eMedicine Specialties > Vascular Surgery > Medical Topics

Renal Vein Thrombosis

Author: Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Coauthor(s): Louis Schwing, MD, Consulting Staff, Department of Internal Medicine, Carle Clinic Associates
Contributor Information and Disclosures

Updated: Sep 17, 2009

Introduction

Background

Although renal vein thrombosis (RVT) has numerous etiologies, it occurs most commonly in patients with nephrotic syndrome (ie, >3 g/d protein loss in the urine, hypoalbuminemia, hypercholesterolemia, edema).

The syndrome is responsible for a hypercoagulable state. The excessive urinary protein loss is associated with decreased antithrombin III, a relative excess of fibrinogen, and changes in other clotting factors; all lead to a propensity to clot. Numerous studies have demonstrated a direct relationship between nephrotic syndrome and both arterial and venous thromboses. Why the renal vein is susceptible to thrombosis is unclear.

The renal vein may also contain thrombus after invasion by renal cell cancer. Other less common causes include renal transplantation, Behçet syndrome, hypercoagulable states, and antiphospholipid antibody syndrome.

Pathophysiology

Hypercoagulability is the etiology for both arterial and venous thromboses. In the setting of malignant invasion of the vein by cancer, the presence of the tumor cells elicits thrombosis of the renal vein only. It may also occur as the result of blunt trauma to the abdomen or back. In infants, renal vein thrombosis can be associated with dehydration.^1,2,3

Frequency

United States

Prevalence of renal vein thrombosis (RVT) has been difficult to establish. Studies have shown a high degree of variability in the presence of renal vein thrombosis (RVT) among patients with nephrotic syndrome, with reported rates of 5-62%.

Mortality/Morbidity

The morbidity and mortality of renal vein thrombosis (RVT) is usually secondary to the effects of nephrotic syndrome (including arterial thrombosis), renal dysfunction and/or failure, or the complications resulting from thromboembolism. If the etiology of the renal vein thrombosis (RVT) is malignancy, morbidity and mortality are a result of either thromboembolism or the cancer itself. In the setting of transplantation, renal vein thrombosis (RVT) may lead to loss of the graft. If the renal vein thrombosis (RVT) eventuates from the other causes discussed, thromboembolism is the source of complications.

Race

No race predilection exists.

Sex

No specific numbers are available. However, theoretically, membranous nephropathy, the most commonly disease associated with renal vein thrombosis (RVT), has a male-to-female ratio of 2:1. Therefore, a male preponderance may exist.

Age

Age is a factor in renal vein thrombosis (RVT) only as associated with any age-related risk of glomerular disease. For example, membranous nephropathy, the lesion most associated with renal vein thrombosis (RVT), is the most common cause of nephrotic syndrome in adults, but it is rare in children. Membranous nephropathy peaks in the fourth through sixth decade, thus making renal vein thrombosis (RVT) more likely in this specific age group. However, exact incidence or prevalence is not available.

Clinical

History

The presentation of renal vein thrombosis (RVT) is variable, and patients may be asymptomatic. When renal vein thrombosis (RVT) occurs as a result of malignancy, the signs of the renal malignancy (eg, hematuria, weight loss) predominate.

• The more common chronic form of renal vein thrombosis (RVT) is generally covert.
• The less frequent acute form usually occurs in younger patients, with flank pain and macroscopic hematuria, which can be severe in the acute onset of thrombosis.
• Patients may present with thrombosis and/or pulmonary embolism.

Physical

Observe for signs of nephrotic syndrome (edema or anasarca).

Causes

• In patients who are nephrotic, the most common underlying nephropathy associated with renal vein thrombosis (RVT) is membranous nephropathy. For a renal biopsy of membranous nephropathy, see Image 1. The tumor association for renal vein thrombosis (RVT) is renal cell carcinoma. However, most cases of membranous nephropathy are idiopathic.

• Renal vein thrombosis (RVT) also may be the result of nephrotic syndrome from membranoproliferative glomerulonephritis, minimal change disease, rapidly progressive glomerulonephritis, amyloid, focal sclerosis, or lupus nephritis. Renal vein thrombosis (RVT) is more common in patients with primary rather than secondary nephropathy.
• Findings relative to the causative disease may be present (eg, systemic lupus erythematosus [SLE]/antiphospholipid antibody syndrome, cancer).
• Theories for the putative relationship between nephrotic syndrome and renal vein thrombosis (RVT) have evolved. Initially, nephrotic syndrome was believed to be a consequence of renal vein thrombosis (RVT). However, this presumed sequence was incorrect.
  • Experimentally induced renal vein thrombosis (RVT) causes only mild proteinuria.
  • Renal vein thrombosis (RVT) in the absence of nephrotic syndrome has been reported in the surgical literature.
  • Nephrotic patients with renal vein thrombosis (RVT) who have undergone histologic evaluation show evidence of an identifiable glomerulopathy.
  • Renal vein thrombosis (RVT) is known to occur after the onset of nephrotic syndrome. Thus, nephrotic syndrome is not a direct result of renal vein thrombosis (RVT) but rather leads to renal vein thrombosis (RVT).
• SLE has also been associated with renal vein thrombosis (RVT).
  • In general, patients with lupus and documented renal vein thrombosis (RVT) have membranous lupus nephritis (World Heath Organization class V).
  • Generally, thrombophlebitis and circulating anticoagulants (anticardiolipin antibodies) are believed to be much less important than nephrotic syndrome as predisposing factors of renal vein thrombosis (RVT) in SLE.
• Renal vein thrombosis (RVT) is an uncommon but definite problem in neonates. A possible association exists between renal vein thrombosis (RVT) and the factor V Leiden mutation in this age group.
• Other diseases or situations that have been associated with renal vein thrombosis (RVT) include antithrombin III deficiency, protein C or S deficiency, antiphospholipid antibody syndrome, pregnancy or estrogen therapy (all hypercoagulable states), renal vein invasion by malignant cells, postrenal transplantation, Behçet syndrome, and extrinsic compression (eg, lymph nodes, tumor, retroperitoneal fibrosis, aortic aneurysm). Other than renal cell cancer, the other associations are uncommon.
• Trauma, ingestion of oral contraceptive agents, dehydration (infants), and steroid administration also have been associated with renal vein thrombosis (RVT).

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