CT diagnosis of renal vein thrombosis in nephrotic syndrome

Nephrotic syndrome and acute coronary syndrome in children, teenagers and young adults: Systematic literature review

Myocardial infarction is rare in children, teenagers and young adults (aged<20 years). The most common aetiologies identified include Kawasaki disease, familial hypercholesterolaemia, collagen vascular disease-induced coronary arteritis, substance abuse (cocaine, glue sniffing), trauma, complications of congenital heart disease surgery, genetic disorders (such as progeria), coronary artery embolism, occult malignancy and several other rare conditions. Nephrotic syndrome is a very rare cause of myocardial infarction, but it is probably underestimated. The purpose of this review was to determine the current state of knowledge on acute coronary syndrome related to nephrotic syndrome. We thus performed a comprehensive structured literature search of the Medline database for articles published between January 1st, 1969 and December 31st, 2021. Myocardial infarction in young adults can be broadly divided into two groups: cases of angiographically normal coronary arteries; and cases of coronary artery disease of varying aetiology. There are several possible mechanisms underlying the association between acute coronary syndrome and nephrotic syndrome: (1) coronary thrombosis related to hypercoagulability and/or platelet hyperactivity; (2) atherosclerosis related to hyperlipidaemia; and (3) drug treatment. All of these mechanisms must be evaluated systematically in the acute phase of disease because they evolve rapidly with the treatment of nephrotic syndrome. In this review, we propose a decision algorithm for the management of acute coronary syndrome in the context of nephrotic syndrome. The final part of the review presents the short- and medium-term therapeutic strategies available. Thromboembolism related to nephrotic syndrome is a rare non-atherosclerotic cause of acute coronary syndrome, and prospective studies are needed to evaluate a systematic approach with personalized therapeutic strategies.

A patient with spontaneous bilateral renal vein thrombosis but no risk factors

INTRODUCTION AND IMPORTANCE

Spontaneous bilateral renal vein thrombosis is a rare condition, especially when the patient has no risk factors.

CASE PRESENTATION

In this report, we describe a patient with bilateral renal vein thrombosis who presented with severe flank pain, renal functions remained normal, and the thrombus resolved completely with anticoagulation. There is no history of hypercoagulable condition in our patient. A one-year followup with CT angiogram revealed that the kidney was functioning normally and that the thrombus in the renal veins had completely resolved.

CLINICAL DISCUSSION

Management of an acute renal vein thrombosis depends upon whether the patient presents with acute kidney injury. In general, patients without acute kidney injury can be treated with therapeutic anticoagulation, whereas those with acute kidney injury should undergo dissolution or removal of the thrombus with thrombolytic therapy with or without thrombectomy.

CONCLUSION

Diagnosis of spontaneous renal vein thrombosis requires a high index of suspicion. Patient can be managed with therapeutic anticoagulation if renal function is intact. If thrombolysis and/or thrombectomy are performed on time, kidney function can be fully restored.

A young Asian woman with thrombosis in the right renal vein and inferior vena cava: A rare case report and literature review

INTRODUCTION

Renal vein thrombosis (RVT) is a rare clinical entity wherein a blood clot forms in one of the major renal veins or its tributaries. Patients with certain risk factors, such as adults with nephrotic syndrome and infants with dehydration, are susceptible to developing it.

PATIENT CONCERNS

We present a young woman with primary thrombosis in the right renal vein and inferior vena cava. Hormonal therapy and the reception of the Medigen Vaccine Biologics Corporation coronavirus disease 2019 vaccine were the suspected risk factors for developing this disease.

PRIMARY DIAGNOSIS, INTERVENTIONS, OUTCOMES

The primary thrombosis in the right renal vein and inferior vena cava was diagnosed using abdominal computed tomography (CT), and 90% of the thrombus in the right renal vein was dissolved after ultrasound-assisted catheter-directed thrombolysis followed by urokinase infusion for 1 week. Antibiotics and rivaroxaban were prescribed for 3 days and 5 months, respectively. Cryoprecipitate transfusions based on the level of fibrinogen were also prescribed. No long-term complications were noted in the clinic visits. We demonstrate the results of ultrasound-assisted catheter-directed thrombolysis using urokinase infusion for thrombosis in the right renal vein and inferior vena cava. Lastly, we review the literature discussing RVT relevant to this case.

CONCLUSION

This study reveals the successful use of the novel technique, ultrasound-assisted catheter-directed thrombolysis using urokinase infusion, for the treatment of RVT.

[Thromboembolic complications in nephrotic syndrome]

This review devoted to the nephrotic syndrome (NS) subsequent thrombotic outcomes. The pathogenesis of hypercoagulation disorders that cause venous and arterial vascular system thrombosis are studied. Discussed procoagulant and anticoagulant mechanisms imbalance due to the anticoagulants natural urinal loss, affected by disfunction of the glomerular filter selective permeability, leading to high molecular weight liver-derived proteins (at least of the albumin size) leakage, fibrinolysis depression, excessive liver synthesis of plasma clotting cascade factors and platelet activation. Presented new data on the thrombogenesis at NS concerning the role of endothelial microparticles with high prothrombogenic activity that go from damaged glomerulus endothelial capillary cells into the systemic circulation, which can turn the local renal hypercoagulation (concomitant to the kidney immune inflammation process) into the generalized, working towards the thrombosis development. The most frequent adverse variants of arterial and venous thromboses are studied, specified their basic and general risk factors, as well as individual, varying in different patients. Indications and prophylactic anticoagulant therapy regimen and thrombosis treatment duration in patients with NS are discussed. It also stressed that the decision on time and method of anticoagulant therapy for a NS patients is still a challenge for healthcare providers.

COVID-19 en el enfermo renal. Revisión breve

En diciembre de 2019 se identificó en China una nueva subespecie de coronavirus al que denominaron SARS-CoV-2, responsable de la enfermedad posterior a la que la OMS llamó COVID-19. La enfermedad se ha propagado rápidamente provocando una pandemia mundial. Todavía se desconoce mucho del SARS-CoV-2, pero las primeras investigaciones respaldan la hipótesis de que la gravedad de la COVID-19 viene condicionada por la respuesta hiperinflamatoria que se produce en nuestro organismo al contacto con el SARS-CoV-2. La gravedad del cuadro se relaciona con la insuficiencia respiratoria que provoca, no obstante, existen estudios que no limitan la afectación pulmonar. Investigaciones apuntan a que el mecanismo de acceso del SARS-CoV-2 al organismo está muy relacionado con la enzima ACE2. Enzima que entre otros tejidos, se puede encontrar en el epitelio de las células tubulares renales. Esta es la causa por la que existen datos de pacientes con COVID-19 que tienen una gran afectación en la función renal y pueden cursar con IRA (factor de mal pronóstico). Por este motivo, unido a que las comorbilidades asociadas con una mayor mortalidad durante la infección COVID-19 son comunes en los pacientes con enfermedad renal crónica, creemos necesario conocer los resultados que aportan los diferentes estudios realizados sobre esa materia.

Characteristics of patients diagnosed with renal vein thrombosis and glomerulopathy: a case series

BACKGROUND

Few contemporary studies have evaluated the clinical characteristics of patients with biopsy-proven glomerulopathy diagnosed with renal vein thrombosis (RVT).

METHODS

Retrospective case series study within an integrated health system in a 12-year period (January 1, 2000 through December 31, 2011) investigating clinical characteristics of all adult patients who underwent native or transplant kidney biopsy and also had a diagnosis of RVT. Patient characteristics, diagnostic studies, and outcomes were evaluated.

RESULTS

Among 3763 eligible patients, 17 had imaging confirmed RVT. Of these, 15 had membranous nephropathy (idiopathic or secondary to autoimmune disease). Although the biopsy population included primary and secondary glomerular disease patients, all 17 RVT patients had severe nephrotic syndrome and profound hypoalbuminemia with mean (SD) of albumin: 1.5 g/dL (0.66).

CONCLUSION

Clinically significant RVT in patients with glomerulopathy appears to be a rather rare entity, occurring predominantly in patients with severe nephrotic syndrome due to idiopathic membranous nephropathy and membranous nephropathy secondary to autoimmune disease.

Active malignancy in patients with renal vein thrombosis: influence upon clinical course and survival

BACKGROUND

Renal vein thrombosis (RVT) is a rare event with myriad clinical manifestations. Published experience regarding the clinical course and management of RVT in patients beyond the neonatal period is limited to case reports and small case series.

METHODS

A multicenter retrospective review of consecutive admitted patients with diagnosed RVT between January 2000 and May 2015 at three different university hospitals.

RESULTS

Thirty-nine patients (53.8 % men and 46.2 % women) were included. Median age was 58 years. Malignancy (n = 19, 48.7 %), nephrotic syndrome (n = 8, 20.5 %) and infection (n = 5, 12.8 %), were the most common underlying conditions. Compared to non-cancer patients, patients with active cancer tended to be significantly older (mean age 63 ± 18 vs. 37 ± 22 years, P = 0.001) and presented with non-acute symptoms (P = 0.01) and unrevealing physical findings (P = 0.02). Thrombosis extension beyond the renal vein occurred in 69.2 % of cases and was more common in cancer patients (P = 0.001). Anticoagulation therapy was administered in 71.8 % of patients leading to resolution of thrombus in most cases (30/32 patients, 94 %) during follow-up evaluation. There were six recurrent thrombotic events during a mean follow-up of 35 ± 43 months. Nine patients (28 %) died during follow-up, all of them with malignancy.

CONCLUSION

Active cancer is the most common cause of RVT and should be excluded when RVT is diagnosed. Clinical course of RVT in cancer patients is more indolent and diagnosis requires high index of suspicion. Survival rates are governed by the presence of malignancy.

Risk factors for predicting venous thromboembolism in patients with nephrotic syndrome: focus on haemostasis-related parameters

PURPOSE

The venous thromboembolic events (VTE) incidence is high in nephrotic syndrome (NS). We aimed to assess prospectively the risk of VTE in a large cohort of NS patients and to identify predictive factors for VTE, especially haemostasis-related parameters.

METHODS

This is the prospective, observational study conducted in 256 adults with idiopathic NS. VTE were the study outcome. Clinical data, proteinuria, albuminuria, haemostasis and fibrinolysis parameters, and D-dimers were evaluated every 6 months.

RESULTS

Median follow-up time was 24 [IQR 12–72] months. VTE cumulative and rate incidence were 11 % and 4.4 per 100 patient-years. Baseline higher proteinuria,lower serum albumin, low antithrombin III activity, and,surprisingly, high ionized calcium were VTE independent predictors. Proteinuria and serum albumin cut-offs, and positive and negative predictive values (PPV and NPV) for VTE were 9.0 g/24 h (30 % PPV and 90 % NPV) and 1.5 g/dL (69 % PPV and 93 % NPV).

CONCLUSIONS

The rate of VTE incidence of 4.4 per 100 patient-years found in this prospective study confirms the idiopathic nephrotic syndrome as a thromboembolism-generating condition. Severe and unremitting proteinuria and hypoalbuminemia,low antithrombin III activity, and, surprisingly, high ionized calcium are independent VTE predictors.

Three-dimensional contrast-enhanced magnetic resonance venography for detection of renal vein thrombosis: comparison with multidetector CT venography

BACKGROUND

Renal vein thrombosis is not uncommon, however, there have been few reports on the diagnostic accuracy of three-dimensional contrast-enhanced magnetic resonance venography (3D-CE-MRV) in the detection of renal vein thrombosis (RVT).

PURPOSE

To evaluate the value of 3D-CE-MRV for detecting RVT with multidetector computed tomography (CT) venography as reference standard.

MATERIAL AND METHODS

Thirty-two patients with nephrotic syndrome underwent renal CT venography and gradient echo pulse sequence (FLASH 3D) 3D-CE-MRV in a clinical 3-T whole-body MR scanner for suspected RVT with time interval of 0-5 days. RVT was recorded on a per-patient and per-vessel (left renal vein, right renal vein, and inferior vena cava) basis. The diagnostic accuracy of 3D-CE-MRV for detection of RVT was calculated with CT venography as reference standard. Inter-reader agreement for RVT detection was evaluated using Kappa statistics.

RESULTS

Of 32 patients, CT venography detected 22 vessels with thrombosis in 17 patients, including five in right renal veins, 14 in left renal veins, and three in inferior vena cava, while 15 patients had no RVT. 3D-CE-MRV detected 21 vessels (21/96, 21.9%) with thrombosis in 16 patients (6/32, 50%), including five in right renal veins, 13 in left renal veins, and three in inferior vena cava, while 16 patients (16/32, 50%) had no RVT. With CT venography as reference standard, the sensitivities and specificities of 3D-CE-MRV for RVT detection were 94.1%, 100%; 95.5%, 100% on a per-patient and a per-vessel basis, respectively. Excellent inter-reader agreement (Kappa value = 0.969, P < 0.001) was observed for RVT detection.

CONCLUSION

3D-CE-MRV has a high diagnostic accuracy in the detection of RVT, which is optimal alternative imaging modality in the detection of RVT.

Nephrotic syndrome complicated by renal and cerebral infarctions in a 14-year-old girl

Venous thrombosis is a well-known complication of nephrotic syndrome (NS), while arterial thrombosis is rare. We know of no reports of children with this complication. Here we report a case of 14-year-old girl with NS, who complicated with renal and cerebral infarctions resulting from arterial thrombosis. Urinary examination showed heavy proteinuria. She had intravascular dehydration. Serum albumin was 0.9 g/dL. Contrast-enhanced computed tomography (CT) showed a low-attenuation area in the right kidney. Decreased blood flow in the right middle cerebral artery was observed on MRA and also on multi-detector-row head CT. Urokinase and heparin were given. Cerebral infarction was treated neuroprotectively by i.v. infusion of edaravone. Comprehensive assessment of intravascular dehydration and the coagulation-fibrinolysis system is needed to guide decisions concerning prophylactic anticoagulation therapy. Better understanding of NS and its risks, as well as the necessity of drug therapy, may help teenagers to accept and cooperate with treatment.

Bilateral renal vein thrombosis and pulmonary embolism secondary to membranous glomerulonephritis treated with percutaneous catheter thrombectomy and localized thrombolytic therapy

Renal vein thrombosis (RVT) is a rare event but is prevalent in patients with nephrotic syndrome. Bilateral RVT is even rarer. The literature is relatively sparse in terms of the management of RVT because of its rarity and consists of a few case reports and case series. We present a case with bilateral RVT complicated by a pulmonary embolism in a patient with membranous glomerulonephritis (MGN). A 19-year-old female presented with acute flank pain and worsening renal function after a couple of weeks in hospital while being treated with diuretics for anasarca secondary to MGN. Venography was used for diagnosis. The patient underwent percutaneous catheter thrombectomy and localized thrombolysis achieving resolution of pain and improvement of renal function. The patient was then anticoagulated for life with warfarin.

Prophylactic Anticoagulation in Nephrotic Syndrome: A Clinical Conundrum

It has long been recognized that nephrotic syndrome is associated with an increased risk for thromboembolic complications, including deep venous thrombosis, renal vein thrombosis, and pulmonary embolism. This risk varies with the nature of the underlying disease and seems to be greatest for membranous nephropathy. Other factors, including the level of serum albumin, previous thromboembolic episodes, and a genetically determined predisposition to thrombosis, may also be involved. Prevention of thromboembolic events with oral anticoagulants in nephrotic syndrome requires a careful case-by-case analysis of the risks for thromboembolic events balanced by the risks for anticoagulant induced bleeding. Markov-based decision analysis using literature-based assumptions regarding these risks has suggested that prophylactic anticoagulants may be indicated in certain circumstances. Such decisions need to take into account the nature of the underlying disease, the severity of the nephrotic syndrome (as assessed by serum albumin concentration), preexisting thrombophilic states, and the overall likelihood of serious bleeding events consequent to oral anticoagulation (as assessed by the international normalized ratio for prothrombin time). The optimal duration of prophylactic anticoagulation is unknown but very likely extends to the duration of the nephrotic state per se.

Thromboembolic complications in the nephrotic syndrome: Pathophysiology and clinical management

Patients with the nephrotic syndrome are at increased risk of developing venous and arterial thromboembolism, the most common of which is renal vein thrombosis. There are several unanswered or controversial issues relating to the nephrotic syndrome and thromboembolism, which include the mechanism of thromboembolism, and optimal diagnostic and anticoagulant management strategies. This review will discuss several of these issues: the epidemiology and clinical spectrum of thromboembolic disease occurring in patients with the nephrotic syndrome; the pathophysiology of the hypercoagulable state associated with the nephrotic syndrome; the diagnosis of renal vein thrombosis in the nephrotic syndrome; and the evidence for prophylactic and therapeutic anticoagulation strategies in such patients.

Vascular abdominal emergencies

Vascular emergencies are an uncommon but significant cause of abdominal pain, back pain, hemorrhagic shock, and death in adults. This article reviews abdominal vascular anatomy, risk factors, signs and symptoms, abdominal vascular thrombosis, mesenteric ischemia and infarction, and abdominal vascular emboli and aneurysms.

Hemostatic complications in renal disorders of the young

This review focuses on the hemorrhagic and thrombotic complications sometimes associated with the most common renal disorders in children. A Medline search of the literature was conducted from 1966 to January 1995, using combinations of key words appropriate for each disorder. Additional references were located through the bibliographies of the publications and recent journals were searched independently. The most common renal disorders with hemostatic complications in children were: renal vein thrombosis (268 children in 80 publications), hemolytic uremic syndrome (473 children in 29 publications), nephrotic syndrome (4,158 children in 51 publications), renal transplantation (3,976 children in 14 publications), glomerulonephritis (20 publications), end-stage renal disease, and dialysis (22 publications). The age distribution, clinical presentation, etiology, diagnosis, treatment, and outcome of the affected children were analyzed for each disorder. Children with inherited pre-thrombotic disorders usually do not present during childhood unless there is a secondary risk factor. Similarly, most children with renal disease do not develop thromboembolic complications. Therefore, when a child with a renal disorder develops a thromboembolic event, evaluation for an inherited pre-thrombotic disorder should be seriously considered. Guidelines for the use of heparin and warfarin in these children (both therapeutically and prophylactically) are given. At this time, the risk/benefit of thrombolytic therapy in children is not known and a general recommendation for thrombolytic therapy cannot be made.