Renal Artery Thrombosis in a Young Woman Taking Oral Contraceptives S. M. GOLBUS, M.D.; Lt Comdr A. R. SWERDLIN, MC, USNR; Lt Comdr J. A. MITAS II, MC, USN; Lt Comdr W. R. ROWLEY, MC, USNR; and Capt D. R. JAMES, MC, USN Naval Regional Medical Center; San Diego, California O R A L CONTRACEPTIVES cause a number of serious side
effects in young women. Prominent among these is an increased incidence of thromboembolic events (1). Although these thromboemboli almost invariably occur on the venous side of the circulation, there have been reports describing the occurrence of arterial thromboses. Occlusions of the femoral, celiac, superior mesenteric, popliteal, iliac, retinal, cerebral, and coronary arteries have been described (2-6). Spontaneous thrombosis of the renal artery is a rare event. When reported, it has usually occurred superimposed on an underlying anatomic abnormality of the renal artery after trauma, or very rarely in the setting of systemic disease such as polycythemia vera or thromboangiitis obliterans (7). Since isolated renal artery thrombosis in the absence of these underlying conditions has not, to our knowledge, been previously described, we wish to bring attention to the diagnosis of this disorder in a young woman taking oral contraceptives and without any other predisposing abnormality. A 22-year-old white woman was admitted to the Naval Regional Medical Center, San Diego, on 24 July 1978 after 12 h of right flank pain. Her medical history was negative except for an episode of cystitis. She was a one-pack-per-day cigarette smoker and had been taking Orthonovum 1/50® for the preceding 6 months. At admission she had a temperature of 37.8 °C and blood pressure of 150/80 mm Hg. With the exception of flank tenderness, physical examination findings were normal. Admission laboratory studies showed a blood urea nitrogen (BUN) concentration of 9 mg/dL; leukocyte count 14 500 mm-; hematocrit 44%; and 2+ protein on urinalysis. Determinations of antinuclear antibody and rheumatoid factor were negative. Coagulation studies revealed a slight decrease in antithrombin III to 14 mg/dL (normal, 17 to 28). There was nonvisualization of the right kidney on intravenous urogram, and a cystoscopy and retrograde pyelogram were both normal. A renal scan on 25 July showed no flow or uptake in the right kidney. Angiography, including an aortic arch study, showed an occluded right renal artery with reconstitution of the distal vessels (Figure 1), and emergency right renal artery thrombectomy with vein patch angioplasty was done. The pathologic diagnosis of the material removed from the renal artery was newly formed thrombus. A postoperative echocardiogram was unremarkable. Brief Reports
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At follow-up 3 months later, BUN and blood pressure were normal and a repeat renal angiogram unremarkable except for nonvisualization of a small portion of the right upper pole. Retrospective epidemiologic studies have established that oral contraceptives predispose to venous thromboembolic disease. The most widely quoted studies have concluded that oral contraceptive users have a sixfold to elevenfold increased risk of venous thromboemboli (8, 9). Postulated mechanisms of increased venous thrombogenicity include decreased negative surface charge on vessel walls and blood cells; decreased linear velocity of blood flow through veins secondary to greater distensibility; and altered coagulation and fibrinolytic systems, manifested by increased levels of Factors II, VII, and X and decreased antithrombin III (1). The number of reports of spontaneous arterial thromboses occurring in young women using oral contraceptives suggests that these medications also predispose to arterial thrombosis. It is noteworthy that our patient was a smoker because smoking and oral contraceptives have been shown to act synergistically in the development of arterial thromboses, specifically, myocardial infarctions and strokes (4, 5). Our patient had a well-documented renal artery thrombosis in the absence of a recognized predisposing cause. She presented with classic features of sudden renal artery occlusion: acute onset of flank pain, leukocytosis, low-grade fever, abnormal urinalysis, nonvisualization of the kidney with an intravenous urogram, and a normal retrograde pyelogram. That her occlusion was thrombotic rather than embolic is substantiated by the pathologic report, the absence of any source of emboli by history or physical examination, and a normal aortic arch study and echocardiogram. Previously recognized causes of renal artery thrombosis were ruled out by the absence of trauma or systemic disease and the anatomically normal artery on angiography. The correct therapy for acute renal artery occlusion has not been established. We chose operative thrombectomy rather than conservative medical management or nephrectomy because of reports of restoration of renal function in patients with documented renal artery obstruction of up to 25 days' duration (10). Only a randomized prospective study, however, will answer the question of which mode of therapy will have the best risk-benefit ratio.
Figure 1 . Renal angiography showing occlusion of the right renal artery. 9 4 0
June 1979 • Annals of Internal Medicine • Volume 90 • Number 6
Downloaded from https://annals.org by Tulane University user on 01/18/2019
The authors thank Ms. Pam Burroughs for her fine editorial assistance. The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department or the Naval Service at large. REFERENCES
1. KAPLAN N M : Cardiovascular complications of oral contraceptives. Annu Rev Med 29:31-40, 1978 2. LANGHORNE WH: Arterial thrombosis, smoking, and oral contraceptives. South Med J 67:523-526, 1974 3. DAHLBACK LO, RAIS O: Aorto-iliac arterial thrombosis in young women. Report of 3 cases. Acta Chir Scand 143:127-130, 1977 4. COLLABORATIVE G R O U P FOR T H E STUDY O F STROKE IN Y O U N G
W O M E N : Oral contraception and increased risk of cerebral ischemia or thrombosis. N Engl J Med 288:871-878, 1973 5. M A N N JI, VESSEY MP, T H O R O G O O D M, D O L L R: Myocardial infarc-
tion in young women with special reference to oral contraceptive practice. Br Med J 2:241-245, 1975 6. ORY HW: Association between oral contraceptives and myocardial infarction. A review. JAMA 237:2619-2622, 1977 7. SHABANAH F H , C O N N O L L Y JE, M A R T I N DC: Acute renal artery occlu-
sion. Surg Gynecol Obstet 131:489-494, 1970 8. Oral contraceptives and venous thromboembolic disease, surgically confirmed gallbladder disease, and breast tumours. Report from the Boston Collaborative Drug Surveillance Program. Lancet 1:1399-1404, 1973 9. VESSEY MP, D O L L R: Investigation of relation between use of oral contraceptives and thromboembolic disease. A further report. Br Med J 2:651-657, 1969 10. BARRY JM, H O D G E S CV: Revascularization of totally occluded renal arteries. / Urol 119:412-415, 1978 © 1 9 7 9 American College of Physicians
effects in young women. Prominent among these is an increased incidence of thromboembolic events (1). Although these thromboemboli almost invariably occur on the venous side of the circulation, there have been reports describing the occurrence of arterial thromboses. Occlusions of the femoral, celiac, superior mesenteric, popliteal, iliac, retinal, cerebral, and coronary arteries have been described (2-6). Spontaneous thrombosis of the renal artery is a rare event. When reported, it has usually occurred superimposed on an underlying anatomic abnormality of the renal artery after trauma, or very rarely in the setting of systemic disease such as polycythemia vera or thromboangiitis obliterans (7). Since isolated renal artery thrombosis in the absence of these underlying conditions has not, to our knowledge, been previously described, we wish to bring attention to the diagnosis of this disorder in a young woman taking oral contraceptives and without any other predisposing abnormality. A 22-year-old white woman was admitted to the Naval Regional Medical Center, San Diego, on 24 July 1978 after 12 h of right flank pain. Her medical history was negative except for an episode of cystitis. She was a one-pack-per-day cigarette smoker and had been taking Orthonovum 1/50® for the preceding 6 months. At admission she had a temperature of 37.8 °C and blood pressure of 150/80 mm Hg. With the exception of flank tenderness, physical examination findings were normal. Admission laboratory studies showed a blood urea nitrogen (BUN) concentration of 9 mg/dL; leukocyte count 14 500 mm-; hematocrit 44%; and 2+ protein on urinalysis. Determinations of antinuclear antibody and rheumatoid factor were negative. Coagulation studies revealed a slight decrease in antithrombin III to 14 mg/dL (normal, 17 to 28). There was nonvisualization of the right kidney on intravenous urogram, and a cystoscopy and retrograde pyelogram were both normal. A renal scan on 25 July showed no flow or uptake in the right kidney. Angiography, including an aortic arch study, showed an occluded right renal artery with reconstitution of the distal vessels (Figure 1), and emergency right renal artery thrombectomy with vein patch angioplasty was done. The pathologic diagnosis of the material removed from the renal artery was newly formed thrombus. A postoperative echocardiogram was unremarkable. Brief Reports
Downloaded from https://annals.org by Tulane University user on 01/18/2019
939
At follow-up 3 months later, BUN and blood pressure were normal and a repeat renal angiogram unremarkable except for nonvisualization of a small portion of the right upper pole. Retrospective epidemiologic studies have established that oral contraceptives predispose to venous thromboembolic disease. The most widely quoted studies have concluded that oral contraceptive users have a sixfold to elevenfold increased risk of venous thromboemboli (8, 9). Postulated mechanisms of increased venous thrombogenicity include decreased negative surface charge on vessel walls and blood cells; decreased linear velocity of blood flow through veins secondary to greater distensibility; and altered coagulation and fibrinolytic systems, manifested by increased levels of Factors II, VII, and X and decreased antithrombin III (1). The number of reports of spontaneous arterial thromboses occurring in young women using oral contraceptives suggests that these medications also predispose to arterial thrombosis. It is noteworthy that our patient was a smoker because smoking and oral contraceptives have been shown to act synergistically in the development of arterial thromboses, specifically, myocardial infarctions and strokes (4, 5). Our patient had a well-documented renal artery thrombosis in the absence of a recognized predisposing cause. She presented with classic features of sudden renal artery occlusion: acute onset of flank pain, leukocytosis, low-grade fever, abnormal urinalysis, nonvisualization of the kidney with an intravenous urogram, and a normal retrograde pyelogram. That her occlusion was thrombotic rather than embolic is substantiated by the pathologic report, the absence of any source of emboli by history or physical examination, and a normal aortic arch study and echocardiogram. Previously recognized causes of renal artery thrombosis were ruled out by the absence of trauma or systemic disease and the anatomically normal artery on angiography. The correct therapy for acute renal artery occlusion has not been established. We chose operative thrombectomy rather than conservative medical management or nephrectomy because of reports of restoration of renal function in patients with documented renal artery obstruction of up to 25 days' duration (10). Only a randomized prospective study, however, will answer the question of which mode of therapy will have the best risk-benefit ratio.
Figure 1 . Renal angiography showing occlusion of the right renal artery. 9 4 0
June 1979 • Annals of Internal Medicine • Volume 90 • Number 6
Downloaded from https://annals.org by Tulane University user on 01/18/2019
The authors thank Ms. Pam Burroughs for her fine editorial assistance. The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department or the Naval Service at large. REFERENCES
1. KAPLAN N M : Cardiovascular complications of oral contraceptives. Annu Rev Med 29:31-40, 1978 2. LANGHORNE WH: Arterial thrombosis, smoking, and oral contraceptives. South Med J 67:523-526, 1974 3. DAHLBACK LO, RAIS O: Aorto-iliac arterial thrombosis in young women. Report of 3 cases. Acta Chir Scand 143:127-130, 1977 4. COLLABORATIVE G R O U P FOR T H E STUDY O F STROKE IN Y O U N G
W O M E N : Oral contraception and increased risk of cerebral ischemia or thrombosis. N Engl J Med 288:871-878, 1973 5. M A N N JI, VESSEY MP, T H O R O G O O D M, D O L L R: Myocardial infarc-
tion in young women with special reference to oral contraceptive practice. Br Med J 2:241-245, 1975 6. ORY HW: Association between oral contraceptives and myocardial infarction. A review. JAMA 237:2619-2622, 1977 7. SHABANAH F H , C O N N O L L Y JE, M A R T I N DC: Acute renal artery occlu-
sion. Surg Gynecol Obstet 131:489-494, 1970 8. Oral contraceptives and venous thromboembolic disease, surgically confirmed gallbladder disease, and breast tumours. Report from the Boston Collaborative Drug Surveillance Program. Lancet 1:1399-1404, 1973 9. VESSEY MP, D O L L R: Investigation of relation between use of oral contraceptives and thromboembolic disease. A further report. Br Med J 2:651-657, 1969 10. BARRY JM, H O D G E S CV: Revascularization of totally occluded renal arteries. / Urol 119:412-415, 1978 © 1 9 7 9 American College of Physicians
