A Rare Case of Renal Vein Thrombosis Secondary to Oral Contraceptive Pills

Renal vein thrombosis (RVT) is a common complication of nephrotic syndrome and renal malignancy. However, its association with oral contraceptive use has rarely been reported. We report a case of a 29-year-old female with a history of oral contraceptive use, presenting with acute flank pain. On further investigation, she was found to have unilateral RVT. Oral contraception was discontinued, and she was started on therapeutic anticoagulation, initially with low-molecular-weight heparin, and then switched to apixaban. Her symptoms improved, and she is currently doing well. This case signifies the importance of proper history-taking and how oral contraception should be considered a significant risk factor for venous thromboembolism.

Rescue From Permanent Kidney Injury in Acute Thrombosis of Both Renal Veins, the Inferior Vena Cava, and Both Iliofemoral Veins by Catheter-Based Thrombectomy

CASE

A 33-year-old man with previously diagnosed lupus membranous nephropathy presented with painful swelling in both legs. Laboratory tests revealed acute kidney injury, and imaging studies by duplex ultrasound and computed tomography scan showed acute thrombosis of both renal veins, the infrahepatic inferior vena cava, and both iliofemoral venous segments. Initially, pharmacomechanical thrombolysis led to an insufficient morphological result. The therapeutic breakthrough was achieved by catheter-based mechanical thrombectomy of the infrarenal vena cava and both renal veins, which successfully cleared all affected venous segments from thrombus, paralleled by improvement of the patient's condition. However, after 1 week, the patient experienced recurrent thrombosis of the right renal vein with hemorrhagic infarction of the right kidney. After further optimization of immunomodulatory and antithrombotic therapy, a repeated catheter-based mechanical thrombectomy resulted in sustained clinical improvement and preservation of renal venous drainage and kidney function.

CONCLUSION

Extensive acute thrombosis of both renal veins, the inferior vena cava, and both iliofemoral venous segments is a rare emergency potentially threatening kidney function. Immediate effective thrombus removal is essential to preserve kidney function and can be achieved by catheter-based mechanical thrombectomy embedded in a comprehensive immunomodulatory and antithrombotic therapeutic concept.

CLINICAL IMPACT

This case demonstrated the efficacy of a catheter-based therapeutic approach in patients with extensive thrombosis of the venous system. A catheter-based approach must be embedded in a comprehensive medical therapeutic concept, which is essential to achieve a sustainable result.

Renal vein thrombosis due to metastatic germ cell tumor, report of a case with a very rare clinical scenario

BACKGROUND

Renal metastasis is a rare manifestation of germ cell tumors. Extension of malignant lesions into the renal vein can complicate the scenario.

CASE

This report presents a 35-year-old man with primary stage IS NSGCT. Fourteen months after radical orchiectomy he presented with metastasis in the lung, kidney, and para-aortic lymph nodes. He received multiple lines of salvage treatments including chemotherapy and surgery. Intraoperative exploration during radical nephrectomy and retroperitoneal lymphadenectomy revealed intra-renal vein involvement with a prominent teratomatous component.

CONCLUSION

Defining the exact extent of malignant lesions, especially endovascular lesions, is very important to clarify how advanced the malignant lesions are. The surgeons must be aware of the risk factors that predict vascular involvement, and therefore, providing intraoperative access to vascular surgery procedures when needed.

Renal Vein Thrombosis Occurring in Association with Oral Contraceptives: A Case Report

Peripheral venous thromboembolism is a well-known complication of hormonal contraception, but reports on its association with visceral vein thrombosis is limited. We report the case of left renal vein thrombosis (RVT) associated with oral contraceptives (OCs) and concurrent smoking. The clinical presentation of this patient was acute left flank pain. Computed tomography revealed left RVT. The OC was discontinued, and we initiated anticoagulation with heparin and switched to edoxaban. Computed tomography 6 months later showed complete resolution of the thrombosis. This report alerts us regarding the importance of OCs as a risk factor for RVT.

Renal Vein Thrombosis Treated With Apixaban in a Patient With COVID-19: A Case Report

Renal vein thrombosis (RVT) is a rare condition characterized by the formation of a blood clot in one or both of the renal veins. Bilateral involvement is more common, but when the condition affects only one side, it usually occurs on the left due to more extensive venous vasculature compared to the right side. RVT can be caused by various factors such as trauma, dehydration, malignancy, and a hypercoagulable state. Acute RVT is typically more severe than chronic, and it can cause symptoms such as renal infarction, acute kidney injury, renal failure, severe flank pain, and hematuria. Some cases of RVT have also been linked to coronavirus disease 2019 (COVID-19), which is widely recognized to induce a hypercoagulable state. The standard treatment for RVT is warfarin but in this case report, we describe a COVID-19 patient with RVT whose thrombus was successfully treated with direct-acting oral anticoagulant (DOAC) apixaban for six months.

Acute on chronic bilateral renal vein thrombosis in the setting of remission of class V lupus nephritis: A case report and literature review

Renal vein thrombosis (RVT), defined as the presence of a thrombus in the major renal vein or one of its tributaries, can present acutely or go unnoticed resulting in acute kidney injury or chronic kidney disease. RVT is associated with multiple etiologies, including nephrotic syndrome, thrombophilia, autoimmune disorders, and malignancy. Patients with systemic lupus erythematosus (SLE), a multiorgan autoimmune disorder, are predisposed to coagulopathy and thus are at a higher risk of venous and arterial thromboembolism. We describe the case of a 41-year-old man with SLE and biopsy-proven membranous glomerulonephritis (WHO class V lupus nephritis) in clinical remission with no evidence of nephrotic range proteinuria who presented with macroscopic hematuria and was diagnosed with acute-on-chronic bilateral RVT. We discuss the different causes of RVT and compare the clinical presentation, diagnostic imaging findings, and management of acute and chronic RVT.

Renal vein thrombosis after COVID-19: A case report

Severe cases of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-Coronavirus-2, can lead to pneumonia or acute respiratory distress syndrome. Non-respiratory manifestations of COVID-19 include venous and arterial thrombosis. The disease can affect all organs and even the kidneys and lead to renal vein thrombosis where renal veins or their branches become thrombotic leading to symptoms such as flank pain, hematuria, or acute kidney damage. In this study, a case of renal vein thrombosis after COVID-19 is introduced and the causes and complications of this disease are analyzed.

Incidental finding of bilateral ovarian and renal veins thromboses post cesarean hysterectomy complicated by ureteric injury: First case presentation

This is a case report of a 36-year-old female patient who developed right flank pain on day 4 postcesarean hysterectomy due to placenta accreta and massive bleeding. Ultrasonography of the abdomen and pelvis showed moderate right hydronephrosis. A nephrostomy tube was urgently inserted followed by computed tomography urography which revealed a large pelvic urinoma secondary to right ureter injury and bilateral ovarian and renal veins thrombi. An abdominal drain was inserted and the hematology team was consulted. The patient was treated with enoxaparin with no subsequent complications. Ureteric injury was managed by reimplantation. We reported this case as the probable first presentation of bilateral ovarian and renal vein thromboses postcesarean hysterectomy.

Two Cases of Vasculitis with Renal Vein Thrombosis

We present a series of two cases of ANCA associated Vasculitis (AAV) presenting as Pulmonary Renal syndrome with associated renal vein thrombosis. Although there are enough evidences suggesting association of venous thrombosis with AAVs, the incidence of renal vein thrombosis is rare. Renal vein thrombosis should be ruled out in cases where there is delay in recovery of renal function in patients with AAV. Positive laboratory values for anti-Proteinase-3 (PR3) and anti-Myeloperoxidase (MPO) ANCA in the cases that presented as Rapidly Progressive Glomerulonephritis, helped in early initiation of treatment with complete recovery of Renal function.

Renal Vein Thrombosis and Pulmonary Embolism Secondary to Vaccine-induced Thrombotic Thrombocytopenia (VITT)

The Medicines and Healthcare products Regulatory Agency (MHRA) of the UK has approved the use of three vaccines to combat COVID-19 (SARS-CoV-2). There have been rare reports of thrombosis after vaccination with the AstraZeneca vaccine. We present three cases of vaccine-induced thrombotic thrombocytopenia (VITT) in one UK district general hospital following administration of this vaccine. Two of the patients had asymptomatic pulmonary emboli, while the other is the first known case of both renal vein thrombosis and pulmonary embolism.

Unexpected success in early post-transplantation renal vein thrombosis: A case report and literature review

Background: Allograft renal vein thrombosis can cause graft loss during the early postoperative period. This diagnosis is sometimes elusive, requiring a strong suspicion. On the other hand, several authors have recognized risk factors for allograft renal vein thrombosis, but neither a preventive approach nor a treatment have been recommended for this complication. Case presentation: We present a case report of early allograft renal vein thrombosis, preceded by femoral common deep vein thrombosis in a recipient of a third kidney transplant. Despite femoral common deep vein thrombosis treatment with low-molecular-weight heparin and progressive improvement of renal function to a nadir serum creatinine of 0.51 mg/dL, the patient experienced a sudden episode of anuria on postoperative day 5. Doppler ultrasonography strongly suggested the diagnosis of allograft renal vein thrombosis. The patient underwent balloon catheter and aspiration venous thrombectomy, followed by unfractionated heparin perfusion. After 4 days of anuria and multiple blood transfusions, when allograft nephrectomy was contemplated, diuresis suddenly resumed. After 1 year of follow-up, the patient still has a normal renal function. Conclusion: This case report shows successful treatment of allograft renal vein thrombosis associated with deep vein thrombosis in the first week of transplantation, using balloon catheter and aspiration venous thrombectomy followed by perfusion of unfractionated heparin. The authors suggest this technique as a treatment option for transplant renal vein thrombosis. However, they reinforce the importance of individualized treatment and they remind that a delay may jeopardize the potential benefit of the procedure.

Thrombosis of the Renal Vein and Inferior Vena Cava Associated With Placental Fetal Vascular Malperfusion in a Neonate Exposed to Methadone Maintenance Therapy In Utero

Methadone, an opioid agonist, is the recommended treatment for pregnant women with opioid use disorder (OUD). Fetal/neonatal autopsy findings as well as placental changes in the setting of maternal OUD or methadone maintenance therapy (MMT) are not well-characterized. Here we present a case of a neonate who had exposure to MMT while in utero and died shortly after birth and was subsequently found to have multifocal calcified renal vein thrombosis, a recent inferior vena cava thrombus, and placental features of fetal vascular malperfusion at autopsy.

Bilateral Adrenal Hemorrhage in Coronavirus Disease 2019 Patient: A Case Report

CONTEXT

Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events.

CASE DESCRIPTION

A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism.

CONCLUSIONS

COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.

Massive thrombosis in an infant with suspected nephrocalcinosis: case report and literature review

Introduction

Perinatal period is characterized by an increased risk of thrombosis due to low resources and limited compensatory capacity of the coagulation system in early stages of life.

Case report

We report a case of a second pregnancy female infant born at 39 weeks by caesarean section, due to pre-labor rupture of membranes, with body weight of 3,570 γ and Apgar score 10. The pregnancy was complicated by hypothyroidism, uterine myoma, urinary tract infections, and mother's appendectomy at 16 Hbd. At 3 months, the girl was admitted to our hospital due to kidney calcifications, which were incidentally found during ultrasound scan. In laboratory workup, no abnormalities in calcium and phosphate homeostasis were detected. However, in ultrasound scan, linear calcifications along pyramids were visualized in both kidneys. Due to atypical location of nephrocalcinosis, Doppler scan was performed, showing lack of visible blood flow from renal veins to inferior vena cava (IVC), with compensatory flow from renal veins to paravertebral plexuses, and IVC obliteration with a massive calcification in the hepatic section. Magnetic resonance confirmed obliteration of IVC and common iliac veins, segmental dilatation of IVC, and compensatory blood flow from kidneys and lower limbs to paravertebral plexuses. Clinical picture and formation of collateral circulation suggested intrauterine thrombosis. Congenital thrombophilia was excluded in laboratory examination.

Conclusions

The differential diagnosis of calcifications in renal parenchyma (nephrocalcinosis) should include renal vein thrombosis. Massive fetal and perinatal thrombosis can be asymptomatic due to high ability to form collateral circulation at the early stage of life.

Macroscopic Hematuria as the Initial Presentation of Polycythemia Vera

Polycythemia vera (PV) is a chronic myeloproliferative neoplasm (CMN) characterized by the accumulation of red blood cells, granulocytes and platelets in the peripheral blood. The main complications of PV are an increased risk of thrombosis, bleeding and transformation to myelodysplasia or acute leukemia. The authors report the case of a 28-year-old man with a complaint of macroscopic hematuria, low back pain and edema of the left arm associated with elevated hemoglobin, hematocrit and lactic dehydrogenase, leukocytosis and increased renal volume. Computed tomography of the chest and abdomen with contrast showed venous ectasia in the left upper limb and thrombosis of the right renal vein with extension to the inferior vena cava. A diagnosis of PV was confirmed by the presence of the JAK2 mutation and a bone marrow biopsy that showed panmyelosis. The patient was anticoagulated and treatment for PV was started with aspirin, phlebotomy and hydroxyurea. Then, the patient was discharged for outpatient follow-up with a hematologist. The case emphasizes the importance of clinical suspicion for atypical presentation of the disease in an unusual age range and of adequate etiological investigation of thrombosis in unusual sites.

A Rare Case of Paroxysmal Nocturnal Hemoglobinuria With Bilateral Renal Vein Thrombosis

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hematopoietic stem cell (HSC) disorder characterized by a partial or complete deficiency of glycosyl-phosphatidylinositol (GPI)-linked membrane proteins, which leads to intravascular hemolysis. The loss of CD55 and CD59, two GPI-anchored proteins on red blood cell surfaces, from mutations in the X-linked phosphatidylinositol glycan class A (PIGA) gene, causes unrestricted proliferation of complement activation. The loss of CD59 especially leads to ‘paroxysms’ of acute intravascular hemolysis during events of stress. Extravascular hemolysis also occurs without CD55 as the accumulation of C3 on red blood cell surfaces leads to their destruction by the reticuloendothelial system. Diagnosis of PNH relies primarily on clinical presentation and flow cytometry assays used to detect the GPI-anchored proteins, CD55 and CD59; however, fluorescein‐labeled proaerolysin variant (FLAER) is seen to have a significant advantage over CD55 and CD59. Typical symptoms of the disorder include fatigue, shortness of breath, hemoglobinuria, abdominal pain and bone marrow failure. Thrombosis also occurs secondary to nitric oxide (NO) deficiency, release of procoagulants, increased tissue factor and reduced fibrinolysis. The classification of PNH is subdivided into three types: classical, PNH with another bone marrow disorder and subclinical PNH. Management of hemolysis, thrombosis and pancytopenia is based on the pathogenesis involved. Inhibition of complement in the form of humanized monoclonal antibody against complement C5 (eculizumab) is seen as an emerging treatment option, while stem cell/bone marrow transplant may also be offered. We present a rare case of PNH with bilateral renal vein thrombosis, who was diagnosed with classical PNH on clinical presentation and flow cytometry. He was initially offered bone marrow transplantation but was lost to follow-up and later presented with bilateral renal vein thrombosis. He was managed conservatively with transfusions and anticoagulation, and was discharged for follow-up on an outpatient basis.

An Unusual Combination of Three Rare Complications: Pleuro-Pancreatic Fistula, Chylous Ascites, and Renal Vein Thrombosis, in a Case of Acute Severe Pancreatitis

Background  Acute pancreatitis is fraught with a variety of complications, which account for the mortality associated. Our case had a fulminant course, with three rare, near-fatal complications and was successfully managed conservatively. Pleural effusion due to pleuro-pancreatic fistula is uncommon, seen in only 1% cases, of which right-sided effusions are rarer still. Management modalities include conservative, endoscopic, and surgical options. Chylous ascites is an extremely rare complication of pancreatitis and is managed with high protein, low lipid diet, restricted to medium-chain triglycerides (MCTs). Extra-splanchnic venous thrombosis is uncommon in pancreatitis, and isolated renal vein thrombosis is very rare.

Case Presentation  A 34-year-old, chronic alcoholic male, presented to the outpatient department (OPD) in a state of shock and respiratory distress. Chest radiograph showed massive right-sided pleural effusion. The pleural fluid was hemorrhagic with markedly elevated amylase levels, and contrast-enhanced computed tomography (CECT) confirmed the presence of a right-sided pleuro-pancreatic fistula. Left renal vein thrombosis was also noted. The patient improved with chest drain, intravenous (IV) octreotide, and anticoagulants. Subsequently, he developed hemorrhagic pancreatic ascites, which later turned chylous. This was managed with dietary modifications. The patient had a prolonged recovery but was finally discharged after 45 days.

Conclusion  It is a challenge managing the various complications of acute severe pancreatitis. We describe this case to emphasize maintaining a high sensitivity for timely diagnosis and appropriate addressal of all the complications for better patient outcomes.

Renal Vein Thrombosis After Open Repair of Abdominal Aortic Aneurysm Successfully Treated by Direct Oral Anticoagulants

INTRODUCTION

Venous thromboembolism (VTE) of the lower extremities frequently occurs after surgery. It is unknown whether the complication of renal vein thrombosis (RVT) develops after an open repair (OR) for abdominal aortic aneurysm (AAA). Furthermore, anticoagulation therapy with apixaban, a direct oral anticoagulant (DOAC), has not been described as treatment for RVT in such cases.

CASE

A 64-year-old man underwent OR for AAA. Postoperative computed tomography revealed RVT in the left renal vein. Apixaban (5 mg twice a day) therapy was initiated. Six months later, we discontinued anticoagulation therapy and observed no recurrence. Following OR, our patient developed RVT for which DOACs were very useful.

CONCLUSION

Thus, RVT can manifest as VTE after OR and direct anticoagulants can be considered as a therapeutic option.

The forgotten urinalysis: an integral part of unmasking thrombophilia

A 43-year-old female presented with flank pain of two days duration. She had been admitted previously for bilateral lower extremity edema which had not improved with diuresis. Abdominal Imaging showed left ovarian vein thrombosis and left renal vein thrombosis extending into the IVC. Chest imaging revealed right lower lobe segmental pulmonary emboli. Careful review of serial urinalysis during previous admissions revealed significant proteinuria. Confirmatory urine tests followed by a renal biopsy led to a diagnosis of membranous nephropathy. We report a case of acute diffuse thromboembolism due to membranous nephropathy, unmasked by serial abnormal urinalysis.

Sequential sonographic features in neonatal renal vein thrombosis

OBJECTIVES

Renal vein thrombosis in newborns is a rare but serious and acute disease. Clinical representations of RVT can vary from discrete symptoms to life-threatening conditions. Therefore imaging, and in particular sonography, plays an important role in the diagnosis of RVT in neonates. Gray-scale, color and spectral/power Doppler ultrasound are all used in the diagnosis of RVT.

MATERIAL AND METHODS

We present retrospective sequential ultrasonic imaging of three patients (two term and one preterm infant) with findings characteristic of RVT.

RESULTS

Initial ultrasound diagnostic features include: renal enlargement, echogenic medullary streaks, lack of the flow pattern characteristic of arcuate vessels and subsequently loss of corticomedullary differentiation, reduced echogenicity around pyramids and echogenic band at the extreme apex of the pyramid. Higher resistance index or less pulsatile venous flow on the affected kidney are helpful Doppler signs.

CONCLUSIONS

Knowledge and identification of specific features of each phase of the evolution of RTV seems essential to prompt diagnosis. We would like to highlight the evolution of specific sonographic features in each subsequent phase of RVT.

Pathological assessment of allograft nephrectomy: An Iranian experience

BACKGROUND

The aim of this study was to determine the pathologic causes of renal allograft failure in transplant nephrectomy specimens.

MATERIALS AND METHODS

In this cross-sectional study performed in the referral transplant center of Isfahan, Iran, medical files of all patients who underwent nephrectomy in 2008-2013 were studied. Age at transplantation, sex, donor's characteristics, causes of primary renal failure, duration of allograft function, and pathologic reasons of nephrectomy were extracted. Slides of nephrectomy biopsies were evaluated. Data were analyzed using SPSS.

RESULTS

Medical files of 39 individuals (male: 56.4%; mean age: 35.1 ± 16.0 years) were evaluated. The main disease of patients was hypertension (17.9%), and most cases (64.1%) were nephrectomized < 6 months posttransplantation. Renal vein thrombosis (RVT) (51.3%) and T-cell-mediated rejection (TCMR) (41.0%) were the most prevalent causes of transplanted nephrectomy. Cause of primary renal failure was correlated to nephrectomy result (P = 0.04). TCMR was the only pathologic finding in all of patients nephrectomized >2 years posttransplantation. There were 14 cases in which biopsy results showed a relationship between primary disease of patients and pathologic assessment of allograft (P = 0.04). A significant relationship between transplantation-nephrectomy interval and both the nephrectomy result and histopathologic result existed (P < 0.0001). A relationship between primary allograft biopsy appearance and further assessment of nephrectomized specimen (P < 0.001) existed as well.

CONCLUSION

The most pathologic diagnoses of nephrectomy in a period of less than and more than 6 months posttransplantation were RVT and TCMR, respectively. Early obtained allograft protocol biopsy is suggested, which leads to better diagnosis of allograft failure.

Edoxaban was Effective for Treating Renal Vein Thrombosis in a Patient with Nephrotic Syndrome

A 39-year-old man with nephrotic syndrome was admitted due to right dorsal pain. Contrast-enhanced CT led to a diagnosis of renal vein thrombosis and segmental pulmonary thromboembolism. Treatment with heparin and warfarin was started. After 1 month, pulmonary thromboembolism recurred. Warfarin was switched to edoxaban, and steroid therapy was initiated, which led to the remission of nephrotic syndrome and the disappearance of renal vein thrombosis. The efficacy of edoxaban was demonstrated; however, this drug has not been routinely selected for patients with renal disease. Our results suggest that edoxaban is also effective for treating venous thrombosis patients with nephrotic syndrome.

Catheter-directed therapy for acute renal vein thrombosis in systemic lupus erythematosus: A case report

We report our experience using catheter-directed thrombectomy/thrombolysis (CDT) to treat a patient with acute renal vein thrombosis (RVT) associated with systemic lupus erythematosus (SLE). A 34-year-old woman presented with persistent left flank pain, and a renal ultrasonography examination revealed an enlarged left kidney. Contrast-enhanced computed tomography confirmed the presence of acute left RVT. Because medical treatment failed to relieve her pain and the renal function was deteriorating, we attempted to salvage the occluded left renal vein using an endovascular approach. The pain was completely relieved after a CDT and an overnight urokinase infusion. A follow-up computed tomography examination revealed the complete resolution of the thrombus. The creatinine level returned to normal (1.7-0.4 mg/dL), along with contrast enhancement in the left kidney, and this suggested the preservation of renal function. To our knowledge, this is the first report utilizing CDT to treat SLE-associated RVT. When the renal function is deteriorating, CDT is worth considering for RVT if conventional medical treatment has failed. © 2016 Wiley Periodicals, Inc.

Renal Manifestations in Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired chronic disorder characterized by a triad of clinical features - hemolytic anemia, pancytopenia, and thrombosis. Not many reports of renal involvement in PNH are available in literature. We present a case series of PNH with renal involvement. We present the data of PNH patients who attended to Departments of General Medicine and Nephrology at a government-run tertiary care institute in South India. The diagnosis of PNH in these patients during initial phase, between 1998 and 2004 was based on sucrose lysis and Ham's test. After 2004, the diagnosis was based on flow cytometry to detect CD59 (membrane inhibitor of reactive lysis), a glycoprotein, and CD55 (decay accelerating factor) in regulation of complement action. The patient data were collected from 1998 to 2014. There were 14 patients of PNH in this period. The mean age was 37 years and the range was 16–68 years. There were eight females. Acute kidney injury (AKI) was noted in six patients. Dialysis was performed in four of them. The mean serum creatinine and urea at the initiation of dialysis were 5.4 ± 0.6 and 64.1 ± 6.1 mg/dl, respectively. The median number of hemodialysis sessions done was four. Renal biopsy was done in four patients. In three patients, the urinalysis and serum chemistry were suggestive of Fanconi syndrome. In our patients, three renal manifestations of PNH were identified. They were AKI, renal vessel thrombosis, and Fanconi syndrome. Chronic renal failure was not identified.

Neonatal Venous Thromboembolism

Neonates are the pediatric population at highest risk for development of venous thromboembolism (VTE), and the incidence of VTE in the neonatal population is increasing. This is especially true in the critically ill population. Several large studies indicate that the incidence of neonatal VTE is up almost threefold in the last two decades. Central lines, fluid fluctuations, sepsis, liver dysfunction, and inflammation contribute to the risk profile for VTE development in ill neonates. In addition, the neonatal hemostatic system is different from that of older children and adults. Platelet function, pro- and anticoagulant proteins concentrations, and fibrinolytic pathway protein concentrations are developmentally regulated and generate a hemostatic homeostasis that is unique to the neonatal time period. The clinical picture of a critically ill neonate combined with the physiologically distinct neonatal hemostatic system easily fulfills the criteria for Virchow's triad with venous stasis, hypercoagulability, and endothelial injury and puts the neonatal patient at risk for VTE development. The presentation of a VTE in a neonate is similar to that of older children or adults and is dependent upon location of the VTE. Ultrasound is the most common diagnostic tool employed in identifying neonatal VTE, but relatively small vessels of the neonate as well as frequent low pulse pressure can make ultrasound less reliable. The diagnosis of a thrombophilic disorder in the neonatal population is unlikely to change management or outcome, and the role of thrombophilia testing in this population requires further study. Treatment of neonatal VTE is aimed at reducing VTE-associated morbidity and mortality. Recommendations for treating, though, cannot be extrapolated from guidelines for older children or adults. Neonates are at risk for bleeding complications, particularly younger neonates with more fragile intracranial vessels. Developmental alterations in the coagulation proteins as well as unique pharmacokinetics must also be taken into consideration when recommending VTE treatment. In this review, epidemiology of neonatal VTE, pathophysiology of neonatal VTE with particular attention to the developmental hemostatic system, diagnostic evaluations of neonatal VTE, and treatment guidelines for neonatal VTE will be reviewed.

Nephrotic syndrome-induced thromboembolism in adults

Nephrotic syndrome (NS) is a well-defined syndrome characterized by the presence of nephrotic range of proteinuria, hypoalbuminemia, and hyperlipidemia. Although venous thromboembolism (VTE) is a well-reported complication associated with NS, the incidence, prevalence, risk factors, treatment options, and preventative strategies are not well-established. Thromboembolic phenomena in nephrotic patients are postulated to be a result of the urinary loss of antithrombotic factors by affected kidneys and increased production of prothrombotic factors by the liver. Most cases of VTE associated with NS reported in the literature have a known diagnosis of NS. We report a case of a young female presenting with dyspnea and a pulmonary embolism. She was found to have NS and right renal vein thrombosis. We review the available literature to highlight the best approach for clinicians treating VTE in patients with NS.

Proteinuria and hematuria in the neonate

PURPOSE OF REVIEW

Neonatal proteinuria and hematuria while not common can have potentially devastating consequences if left undiagnosed and untreated. It is important to distinguish between inherited and acquired causes of proteinuria to initiate appropriate and timely treatment. With regards to hematuria, it is critical to identify true hematuria from pseudo-hematuria to balance between thorough investigation and unnecessary laboratory work up. This review provides an overview of the common causes of hematuria and proteinuria in a neonate.

RECENT FINDINGS

The identification of genetic mutations in nephrotic syndrome has improved our understanding of the role of various proteins that play an important role in maintaining the glomerular filtration barrier. With the advancement in our ability to provide care for extreme premature neonates, the incidence of acute kidney injury has increased in these neonates along with proteinuria and hematuria.

SUMMARY

Persistent proteinuria after neonatal acute kidney injury would be of interest in regards to the risk of developing future chronic kidney disease and hypertension.

Neonatal renal vein thrombosis: role of anticoagulation and thrombolysis--an institutional review

Neonatal renal vein thrombosis (NRVT) is a rare thromboembolic complication in the neonatal period, and sequelae from renal dysfunction can cause significant morbidity. The authors retrospectively reviewed 10 patients with NRVT treated at their institution. The majority of the cohort were male (n = 9), preterm (n = 6), and had unilateral NRVT (n = 6). Six patients received thrombolysis and/or anticoagulation, and 4 patients received supportive care only. Two of the 6 patients treated with anticoagulation who had bilateral NRVT and anuria received thrombolysis with low-dose tissue plasminogen activator. Thrombolysis was not associated with any major adverse events, and both patients had marked improvement of renal function. Eight patients subsequently developed renal atrophy (3 received anticoagulation, 2 received thrombolysis with anticoagulation, and 3 received supportive care). Anticoagulation/thrombolysis did not appear to prevent renal atrophy. The role of thrombolysis needs to be further studied and considered in the setting of bilateral NRVT and acute renal failure.

Successful management of neonatal renal venous thrombosis

Renal vein thrombosis is the most common vascular condition involving the newborn kidney and it can result in severe renal damage. We report a newborn with renal vein thrombosis treated with continuous infusion of unfractionated heparin who had normal total renal function after 3 years of follow up, despite reduction of the functional contribution of the affected kidney.

Renal failure due to renal vein thrombosis in a fetus with growth restriction and thrombophilia

We report a case of renal vein thrombosis diagnosed at 27 weeks of gestation in a dichorionic twin pregnancy. The left kidney of one fetus was hyperechoic and enlarged with echoic streaks following the direction of interlobular veins and the loss of corticomedullary differentiation. In the following weeks, left kidney became smaller and echoic, and Doppler examination showed no flow in both artery and vein. The right kidney had totally normal appearance in the beginning, but it became enlarged and hyperechoic, and progressed into a small echoic kidney with no flow in artery and vein. In the postnatal ultrasound examination, both kidneys appeared hyperechoic with no vascularization in the hilum region. There was thrombosis in arteries and veins of both kidneys, as well as in the inferior vena cava. The investigation for thrombophilia resulted with the combined presence of heterozygote mutation in factor V Leiden and prothrombin 20210 genes.

High prevalence of cerebral venous sinus thrombosis (CVST) as presentation of cystathionine beta-synthase deficiency in childhood: molecular and clinical findings of Turkish probands

Classical homocystinuria is the most commonly inherited disorder of sulfur metabolism, caused by the genetic alterations in human cystathionine beta-synthase (CBS) gene. In this study, we present comprehensive clinical findings and the genetic basis of homocystinuria in a cohort of Turkish patients. Excluding some CBS mutations, detailed genotype-phenotype correlation for different CBS mutations has not been established in literature. We aimed to make clinical subgroups according to main clinical symptoms and discussed these data together with mutational analysis results from our patients. Totally, 16 different mutations were identified; twelve of which had already been reported, and four are novel (p.N93Y, p.L251P, p.D281V and c.829-2A>T). The probands were classified into three major groups according to the clinical symptoms caused by these mutations. A psychomotor delay was the most common diagnostic symptom (n=12, 46.2% neurological presentation), followed by thromboembolic events (n=6, 23.1% vascular presentation) and lens ectopia, myopia or marfanoid features (n=5, 19.2% connective tissue presentation). Pyridoxine responsiveness was 7.7%; however, with partial responsive probands, the ratio was 53.9%. In addition, five thrombophilic nucleotide changes including MTHFR c.677 C>T and c.1298 A>C, Factor V c.1691 G>A, Factor II c.20210 G>A, and SERPINE1 4G/5G were investigated to assess their contributions to the clinical spectrum. We suggest that the effect of these polymorphisms on clinical phenotype of CBS is not very clear since the distribution of thrombophilic polymorphisms does not differ among specific groups. This study provides molecular findings of 26 Turkish probands with homocystinuria and discusses the clinical presentations and putative effects of the CBS mutations.

Anti-neutrophil cytoplasmic antibody vasculitis presenting with bilateral renal vein thrombosis

We report a case of anti-neutrophil cytoplasmic antibody (ANCA)-associated necrotizing crescentic glomerulonephritis presenting with bilateral renal vein thrombosis and pulmonary emboli in a patient who also had a lupus anticoagulant and anti-cardiolipin antibodies. Although the link between venous thrombosis and ANCA vasculitis is well established, the coexistence of renal vein thrombosis is unusual. Furthermore, despite the positive ANCA, he was initially negative for antibodies to myeloperoxidase (MPO) and proteinase-3 (PR3), illustrating that a positive ANCA may be significant despite a negative test for antibodies to MPO and PR3.

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.

Nephrotic syndrome associated with renal vein thrombosis--a report of 3 cases

The coexistence of nephrotic syndrome and renal vein thrombosis has been of medical interest since Rayer’s description in 1840. Renal vein thrombosis has been underdiagnosed because of its variable clinical and radiological findings but it becomes a more frequently recognizable clinical entity since diagnosis can be easily established by modern angiographic techniques. Generally it has been believed that renal vein thrombosis may cause nephrotic syndrome. But recent articles strongly suggest that renal vein thrombosis is a complication of the nephrotic syndrome rather than a cause. We report three cases of nephrotic syndrome associated with renal vein thrombosis.