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Renal Vein Thrombosis Treatment & Management

  • Author: Igor A Laskowski, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Dec 08, 2014
 

Medical Care

Measures employed to treat nephrotic syndrome may include steroids and immunosuppressive therapy. Treatment of underlying renal cell carcinoma (RCC) includes surgery for early-stage disease.

Symptomatic treatment includes diuretics and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) to decrease proteinuria from nephrotic syndrome. If a combination of ACEIs and ARBs lowers protein excretion more than either does alone, the two types of medication should be used together. Decreasing protein loss in the urine decreases hypercoagulability.

Anticoagulation with warfarin has been recommended in some studies for prophylaxis against pulmonary embolism (PE). PE from renal vein thrombosis (RVT) should be diagnosed and treated exactly as it is when it results from other sources (ie, heparin, warfarin). If RVT is associated with PE, anticoagulation must be continued as long as nephrotic syndrome is present.

The indicators for thrombolysis in the setting of RVT are unclear. No data are available comparing thrombolytic therapy with anticoagulation.[8] In pulmonary embolic disease from other causes, thrombolytics are indicated in the setting of pulmonary hypertension (as found during examination or discovered by echocardiography). Catheter-based techniques for rapid delivery of thrombolytics in the setting of acute or refractory RVT have been described.[9, 10]

Hypercholesterolemia should be treated according to accepted national guidelines (ie, by using appropriate low-density lipoprotein targets for primary or secondary prevention).

A study by Bianchi suggested that atorvastatin decreases the rate of progression of kidney disease, proteinuria, and hypercholesterolemia.[11]

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Surgical Care

Surgical treatment of RVT is rarely indicated today. It has been used if bilateral RVT is present or if pulmonary emboli have occurred and anticoagulation is contraindicated.[12] Inferior vena caval filters may be used in this instance.[13] Surgery may be necessary for RVT of RCC, particularly for cure of malignancy.

Hypernephroma or RCC is unique in that intraluminal tumor extends into the renal vein and inferior vena cava and sometimes extends into the right atrium. In such cases, radical nephrectomy and removal of the tumor from the inferior vena cava and right atrium affords the chance of cure. This is not distant metastasis; rather, it is tumor extension within the renal vein and inferior vena cava.

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Consultations

Consult a nephrologist and an interventional radiologist (only when medical therapy does not prevent pulmonary emboli).

A surgeon (urologist) can assist in the staging and potential surgery for RCC (early-stage disease). A combined team that consists of a urologist, vascular surgeon, cardiac surgeon, transplant surgeon, or a combination thereof works together in complex cases of RCC with extension into the renal vein, inferior vena cava, and right atrium.

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Diet and Activity

Many nephrologists recommend normal protein intake for patients with nephrotic syndrome. Protein restriction may be used with benefit in patients who are nephrotic who do not spill massive amounts of protein (approximately 10 g or more over 24 hours) or in those who have chronic renal failure.[14]

Activity is allowed as tolerated.

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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, Society for Vascular Surgery, Americas Hepato-Pancreato-Biliary Association, Vascular and Endovascular Surgery Society, Transplantation Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Travis J Phifer, MD 

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Sateesh C Babu, MD Professor of Clinical Surgery, New York Medical College; Chief, Vascular and Endovascular Surgery, Westchester Medical Center

Disclosure: Nothing to disclose.

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.

References
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This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.
This CT scan shows renal vein thrombosis secondary to renal cell cancer. The arrow is pointed at the thrombosed renal vein.
This MRI is from a patient with renal cell cancer and renal vein thrombosis. The arrow is on the thrombosed vein.
 
 
 
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