti MG, Fossali EF. Postural Proteinuria Associated With Left Renal Vein Entrapment: A Follow-up Evaluation. Am J Kidney Dis 2010; 55:e29-31. [DOI: 10.1053/j.ajkd.2010.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 03/01/2010] [Indexed: 11/11/2022]
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Abstract
Nutcracker phenomenon refers to compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The nutcracker syndrome (NCS) is the clinical equivalent of nutcracker phenomenon characterized by a complex of symptoms with substantial variations. Depending on specific manifestations, NCS may be encountered by different medical specialists. Although it may be associated with substantial morbidity, the diagnosis of NCS is often difficult and is commonly delayed. Diagnostic and treatment criteria are not well established, and the natural history of NCS is not well understood. We performed an initial review of the literature through MEDLINE, searching from 1950 to date and using the keywords nutcracker syndrome, nutcracker phenomenon, and renal vein entrapment. We performed additional reviews based on the literature citations of the identified articles. We attempted to elucidate clinical relevance of these conditions and their prominent features and to summarize professional experience.
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Multidetector computed tomography findings and correlations with proteinuria in nutcracker syndrome. Pediatr Nephrol 2010; 25:469-75. [PMID: 20020159 DOI: 10.1007/s00467-009-1383-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 09/27/2009] [Accepted: 10/20/2009] [Indexed: 10/20/2022]
Abstract
We evaluated the effectiveness of multidetector computed tomography (MDCT) as a diagnostic tool for nutcracker syndrome (NS) and its association with proteinuria. The angle and distance between the aorta and the superior mesenteric artery (SMA), the degree of difference in corticomedullary enhancement (DCE) between kidneys in the nephrographic phase of computed tomography, peak velocity ratio (PVR), and anteroposterior diameter ratio (APDR) in the sonogram were measured. The MDCT results, sonogram results, and the ratio of protein:creatinine were significantly different between NS patients and the controls. The area under the curve for angle, distance, and DCE were 0.895 +/- 0.058, 0.876 +/- 0.063, and 0.942 +/- 0.036, respectively. The cutoff values for angle and distance had sensitivity and specificity values of 96.2 and 80% for <22.4 degrees and 84.6 and 80% for <4.9 mm, respectively. The DCE had a sensitivity of 88.5% and a specificity of 100% for the positive scores. There were significant correlations between the degree of DCE and the ratio of protein:creatinine (r = 0.337, p = 0.031), and between distance and the ratio of protein:creatinine (r = -0.419, p = 0.006). We conclude that MDCT has diagnostic value for NS in children and that MDCT findings are correlated with proteinuria.
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Milani G, Fossali EF, Bianchetti MG. Re: Wang et al.: Diagnosis and Surgical Treatment of Nutcracker Syndrome: A Single-Center Experience. (Urology 2009;73:871-876). Urology 2009; 74:476-7; author reply 477-8. [DOI: 10.1016/j.urology.2009.04.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 03/31/2009] [Accepted: 04/05/2009] [Indexed: 11/28/2022]
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Nutcracker syndrome in a child with familial Mediterranean fever (FMF) disease: renal ultrastructural features. Int Urol Nephrol 2008; 41:1047-53. [DOI: 10.1007/s11255-008-9500-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 10/24/2008] [Indexed: 11/26/2022]
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Ragazzi M, Milani G, Edefonti A, Burdick L, Bianchetti MG, Fossali EF. Left renal vein entrapment: a frequent feature in children with postural proteinuria. Pediatr Nephrol 2008; 23:1837-9. [PMID: 18607641 DOI: 10.1007/s00467-008-0909-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 05/04/2008] [Accepted: 05/07/2008] [Indexed: 11/30/2022]
Abstract
In most Asian subjects with postural proteinuria, ultrasonic imaging and Doppler flow scanning disclose entrapment of the left renal vein in the fork between the aorta and the superior mesenteric artery. Little information is available on the possible occurrence of left venal rein entrapment in European subjects with postural proteinuria. Renal ultrasound with Doppler flow imaging was therefore performed on 24 Italian or Swiss patients with postural proteinuria (14 girls and ten boys, aged between 5.2 years and 16 years). Signs of aorto-mesenteric left renal vein entrapment were noted in 18 of the 24 subjects. In conclusion, aorto-mesenteric left renal vein entrapment is common also among European subjects with postural proteinuria.
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Affiliation(s)
- Monica Ragazzi
- Clinica Pediatrica De Marchi, Foundation Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
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Krishnan SGS, Pritsiolas J, Susin M, Linden E, Beil-Levi E, Gitman M, Mossey R, Bhaskaran M. Reversible renal allograft dysfunction and proteinuria from nutcracker-like syndrome: a case report. Transplant Proc 2007; 39:1685-7. [PMID: 17580220 DOI: 10.1016/j.transproceed.2007.02.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 02/06/2007] [Accepted: 02/23/2007] [Indexed: 11/26/2022]
Abstract
A 27-year-old Hispanic man with hypertension and renal failure was on hemodialysis for 4 years prior to receiving a living donor renal transplant from his 19-year-old sister. His serum creatinine decreased to 1.7 mg/dL at 3 weeks posttransplant with a urine protein creatinine ratio (UP) of 0.1 (g/g). Over the next 2 months, he experienced repeated episodes of allograft dysfunction with elevation of creatinine and proteinuria levels, associated with a lymphocele. Doppler studies of the allograft revealed renal vein compression. His symptoms responded to aspiration of the fluid collection, resolving completely with surgical drainage. We believe that the episodes of allograft dysfunction and proteinuria were related to recurrent lymphocele, causing a nutcracker-like syndrome.
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Affiliation(s)
- S G S Krishnan
- Division of Kidney Diseases/Hypertension, North Shore University Hospital, 100 Community Drive, Great Neck, NY 11021, USA
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Fitoz S, Ekim M, Ozcakar ZB, Elhan AH, Yalcinkaya F. Nutcracker syndrome in children: the role of upright position examination and superior mesenteric artery angle measurement in the diagnosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:573-80. [PMID: 17459998 DOI: 10.7863/jum.2007.26.5.573] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the pathophysiologic characteristics of nutcracker syndrome (NS) and to assess the role of upright position imaging and superior mesenteric artery (SMA) angle measurement in the diagnosis. METHODS Doppler sonographic findings in 23 children with NS and in 26 healthy control subjects were compared. The mesenteric angle, peak velocity (PV), and anteroposterior diameter of the left renal vein (LRV) at the hilar and aortomesenteric portions were measured in both the supine and upright positions. The means +/- SD of the SMA angle, anteroposterior diameter, and PV ratio between the two portions were calculated, and cutoff levels for the diagnosis of NS were established. RESULTS The diameter and PV ratios were significantly different between the patient and control groups in both the supine and upright positions (P < .001). Differences between the supine and upright positions were also significant for the diameter of the LRV at the aortomesenteric portion, diameter ratio, and SMA angle in both groups. Upright position imaging revealed comparatively narrower SMA angles and more pronounced entrapment findings in patients with NS. The SMA angle measurement had sensitivity and specificity of 69.6% and 61.5%, respectively, in the supine position and 87.0% and 76.9% in the upright position when the cutoff values were set to less than 41 degrees and 21 degrees , respectively. CONCLUSIONS The upright position has significant effects on the LRV hemodynamics and angle of the SMA in both patients and healthy subjects. Superior mesenteric artery angle measurement may be a useful adjunct parameter in the diagnosis of NS.
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Affiliation(s)
- Suat Fitoz
- Department of Radiology, Ankara University, School of Medicine, Ankarar, Turkey.
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Marrocco-Trischitta MM, Melissano G, Kahlberg A, Setacci F, Segreti S, Spelta S, Chiesa R. Glomerular filtration rate after left renal vein division and reconstruction during infrarenal aortic aneurysm repair. J Vasc Surg 2007; 45:481-6. [PMID: 17257799 DOI: 10.1016/j.jvs.2006.11.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 11/17/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The study assessed the effect on postoperative renal function of left renal vein (LRV) division and reconstruction by direct reanastomosis or graft interposition during infrarenal abdominal aortic aneurysm (AAA) repair. METHODS Between January 2001 and March 2006, 1189 patients underwent elective open repair of infrarenal AAAs. LRV division was performed in 15 (1.3%) and its reconstruction in all but one (LRV group), where the LRV was occluded. Patients' glomerular filtration rates (GFRs) were retrospectively estimated through postoperative day 4 by using the Cockcroft-Gault equation and compared with the GFRs of 56 controls undergoing AAA repair without LRV division (control group) randomly identified from a prospectively compiled database in a 4:1 ratio. Post hoc 1:1 case-matched analysis was also performed. Statistical analyses were performed as appropriate. RESULTS Comparison of demographics and risk factors revealed no statistically significant differences between the two groups with the exception of the following: AAAs were larger in LRV group (71.4 +/- 17.1 mm vs 56.0 +/- 14.6 mm; P = .003) and preoperative GFR was lower in LRV group (65.3 +/- 19.0 mL/min/1.73 m(2) vs 82.8 +/- 22.3 mL/min/1.73 m(2); P = .009). Postoperatively, the trend of GFR with time did not differ between groups (P = .33). The variation of GFR at day 4 after surgery compared with preoperative values was not different either (5.6 +/- 12.6 mL/min/1.73 m(2) vs 1.0 +/- 15.5 mL/min/1.73 m(2); P = .67). A further 1:1 case-matched multivariate analysis of variance, matching patients and controls by AAA size and preoperative GFR, showed no difference in trend of GFR with time between groups (P = .15). Operative time was not significantly longer in LRV group (148.4 +/- 35.8 minutes vs 131.0 +/- 40.3 minutes; P = .07). No differences between groups were found for blood loss (585.7 +/- 264.2 mL vs 567.7 +/- 222.5 mL; P = .88), perioperative complications (5 vs 8; P = .12), or hospital length of stay (6.2 +/- 1.8 days vs 5.5 +/- 1.2 days; P = .10). A 6-month follow-up of renal function available in 12 patients of LRV group showed no significant decrease in GFR compared with postoperative values (70.8 +/- 24.8 mL/min/1.73 m(2) vs 69.1 +/- 23.5 mL/min/1.73 m(2); P = .86). At duplex scan, the reconstructed LRV could be insonated in nine of these 12 patients and all were patent. CONCLUSIONS LRV division during AAA repair was associated with larger aneurysms and preoperative subclinical renal function impairment. In these patients, LRV reconstruction was associated with the maintenance of preoperative renal functional status without significantly lengthening of operative time or increasing the complications from surgery.
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Ha TS, Lee EJ. ACE inhibition can improve orthostatic proteinuria associated with nutcracker syndrome. Pediatr Nephrol 2006; 21:1765-8. [PMID: 16902785 DOI: 10.1007/s00467-006-0206-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2006] [Revised: 04/05/2006] [Accepted: 04/28/2006] [Indexed: 11/25/2022]
Abstract
Left renal vein entrapment syndrome (nutcracker syndrome) was documented by magnetic resonance angiography (MRA) as a cause of orthostatic proteinuria in a 14-year-old girl female adolescent. Because of continuous proteinuria we performed a left renal biopsy which showed moderate mesangial hypercellularity. Her overt orthostatic proteinuria disappeared after a treatment of angiotensin-converting enzyme (ACE) inhibition. Nutcracker syndrome remains a rare but important cause of elevated protein excretion, which can induce mesangial changes and be improved by ACE inhibitor treatment.
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Affiliation(s)
- Tae-Sun Ha
- Department of Pediatrics, Chungbuk National University Hospital, Gaesin-dong 62, Heungdeok-gu, Cheongju, Chungbuk, 361-240, South Korea.
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Shin JI, Park JM, Lee SM, Shin YH, Kim JH, Lee JS, Kim MJ. Factors affecting spontaneous resolution of hematuria in childhood nutcracker syndrome. Pediatr Nephrol 2005; 20:609-13. [PMID: 15772835 DOI: 10.1007/s00467-004-1799-z] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 11/24/2004] [Accepted: 12/01/2004] [Indexed: 12/15/2022]
Abstract
To identify factors affecting spontaneous resolution of hematuria in children with nutcracker syndrome, 20 patients diagnosed as having nutcracker syndrome using renal Doppler ultrasound (US) were analyzed retrospectively. Sixteen patients had microscopic hematuria, and four had gross hematuria at presentation. The mean age was 10.6 years (range 2.5-14 years). All underwent a follow-up Doppler US examination after a mean period of 1.4 years (range 0.5-3.5 years) after the first US was performed, and height and weight were measured at the time of US. At the time of follow-up US, hematuria disappeared in 15 patients and improved in 3. The peak velocity (PV) ratios of the left renal vein (LRV) at the follow-up US decreased significantly when compared to the first US examination (7.74+/-2.64 vs 3.50+/-1.09, p<0.0001), and height (147.4+/-20.1 vs 152.3+/-18.8 cm) and weight (36.1+/-10.9 vs 42.3+/-12.7 kg) increased (p<0.0001). Changes in the PV ratios of the LRV correlated positively with changes in the PV at the aortomesenteric portion (r=0.569, p=0.009). Changes in the PV at the aortomesenteric portion correlated negatively with changes in body mass index (BMI) (r=-0.543, p=0.013). Although spontaneous resolution of hematuria in children with nutcracker syndrome is obscure, our findings suggest the increase in BMI may be a possible hemodynamic factor.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Proteinuria is occasionally detected on "routine" examination (not done for a suspected renal or urinary tract problem) and often presents a diagnostic problem. Even mild proteinuria is abnormal and needs an explanation. Its degree and persistence should be ascertained and associated hematuria looked for. Nonpathological (including orthostatic) proteinuria and renal tubular disorders should be excluded. Persistent proteinuria is mostly due to a primary or secondary (eg hepatitis B) glomerular condition, which requires expert evaluation of renal biopsy. Aggressive therapy may be needed in some cases. The intensity of proteinuria can be decreased with ACE inhibitors. Long-term observation is essential.
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Affiliation(s)
- R N Srivastava
- Department of Pediatrics, Apollo Indraprastha Hospital, New Delhi, India.
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Park SJ, Lim JW, Cho BS, Yoon TY, Oh JH. Nutcracker syndrome in children with orthostatic proteinuria: diagnosis on the basis of Doppler sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2002; 21:39-46. [PMID: 11794401 DOI: 10.7863/jum.2002.21.1.39] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate the Doppler sonographic findings of the left renal vein in children with orthostatic proteinuria in comparison with healthy children and to propose more reliable sonographic criteria for diagnosing nutcracker syndrome in children. METHODS Doppler sonographic findings in 47 children with orthostatic proteinuria and in 27 healthy control subjects were compared. The diagnosis of orthostatic proteinuria was made on the basis of clinical and laboratory findings. The peak velocity and anteroposterior diameter were measured at the hilar and aortomesenteric portions of the left renal vein. The means +/- 2 SD of the anteroposterior diameter ratio and peak velocity ratio between the 2 portions were calculated for control subjects and used as the cutoff levels for nutcracker syndrome. RESULTS The peak velocity ratios between aortomesenteric and hilar portions were 5.21+/-2.55 in the patient group and 2.57+/-0.70 in the control group. The anteroposterior diameter ratios between the 2 portions were 5.31+/-2.65 in the patient group and 2.77+/-0.69 in the control group. We set the cutoff level of anteroposterior diameter and peak velocity ratios for the diagnosis of nutcracker syndrome at mean +/- 2 SD of the value for the control group (3.98 for the peak velocity ratio and 4.16 for the anteroposterior diameter ratio). When these cutoff levels were applied, the patients with orthostatic proteinuria had abnormal levels of anteroposterior diameter in 27 (57.4%) of 47, peak velocity in 30 (63.8%) of 47, and both in 23 (48.9%) of 47. CONCLUSIONS Nutcracker syndrome may be an important cause of orthostatic proteinuria in children. Doppler sonography of the left renal vein may be a useful screening tool in patients with suspected orthostatic proteinuria to evaluate whether the cause is nutcracker syndrome.
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Affiliation(s)
- Seong Jin Park
- Department of Diagnostic Radiology, School of Medicine, Kyung Hee University, Seoul, Korea
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Cho BS, Choi YM, Kang HH, Park SJ, Lim JW, Yoon TY. Diagnosis of nut-cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria. Nephrol Dial Transplant 2001; 16:1620-5. [PMID: 11477164 DOI: 10.1093/ndt/16.8.1620] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We evaluated the efficacy of non-invasive renal Doppler ultrasound (US) to detect the nut-cracker phenomenon (NCP) and we studied the prevalence of NCP in children with orthostatic proteinuria. METHODS Among a total 66 cases of orthostatic proteinuria, 39 cases of NCP were found, with 27 cases being detected in a normal control group. Using Doppler US, the anteroposterior (AP) diameter and peak velocity (PV) of the left renal vein (LRV) were measured at the hilar and aortomesenteric portion. We calculated the ratio of AP and PV diameters between the two portions. The parameters were analysed using Student's t-test. RESULTS The AP diameters and the ratio in the hilar and narrow portions were all significantly different between the two groups (P<0.01). The PV in the narrow portion and the ratio of PV were significantly different (P<0.01), but the PV in the hilar portion was not statistically different between the two groups (P>0.05). If the diagnostic criteria for NCP was that the ratio of PV was more than 5, then 22 subjects (56.4%) in the orthostatic proteinuria group and none in the control group could be diagnosed as NCP. If, however, the cut-off values for the diagnosis of NCP were set at the mean+/-2 SD of the ratio (PV ratio 3.98 and size ratio 4.16), then the orthostatic proteinuria group showed abnormal AP diameter in 25 (64.1%), peak velocity in 28 (71.8%), and both in 21 patients (53.8%), and the control group showed an abnormal AP diameter in one subject (3.7%). CONCLUSIONS NCP may be one of the leading causes of orthostatic proteinuria, and non-invasive renal Doppler US may be a useful diagnostic tool in the screening of NCP. In the future, the diagnostic criteria of NCP must be redefined in children.
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Affiliation(s)
- B S Cho
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Korea
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Meyerson SL, Haider SA, Gupta N, O'Dorsio JE, McKinsey JF, Schwartz LB. Abdominal aortic aneurysm with aorta-left renal vein fistula with left varicocele. J Vasc Surg 2000; 31:802-5. [PMID: 10753290 DOI: 10.1067/mva.2000.102330] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abdominal aortic aneurysm with spontaneous aorto-left renal vein fistula is a rare but well-described clinical entity usually with abdominal pain, hematuria, and a nonfunctioning left kidney. This report describes a 44-year-old man with left-sided groin pain and varicocele who was treated with conservative measures only. The diagnosis was eventually made when he returned with microscopic hematuria, elevated serum creatinine level, and nonfunction of the left kidney; computed tomography scan demonstrated a 6-cm abdominal aortic aneurysm, a retroaortic left renal vein, and an enlargement of the left kidney. This patient represents the youngest to be reported with aorto-left renal vein fistula and the second case with a left-sided varicocele.
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Affiliation(s)
- S L Meyerson
- Department of Surgery, University of Chicago, IL 60637, USA
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Leung AK, Robson WL. Evaluating the child with proteinuria. THE JOURNAL OF THE ROYAL SOCIETY FOR THE PROMOTION OF HEALTH 2000; 120:16-22. [PMID: 10918778 DOI: 10.1177/146642400012000112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Proteinuria is a common laboratory finding in children. It might represent a benign condition or herald the presence of a serious underlying renal disease or systemic disorder. Investigation to confirm a diagnosis or seek reassurance is important. This paper discusses the various causes of proteinuria, and those aspects of the history, physical examination, and the laboratory tests that will help determine the cause or reassure that a serious problem is not currently present.
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Baptista-Silva JC, Dolnikoff MS, Moura LA, Pestana JO, Vieira JG, Miranda F, Schor N, Peres CDA, Burihan E. Ligation of the left renal vein in epm1-Wistar rats: functional and morphologic alterations in the kidneys, testes and suprarenal glands. SAO PAULO MED J 1997; 115:1475-84. [PMID: 9595812 DOI: 10.1590/s1516-31801997000400005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The ligation of the left renal vein (LLVR) in man is a controversial procedure in view of the risks of lesion to the renal parenchyma. With the objective of studying the morphologic and functional alterations caused by these lesions, we conducted experimental research with rats. MATERIAL AND METHODS 64 male adult EPM1-WISTAR rats were used, divided into 8 groups-4 for LLRV and four for control. Each LLRV group and corresponding control group were sacrificed progressively on the 7th, 15th, 30th and 60th day after the initial surgery. RESULTS We found morphofunctional alterations only in animals that underwent LLRV in the four periods of sacrifice. The proteinuria creatinine in serum, testosterone in serum and serum corticosterone in serum showed practically no alteration in relation to the normal values for rats. Statistically significant severe histological lesions were found in the kidneys and testes of the LLRV groups. Lesions in the suprarenal glands were also present in these groups, but no sufficient to demonstrate statistical significance. CONCLUSION Based on these results we can conclude that the ligation of the left renal vein is a procedure of high risk in these animals.
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Affiliation(s)
- J C Baptista-Silva
- Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), Brazil
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Tsukahara H, Okada T, Hori C, Tsuchida S, Hiraoka M, Sudo M. Measurement of urinary fibrin/fibrinogen degradation products revisited and re-emphasized. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1995; 37:120-1. [PMID: 7754757 DOI: 10.1111/j.1442-200x.1995.tb03703.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- H Tsukahara
- Department of Pediatrics, Fukui Medical School, Japan
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Zerin JM, Hernandez RJ, Sedman AB, Kelsch RC. "Dilatation" of the left renal vein on computed tomography in children: a normal variant. Pediatr Radiol 1991; 21:267-9. [PMID: 1870922 DOI: 10.1007/bf02018620] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta is thought to be a cause of hematuria, periureteral and gonadal varices, and varicocele ("Nutcracker phenomenon"). Previous investigators have suggested that this diagnosis can be made on computed tomography when the LRV ratio greater than or equal to 1.5 (the diameter of the LRV proximal to the aorto-mesenteric angle divided by the diameter of the LRV distal to the aorto-mesenteric angle). This study was designed to establish the normal range for the LRV ratio on CT in children. The LRV ratio was measured in thirty-nine consecutive children undergoing intravenously enhanced CT of the abdomen. None of the children had hematuria on urinalysis immediately before or after the CT. Children with any known abnormality involving the kidneys, adrenal glands, IVC, or renal or gonadal veins were excluded. The patients ranged in age from 3.4 to 18.5 years (mean = 10.6 years). LRV ratio ranged from 0.78 to 2.00 (mean = 1.46; S.D. = 0.312). Twenty of the 39 children (51.3%) had a LRV ratio greater than or equal to 1.50. The conclusion is that the normal range for the LRV ration is too wide for it to be useful in diagnosing LRV entrapment and that a LRV ratio greater than or equal to 1.5 on CT is normal in children.
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Affiliation(s)
- J M Zerin
- University of Michigan Hospitals, Ann Arbor
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Affiliation(s)
- V M Vehaskari
- Division of Pediatric Nephrology, St. Louis Children's Hospital, MO 63110
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