Renal Vein Thrombosis Workup

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

Laboratory Studies

No specific laboratory studies are indicated for renal vein thrombosis (RVT) except those specific for nephrotic syndrome or other associated factors such as trauma or a coexisting hypercoagulable state. Studies that may be helpful include the following:

  • Cholesterol levels for hypercholesterolemia
  • Albumin levels for hypoalbuminemia
  • Serum complement levels
  • Urine protein and loss renal function studies, including serum creatinine and blood urea nitrogen (BUN); these are necessary because RVT may present as unexplained acute renal failure or a sudden increase in proteinuria
  • Review of renal biopsy
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Imaging Studies

In RVT, intravenous pyelography (IVP) with an abdominal plain film may reveal an enlarged kidney. If the renal pelvis is observed, it is usually distorted. An infrequent but characteristic finding of RVT is notching of the ureter, which occurs when collateral veins near the ureters become tortuous. IVP seldom is used to help make the diagnosis.

Inferior vena cavography may help provide a diagnosis of RVT. Occasionally, it is not diagnostic, in which case selective renal vein catheterization can be performed.

Renal arteriography may be useful in situations where RVT is secondary to trauma or tumor, in which case renal artery involvement is common.

Renal ultrasonography (US) is a safe noninvasive technique. With underlying RVT, the kidneys swell and become echogenic, with prominent echo-poor medullary pyramids. Color Doppler scanning may also provide information. However, US usually is not sensitive enough to assist in making the diagnosis, [13]  though it is possible that contrast-enhanced US may yield better results. [14]

Computed tomography (CT) is the procedure of choice for diagnosing RVT noninvasively (see the image below). Intravenous (IV) infusion of contrast material assists in visualizing the renal veins. CT also demonstrates the presence of renal cell cancer.

CT scan shows renal vein thrombosis secondary to r CT scan shows renal vein thrombosis secondary to renal cell cancer. Arrow is pointed at thrombosed renal vein.

At some point, magnetic resonance imaging (MRI) may become the procedure of choice for the diagnosis of RVT (see the image below). MRI produces high-contrast images between flowing blood, vascular walls, and surrounding tissue. Its major benefit is the avoidance of radiation and IV contrast material. MRI also may help detect RVT and the presence of tumor.

MRI is from patient with renal cell cancer and ren MRI is from patient with renal cell cancer and renal vein thrombosis. Arrow is on thrombosed renal vein.

In a study comparing the diagnostic accuracy of three-dimensional contrast-enhanced magnetic resonance venography (3D-CE-MRV) with that of multidetector CT venography (as the reference standard) for detecting RVT, Zhang et al found that the sensitivities and specificities of 3D-CE-MRV relative to CT venography were 94.1% and 100% on a per-patient basis and 95.5% and 100% on a per-vessel basis. [15] They concluded that 3D-CE-MRV would be an optimal alternative imaging modality for detecting RVT.

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Histologic Findings

Renal biopsy plays an essential role in the evaluation of patients who are nephrotic and who have RVT. Renal histologic features of these patients reflect the responsible primary renal disease. Membranous nephropathy is the most common finding (see the image below).

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