Renal Vein Thrombosis Treatment & Management

Updated: Aug 27, 2020
  • Author: Igor A Laskowski, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
  • Print
Treatment

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 (ACE) inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) to decrease proteinuria from nephrotic syndrome. Urinary protein is injurious to the renal tubules. ACEIs and ARBs decrease urine protein through an effect on efferent arteriolar pressure. Titrate to as high a dose as tolerated. 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.

Atorvastatin may be helpful. A study by Bianchi suggested that atorvastatin decreases the rate of progression of kidney disease, proteinuria, and hypercholesterolemia. [16]

Cyclosporine has demonstrated benefit in early trials for treatment of membranous nephropathy. Cure of the underlying nephropathy reverses nephrotic syndrome and renal vein thrombosis (RVT).

Anticoagulation with warfarin has been recommended in some studies for prophylaxis against pulmonary embolism (PE). PE from 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. [17] In PE 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. [18, 19, 20, 21]

For thrombolytic therapy or interventional radiology, transfer patients, especially if a vena caval filter is necessary in the event of failure of medical therapy for recurrent thromboembolism. The vena cava filter in these cases must be placed above the level of the renal veins (ie, suprarenally). This requirement is unique because in all other forms of deep vein thrombosis (DVT) and PE, the filters are placed in the infrarenal segment of the inferior vena cava (IVC). Either the interventional radiologist or the vascular surgeon can place the filter.

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

Next:

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. [22] IVC filters may be used in this instance. [23] Surgery may be necessary for RVT of RCC, particularly for cure of malignancy. Partial nephrectomy with thrombectomy has been used to treat RCC extending to the main renal vein. [24]

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

Previous
Next:

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 (~10 g or more over 24 hours) or in those who have chronic renal failure. [25]

Activity is allowed as tolerated.

Previous
Next:

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, a vascular surgeon, a cardiac surgeon, a transplant surgeon, or a combination thereof works together in complex cases of RCC with extension into the renal vein, IVC, and right atrium.

Previous