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.

This renal biopsy shows membranous nephropathy. L...

This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.

This renal biopsy shows membranous nephropathy. L...

This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.


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.

Renal vein thrombosis (RVT) from renal cell carcinoma occurs in older age groups.

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.
This renal biopsy shows membranous nephropathy. L...

This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.

This renal biopsy shows membranous nephropathy. L...

This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.


  • 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).

More on Renal Vein Thrombosis

Overview: Renal Vein Thrombosis
Differential Diagnoses & Workup: Renal Vein Thrombosis
Treatment & Medication: Renal Vein Thrombosis
Follow-up: Renal Vein Thrombosis
Multimedia: Renal Vein Thrombosis
References
Further Reading

References

  1. Reimold EW, Wittel RA. Renal venous thrombosis in children: changes in management. South Med J. Oct 1983;76(10):1277-84. [Medline].

  2. Dutta TK, Venugopal V. Venous thromboembolism: the intricacies. J Postgrad Med. Jan-Mar 2009;55(1):55-64. [Medline].

  3. Dauger S, Michot C, Garnier A, Hurtaud-Roux MF. [Neonatal renal venous thrombosis in 2008]. Arch Pediatr. Feb 2009;16(2):132-41. [Medline].

  4. Decoster T, Schwagten V, Hendriks J, Beaucourt L. Renal colic as the first symptom of acute renal vein thrombosis, resulting in the diagnosis of nephrotic syndrome. Eur J Emerg Med. Apr 20 2009;[Medline].

  5. Basterrechea Iriarte F, Sota Busselo I, Nogués Pérez A. [Evolution of imaging in renal vein thrombosis in the newborn]. An Pediatr (Barc). Nov 2008;69(5):442-5. [Medline].

  6. Bianchi S, Bigazzi R, Caiazza A, et al. A controlled, prospective study of the effects of atorvastatin on proteinuria and progression of kidney disease. Am J Kidney Dis. Mar 2003;41(3):565-70. [Medline].

  7. Jaako Dardashti V, Bekassy ZD, Ljung R, Gelberg J, Wingren P, Simonsen O, et al. Successful thrombolysis of neonatal bilateral renal vein thrombosis originating in the IVC. Pediatr Nephrol. Mar 24 2009;[Medline].

  8. Maroni BJ. Protein restriction in the pre-end-stage renal disease (ESRD) patient: who, when, how, and the effect on subsequent ESRD outcome. J Am Soc Nephrol. Dec 1998;9(12 Suppl):S100-6. [Medline].

  9. Babu SC, Manoni T, Shah PM. Malignant renal tumor with extension to the inferior vena cava. The American Journal of Surgery. 1998;176:137 -139.

  10. Borrello JA. Renal MR angiography. Magn Reson Imaging Clin N Am. Feb 1997;5(1):83-93. [Medline].

  11. Irish AB, Green FR, Gray DW, et al. The factor V Leiden (R506Q) mutation and risk of thrombosis in renal transplant recipients. Transplantation. Aug 27 1997;64(4):604-7. [Medline].

  12. Kim HS, Fine DM, Atta MG. Catheter-directed thrombectomy and thrombolysis for acute renal vein thrombosis. J Vasc Interv Radiol. May 2006;17(5):815-22. [Medline].

  13. Markowitz GS, Brignol F, Burns ER, et al. Renal vein thrombosis treated with thrombolytic therapy: case report and brief review. Am J Kidney Dis. May 1995;25(5):801-6. [Medline].

  14. Meehan SM, Limsrichamrern S, Manaligod JR, et al. Platelets and capillary injury in acute humoral rejection of renal allografts. Hum Pathol. Jun 2003;34(6):533-40. [Medline].

  15. Nickolas TL, Radhakrishnan J, Appel GB. Hyperlipidemia and thrombotic complications in patients with membranous nephropathy. Semin Nephrol. Jul 2003;23(4):406-11. [Medline].

  16. Orth SR, Ritz E. The nephrotic syndrome. N Engl J Med. Apr 23 1998;338(17):1202-11. [Medline].

  17. Zini L, Haulon S, Leroy X, et al. Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro- or suprahepatic caval thrombus. BJU Int. Jun 2006;97(6):1216-20.

Further Reading

Clinical guidelines

Venous thromboembolism.
Institute for Clinical Systems Improvement - Private Nonprofit Organization.  1998 Jun (revised 2007 Jun).  91 pages.  [NGC Update Pending] NGC:005885

Antithrombotic therapy supplement.
Institute for Clinical Systems Improvement - Private Nonprofit Organization.  2001 Sep (revised 2007 Aug).  64 pages.  NGC:005971

Prevention of venous thromboembolism. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).
American College of Chest Physicians - Medical Specialty Society.  2001 Jan (revised 2008 Jun).  73 pages.  NGC:006665

Clinical trials

Use of Low Molecular Weight Heparin (Tinzaparin) to Treat Blood Clots in Patients With Kidney Failure

Impact of Providing High Protein Bar to Dialysis Patients With Low Serum Albumin

CNI-Free de Novo Protocol in Patients Undergoing Liver Transplantation With Renal Impairment

Related eMedicine topics

Renal Vein Thrombosis  (Radiology)

Chronic Renal Failure

Pulmonary Embolism

Renal Cell Carcinoma

Inferior Vena Caval Thrombosis

Keywords

renal vein thrombosis, thrombosis, renal vein, RVT, nephrotic syndrome, hypercoagulable state, renal vein, clotting, clot, hypoalbuminemia, hypercholesterolemia, arterial thrombosis, renal dysfunction, renal failure, thromboembolism

Contributor Information and Disclosures

Author

Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Igor A Laskowski, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Peripheral Vascular Surgery Society, Society for Vascular Surgery, and Transplantation Society
Disclosure: Nothing to disclose.

Coauthor(s)

Louis Schwing, MD, Consulting Staff, Department of Internal Medicine, Carle Clinic Associates
Louis Schwing, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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