Thrombosis of the renal vein

Thrombosis of the renal vein in adults is rare. A thrombus can occur in the inferior vena cava or in small branches of the renal vein.

Causes of the thrombosis of the renal vein

The defeat is usually one-sided. Occurs usually on a background:

• continuing ascending thrombosis of the inferior vena cava;
• venous stasis due to congestive heart failure in the stage of decompensation;
• disorders of the coagulating system of blood, conditions leading to blood thickening - nephrotic syndrome, erythremia;
• membranous nephropathy;
• antiphospholipid syndrome.

Among other causes of renal vein thrombosis, kidney cancer and bulk formations of the retroperitoneal space should be noted. In children, thrombosis of the renal vein can occur due to severe dehydration with profuse diarrhea.

[1], [2], [3], [4], [5], [6], [7], [8]

Symptoms of the thrombosis of the renal vein

Symptoms of renal vein thrombosis are characterized by edema, venous renal disease and secondary nephron damage. Acute thrombosis of the renal vein is manifested by severe pain in the lumbar region from the side of the lesion, hematuria of varying intensity, with bilateral thrombosis, a decrease in diuresis is possible; with right-side lesion there is pain in the right side.

Chronic venous thrombosis develops after an acute initial phase with pain and haematuria or as a primarily chronic condition. Pain, if any, is weak, dull, aching; hematuria is visually invisible in most cases, but proteinuria due to developed renal venous hypertension quickly reaches the nephrotic level and leads to characteristic nephritic edema, arterial hypertension is possible but uncharacteristic.

In some patients with slowly developing thrombosis it is time to adequately form outflow of blood through collateral vessels, and patients do not make any significant complaints at all.

Forms

Thrombosis of the renal vein can be one- and two-sided, acute and chronic.

[9], [10], [11], [12], [13], [14], [15], [16]

Diagnostics of the thrombosis of the renal vein

If this disease is suspected, special attention should be paid to the collection of an anamnesis, since isolated primary thrombosis of the renal veins is practically impossible. Very important is the question of the propensity to recurrent venous thrombosis and thromboembolism, as well as the ongoing therapy. The thrombosis can be provoked by inadequate reception of anticoagulants. With a clear clinical picture of circulatory failure, it should be borne in mind that thromboses develop with severe right ventricular failure, which leads to stagnation of blood in the veins of a large circle. Nephrotic syndrome, which can lead to venous thrombosis, must be extremely decompensated.

As with circulatory failure, and with nephrotic syndrome, renal vein thrombosis can be provoked by an attempt to achieve compensation by administering loop diuretics, especially in large doses and for a long time. Finally, any recurrent venous thrombosis, including renal veins, without any apparent cause, is very typical for malignant tumors, with the first manifestation of the disease being thrombosis. The outcome of the disease is nephrosclerosis, but with adequate treatment, it is possible to restore the kidney function.

In acute thrombosis of the renal vein, physical methods can be used to determine the soreness in the lumbar region from the side of the lesion, the admixture of blood in the urine.

In chronic thrombosis, examination and palpation reveal nephrotic edema. It is important to pay attention to the signs of venous stasis in the lower extremities, the swelling of the lower half of the body, which can indicate a violation of the outflow of blood along the inferior vena cava, and also to the developed venous collaterals of the anterior abdominal wall.

Laboratory diagnosis of renal vein thrombosis

In the general analysis of urine with acute thrombosis of the renal vein, haematuria is characteristic, which can be very pronounced. In chronic thrombosis of the renal vein, microhematuria is revealed, and, most importantly, proteinuria, which can reach the nephrotic level (more than 3.5 g / day). Patients with proteinuria naturally detect hyaline cylinders.

Determination of daily proteinuria is indicated for any increase in protein excretion to assess its actual loss. With daily proteinuria 3.5 g or more, the probability of developing a nephrotic syndrome is higher. In a general blood test, thrombocytopenia can be detected. Biochemical blood analysis can reveal an elevated level of creatinine (especially with bilateral thrombosis), and with nephrotic syndrome - hypoproteinemia, hyperlipidemia.

[17], [18], [19], [20], [21], [22], [23], [24]

Instrumental diagnosis of renal vein thrombosis

Review and excretory urography in the acute phase of the disease reveals an increase in the affected kidney and a characteristic decrease in its function until complete absence. Sometimes in the cup-and-pelvis system, defects in filling are seen due to blood clots. On the contours of the proximal part of the ureter, impressions are sometimes seen. Corresponding to the enlarged collateral veins.

Cystoscopy, which is referred to as hematuria, can reveal a blood-colored urine on one of the ureters, which allows us to determine the side of the lesion, and also unambiguously exclude glomerulonephritis.

A coagulogram is necessary in the shortest possible time to evaluate hemocoagulation. Without a coagulogram, the appointment of anticoagulants or hemostatic drugs with suspicion of thrombosis of the renal veins is contraindicated.

Kidney ultrasound with dopplerography allows you to quickly assess the condition of the kidneys and trunk kidney vessels. The value of this technique lies in the comparative simplicity and availability in a round-the-clock mode.

Radioisotope renography and dynamic nephroscintigraphy are performed in a planned manner mainly to assess the symmetry of nephropathy. With chronic renal vein thrombosis, even bilateral, renal damage is always asymmetric, while with immune nephropathies it is always symmetrical.

Informative diagnostic methods are CT and MRI.

Selective renal venography is the main diagnostic method that allows the most reliable determination of the nature and extent of renal veins, although the diagnosis can sometimes be made by performing a cavagra.

Indications for consultation by other specialists

All persons with suspicion of renal venous hypertension are advised by a urologist (and, in his absence, a vascular surgeon) and a roentgenologist, an angiography specialist. If the patient has proteinuria and, if necessary, exclude glomerulonephritis, the consultation of the nephrologist is indicated.

Differential diagnosis

Acute thrombosis of the renal vein must be differentiated first and foremost with renal colic. A fundamental difference in proteinuria. For renal colic is not characteristic of any significant proteinuria, while with thrombosis of the renal vein, it is natural. Usually the situation permits the execution of ultrasound (preferably with a doppler). Pronounced hematuria, especially with clots, may suggest a possible tumor of the kidney or urinary tract.

With pronounced proteinuria, the first thing to do is to exclude the various forms of chronic glomerulonephritis that occur with the nephrotic syndrome. This question is quite complicated, because in itself a nephrotic syndrome can be the cause of venous thrombosis. Pronounced proteinuria with poor urinary sediment may require differential diagnosis with kidney amyloidosis, especially if the patient has at least a slight decrease in glomerular filtration. A kidney biopsy, which usually allows you to clearly differentiate different forms of glomerulonephritis, amyloidosis, becomes susceptible to suspected illness because of the high risk of bleeding from the dilated intrarenal veins.

[25], [26], [27], [28], [29], [30], [31],

Treatment of the thrombosis of the renal vein

Indications for hospitalization

Acute thrombosis of the renal veins serves as an absolute indication for hospitalization. If you suspect a chronic thrombosis of the renal vein, hospitalization for in-patient examination is also indicated.

In addition, the severity of the condition of such patients for the underlying disease, against which there is a thrombosis of the renal vein, usually also requires inpatient treatment.

In the case of severe hematuria, a strict bed rest is indicated.

Drug treatment for renal vein thrombosis

With the confirmed diagnosis, an attempt of thrombolysis with the help of direct anticoagulants - heparin sodium or low-molecular heparins, for example sodium enoxaparin (kleksana) 1-1.5 mg / (kghsut), is quite legitimate. Obviously, this treatment of renal vein thrombosis is contraindicated in the presence of even a small hematuria. Thrombolysis is also effective, which can lead to the restoration of kidney function. Children, in addition to anticoagulant therapy, showed a correction of water-electrolyte disorders.

Expressed hematuria is an indication for the immediate onset of haemostatic therapy, even despite the possibility of progression of venous thrombosis. Usually begin with etamzilate 250 mg 3-4 times a day intramuscularly or intravenously.

Medication for chronic thrombosis of the renal veins is extremely difficult. If proteinuria is non-immune, and is associated exclusively with renal venous hypertension, then immunosuppressive therapy (glucocorticoids, cytostatics) will certainly be ineffective. The appointment of diuretics is quite dangerous, as the resulting thickening of blood naturally increases the risk of progression of thrombosis. If absolutely necessary, you can prescribe diuretics in combination with anticoagulants. Anticoagulant therapy for chronic thrombosis should be performed in all patients who do not have severe hematuria.

[32], [33], [34], [35], [36], [37], [38], [39]

Operative treatment of renal vein thrombosis

Surgical treatment of renal vein thrombosis consists in removing a blood clot from the renal vein and restoring its patency. With the onset of irreversible changes in the kidney, with severe hematuria, as well as with a severe condition of the patient, the patient may need a nephrectomy. Obviously, nephrectomy is contraindicated in the bilateral nature of thrombosis.

The patient who suffered thrombosis of the renal veins showed a long (almost lifelong) reception of indirect anticoagulants - warfarin 2.5-5 mg under the control of the international normalized ratio (MHO, target level MHO 2-3). It is worth noting that the entire group of indirect anticoagulants, including warfarin, has a lot of drug interactions, which must be taken into account when prescribing any medications.

Prevention

Screening is not carried out because of the rarity of this condition.

Thrombosis of the renal vein can be prevented if adequate treatment is made of diseases that are naturally complicated by this condition - nephrotic syndrome, antiphospholipid syndrome, decompensation of circulatory insufficiency, erythremia, etc.

[40], [41], [42], [43], [44], [45], [46], [47]

Forecast

With thrombosis of renal veins, the prognosis is usually determined by the underlying disease that led to such a complication. It should be noted that this pathology develops only with a severe, extremely unfavorable course of the underlying disease.

[48], [49], [50], [51], [52]