Letter to the Editor Am J Nephrol 1992;12:134-136
Division of Nephrology. S. Chiara Hospital. Pisa: Institute of Radiology. Faculty of Medicine, University of Pisa. Italy
Unilateral Renal Vein Thrombosis and Pulmonary Embolism Complicating Membranous Nephropathy
Dear Sir, Renal vein thrombosis has been observed in a variety of conditions, especially in association with the nephrotic syndrome [1-5]. Membranous nephropathy and membranoproliferative glomerulonephritis are the main renal his tologic pictures more frequently reported in association with the nephrotic syndrome [1, 5], Several cases of uni lateral renal vein thrombosis consequent to nephrotic syndrome have been described [6-8], History of pulmo nary embolism has sometimes been described [1, 3]. We report on a patient with the rare condition of unilateral renal vein thrombosis and bilateral pulmonary embolism complicating the membranous glomerulonephritis with nephrotic syndrome.
Case Presentation First Admission A 64-vear-old man was referred to the Division of Nephrology because of severe peripheral edema in August 1988. He was suffering from proteinuria and hematuria since May 1988. Upon admission, the body weight was 79 kg, and the blood pressure 160/90 mm Hg. Anasarca with severe pitting edema and pleural effusion was present. Urinalysis showed proteinuria amounting to 5-18 g over a 24-hour period. The sediment contained 30-40 red blood cells and 6-8 white blood cells per highpower field and a few granular casts. His red blood cell count was 4.700.000. hemoglobin 10.6 g/100 ml. the white blood cell count 6,500, hematocrit 35%. The erythrocyte sedimenta tion rate was 54 during the 1st h. Blood urea nitrogen was 35 mg/ 100 ml, serum creatinine 0.8mg/100ml and creatinine clearance 100 ml/min. Total scrum protein was 3.9 g/100 ml, albumin 1.8, and gamma globulin 0.4 g/100 ml. Total cholesterol was 320 mg/100 ml, triglyceride 170, fasting blood glucose 90 mg/100 ml. All remaining hematochemical parameters were found to be in the normal range.
Received: March 16.1990 Accepted: March 18. 1992
HBsAg, RA test, CRP. anti-DNA antibody, antinuclear antibody, and cryoglobulins were negative. Intravenous urography revealed no structural or functional anomalies and a normal renal size bilaterally. The abdominal ultrasound investigation revealed moderate perito neal effusion and confirmed the presence of a normal size of the kid neys with a left renal longitudinal diameter of 122 mm and a right renal longitudinal diameter of 120 mm. A percutaneous kidney biopsy performed on the 12th day of hospitalization revealed by immunofluorescence and light microscopy the typical picture of not evolved membranous nephritis. He was treated with intravenous infusion of human albumin, spironolactone 100 mg/day. and furoscmide 100 mg every 3-4 days. At the time he went home, edemas were absent, the body weight was 65 kg. Total serum protein was 6.1 g/ 100 ml with a normal serum electrophoretic spectrum. Second Admission In May 1989 the patient was transferred to our department from another hospital, where he was admitted some days earlier because of fever (39 °C). dyspnea, and peripheral edema. At the time of admis sion physical examination revealed generalized edema with ascites, left pleural effusion, marked dyspnea, polypnea, orthopnea with severe respiratory insufficiency, and peripheral cyanosis. The blood pressure was 140/80 mm Hg. Urinalysis showed no variation as com pared with the first admission. Blood urea nitrogen was 70 mg/ 100 ml. serum creatinine 1.4 mg/100 ml. creatinine clearance 50 ml/ min and the erythrocyte sedimentation rate was 52 during the 1st h. Total serum protein was 4 g/100 ml with the typical electrophoretic protein diagram of nephrotic syndrome. Serum immunoglobulin lev els revealed marked reduction of IgG globulins. All rheumatic and immunological tests were negative. Fibrinogen was 620 mg/100 ml. Red and white blood cell and platelet counts were in the normal ranges. Plasma cholesterol was 310 mg/100 ml. triglyceride 175 mg/ 100 ml. The INR time for prothrombin time was normal. Echocardi ography revealed moderate pericardial effusion with conspicuous left atrial and ventricular enlargement. No thromboembolic phenome non of the inferior vena cava was detected with abdominal echogra phy. Renal ultrasound detected evident asymmetric enlargement of
Antonio Pasquariello. MI) Division o f Nephrology S. Chiara Hospital Via Roma. 57 1-56100 Pisa (Italy)
© 1992 S. Kargcr AG. Basel 0250-8095/92/0122-0134 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/13/2018 2:27:45 PM
Antonio Pasquarielloa Emilio Camerinib
Fig. 1. Abdominal computerized tomogram showing renal asym metry with marked enlargement of the left kidney.
Fig. 2. Dilatation and thrombosis of the left renal vein (arrow head).
the left kidney with a longitudinal diameter of 15 cm and a right renal longitudinal diameter of 12 cm. Because of severe cardiopul monary conditions, a cavography with direct vascular dye injection was not possible to perform. A computed tomography of abdomen confirmed considerable enlargement of the left kidney (fig. 1) and the clinically suspected dilatation and thrombosis of the left renal vein (fig. 2). Chest X-ray demonstrated discrete pleural effusion and parenchymal basilar infiltrates of the right lung. Pulmonary perfu sion scintiphotographs obtained by intravenous injection of gammaemitting radionuclides 99mTc were indicative of bilateral emboli. The patient has been treated with continuous intravenous infusion of heparin and intermittent oxygen therapy during the first 3 days and later with platelet aggregation inhibitors (ticlopidinc 100mg/day). coumarin derivatives (acenocumarin), spironolactone, and intrave nous infusion of human albumin, resulting in progressive improve ment of the general health conditions and complete resolution of car diopulmonary pathology. The serum creatinine level during the hos pitalization was 1.5 mg/100 ml and creatinine clearance about 50 ml/min. No surgical thrombectomy or pharmacological thrombo lysis with direct intravenous injection of streptokinase or intrinsic plasminogen activator was performed because of the critical respira tory conditions with consequent stabilization of the left renal vascu lar lesion. The patient went home with the prescription of antiplate let drugs (ticlopidine 100mg/day) as anticoagulant prophylaxis, diuretics, and intravenous infusion of human albumin twice weekly. The course of renal function was favourable until 4 months later with a serum creatinine level of 1.2 mg/100 ml and a creatinine clear ance of 78 ml/min. Unfortunately, after this period the patient was lost to follow-up.
enon has been a complication rather than the cause, prob ably due to a platelet hyperaggregability condition [9], Laboratory findings, except serum creatinine and creati nine clearance were identical at both hospitalizations. Thrombosis in nephrotic syndrome is probably due to many factors. In this case thrombosis and embolism occurred after an intercurrent hyperpyretic episode and consequent hemoconcentration, factors that in associa tion with severe hypoalbuminemia increase the risk of thrombosis. Whether long-term therapy with anti-platelet agents in nephrotic syndrome is effective to prevent thrombotic phenomena remains an open question [9. 10], Although direct dye injection is the elective diagnos tic instrument in endoluminal vascular pathologic con ditions. in particular cases alternative techniques such as tomography, nuclear magnetic resonance, and color Doppler ultrasound can adequately substitute it.
Discussion
135
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This report documents (1) the rare occurrence of uni lateral renal vein thrombosis and pulmonary embolism in nephrotic syndrome and (2) that the thrombotic phenom-
References 1 Briefel GR. Manis T. Gordon DH. Nicastri AD. Friedman HA: Recurrent renal vein thrombosis consequent to membranous glo merulonephritis. Clin Nephrol 1978:10:32. 2 Cameron JS: The nephrotic syndrome and its complications. Am J Kidney Dis 1987:10 :151 — 171. 3 Llaclt F. KolTler A. Finck E. Massry SG: On the incidence of renal vein thrombosis in the ne phrotic svndrome. Arch Intern Med 1977:137: 333.
4 McCarthy LJ. Titus JL. Daugherty GW: Bilat eral renal vein thrombosis and nephrotic syn drome in adults. Ann Intern Med 1963:58: 837. 5 Trew PA, Biava CG. Jacobs RP. Hopper J Jr: Renal vein thrombosis in membranous glome rulopathy: Incidence and association. Medi cine (Baltimore) 1978:57:69. 6 Kauffmann RH. DeGraal'J, de la Rivière GB. van Es LA: Unilateral renal vein thrombosis and nephrotic syndrome. Report of a case with protein selectivity and antithrombin III clear ance studies. Am J Med 1976:60:1048.
Pasquariello/Camerini
7 Morris JF. Ginn HE. Thompson DD: Unilat eral renal vein thrombosis associated with the nephrotic syndrome. Am J Med 1963:34:867. 8 Richet G. Gillot C, Vayasse J, Meycrovitch A: La thrombose isolée de la veine rénale. Presse Méd 1965:73:2035. 9 Remuzzi G. Mecca G. Marchesi D. Liuio M. de Gaetano G. Donati MB. Silver MJ: Platelet hyperaggregability and nephrotic syndrome. Thromb Res 1979:16:345. 10 RossDL. Lubowitz H: Anticoagulation in renal vein thrombosis. Arch Intern Med 1978:178: 1349-1351.
Unilateral Renal Vein Thrombosis and Embolism in Nephrotic Syndrome
Announcem ent
The National Kidney Foundation 1992 Annual Scientific Meeting November 13-15. 1992. Baltimore. Md.. USA The National Kidney Foundation (NKF) will present its Annual Scientific Meeting this fall. It will offer state-of-the-art presentations on the pathogenesis, diagnosis, cure and pre vention of diseases of the kidney and urinary tract. A computer-assisted audience interactive workshop will address the role of the referring nephrologist in kidney transplantation. Other topics on the program include: pathogenesis of diabetes, benign prostatic hyperplasia, adult polycystic kidney disease, hypertension, renal stone disease, glomerulonephritis, renal diag nostic imaging, reflux nephropathy, nutrition and dialysis care. All events will be held at the Convention Center in Baltimore. Md. For additional infor mation. please contact:
136
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The National Kidney Foundation 30 East 33rd Street New York, NY I0016(USA) TLF: (212) 889-2210; (800) 622-9010.
Division of Nephrology. S. Chiara Hospital. Pisa: Institute of Radiology. Faculty of Medicine, University of Pisa. Italy
Unilateral Renal Vein Thrombosis and Pulmonary Embolism Complicating Membranous Nephropathy
Dear Sir, Renal vein thrombosis has been observed in a variety of conditions, especially in association with the nephrotic syndrome [1-5]. Membranous nephropathy and membranoproliferative glomerulonephritis are the main renal his tologic pictures more frequently reported in association with the nephrotic syndrome [1, 5], Several cases of uni lateral renal vein thrombosis consequent to nephrotic syndrome have been described [6-8], History of pulmo nary embolism has sometimes been described [1, 3]. We report on a patient with the rare condition of unilateral renal vein thrombosis and bilateral pulmonary embolism complicating the membranous glomerulonephritis with nephrotic syndrome.
Case Presentation First Admission A 64-vear-old man was referred to the Division of Nephrology because of severe peripheral edema in August 1988. He was suffering from proteinuria and hematuria since May 1988. Upon admission, the body weight was 79 kg, and the blood pressure 160/90 mm Hg. Anasarca with severe pitting edema and pleural effusion was present. Urinalysis showed proteinuria amounting to 5-18 g over a 24-hour period. The sediment contained 30-40 red blood cells and 6-8 white blood cells per highpower field and a few granular casts. His red blood cell count was 4.700.000. hemoglobin 10.6 g/100 ml. the white blood cell count 6,500, hematocrit 35%. The erythrocyte sedimenta tion rate was 54 during the 1st h. Blood urea nitrogen was 35 mg/ 100 ml, serum creatinine 0.8mg/100ml and creatinine clearance 100 ml/min. Total scrum protein was 3.9 g/100 ml, albumin 1.8, and gamma globulin 0.4 g/100 ml. Total cholesterol was 320 mg/100 ml, triglyceride 170, fasting blood glucose 90 mg/100 ml. All remaining hematochemical parameters were found to be in the normal range.
Received: March 16.1990 Accepted: March 18. 1992
HBsAg, RA test, CRP. anti-DNA antibody, antinuclear antibody, and cryoglobulins were negative. Intravenous urography revealed no structural or functional anomalies and a normal renal size bilaterally. The abdominal ultrasound investigation revealed moderate perito neal effusion and confirmed the presence of a normal size of the kid neys with a left renal longitudinal diameter of 122 mm and a right renal longitudinal diameter of 120 mm. A percutaneous kidney biopsy performed on the 12th day of hospitalization revealed by immunofluorescence and light microscopy the typical picture of not evolved membranous nephritis. He was treated with intravenous infusion of human albumin, spironolactone 100 mg/day. and furoscmide 100 mg every 3-4 days. At the time he went home, edemas were absent, the body weight was 65 kg. Total serum protein was 6.1 g/ 100 ml with a normal serum electrophoretic spectrum. Second Admission In May 1989 the patient was transferred to our department from another hospital, where he was admitted some days earlier because of fever (39 °C). dyspnea, and peripheral edema. At the time of admis sion physical examination revealed generalized edema with ascites, left pleural effusion, marked dyspnea, polypnea, orthopnea with severe respiratory insufficiency, and peripheral cyanosis. The blood pressure was 140/80 mm Hg. Urinalysis showed no variation as com pared with the first admission. Blood urea nitrogen was 70 mg/ 100 ml. serum creatinine 1.4 mg/100 ml. creatinine clearance 50 ml/ min and the erythrocyte sedimentation rate was 52 during the 1st h. Total serum protein was 4 g/100 ml with the typical electrophoretic protein diagram of nephrotic syndrome. Serum immunoglobulin lev els revealed marked reduction of IgG globulins. All rheumatic and immunological tests were negative. Fibrinogen was 620 mg/100 ml. Red and white blood cell and platelet counts were in the normal ranges. Plasma cholesterol was 310 mg/100 ml. triglyceride 175 mg/ 100 ml. The INR time for prothrombin time was normal. Echocardi ography revealed moderate pericardial effusion with conspicuous left atrial and ventricular enlargement. No thromboembolic phenome non of the inferior vena cava was detected with abdominal echogra phy. Renal ultrasound detected evident asymmetric enlargement of
Antonio Pasquariello. MI) Division o f Nephrology S. Chiara Hospital Via Roma. 57 1-56100 Pisa (Italy)
© 1992 S. Kargcr AG. Basel 0250-8095/92/0122-0134 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/13/2018 2:27:45 PM
Antonio Pasquarielloa Emilio Camerinib
Fig. 1. Abdominal computerized tomogram showing renal asym metry with marked enlargement of the left kidney.
Fig. 2. Dilatation and thrombosis of the left renal vein (arrow head).
the left kidney with a longitudinal diameter of 15 cm and a right renal longitudinal diameter of 12 cm. Because of severe cardiopul monary conditions, a cavography with direct vascular dye injection was not possible to perform. A computed tomography of abdomen confirmed considerable enlargement of the left kidney (fig. 1) and the clinically suspected dilatation and thrombosis of the left renal vein (fig. 2). Chest X-ray demonstrated discrete pleural effusion and parenchymal basilar infiltrates of the right lung. Pulmonary perfu sion scintiphotographs obtained by intravenous injection of gammaemitting radionuclides 99mTc were indicative of bilateral emboli. The patient has been treated with continuous intravenous infusion of heparin and intermittent oxygen therapy during the first 3 days and later with platelet aggregation inhibitors (ticlopidinc 100mg/day). coumarin derivatives (acenocumarin), spironolactone, and intrave nous infusion of human albumin, resulting in progressive improve ment of the general health conditions and complete resolution of car diopulmonary pathology. The serum creatinine level during the hos pitalization was 1.5 mg/100 ml and creatinine clearance about 50 ml/min. No surgical thrombectomy or pharmacological thrombo lysis with direct intravenous injection of streptokinase or intrinsic plasminogen activator was performed because of the critical respira tory conditions with consequent stabilization of the left renal vascu lar lesion. The patient went home with the prescription of antiplate let drugs (ticlopidine 100mg/day) as anticoagulant prophylaxis, diuretics, and intravenous infusion of human albumin twice weekly. The course of renal function was favourable until 4 months later with a serum creatinine level of 1.2 mg/100 ml and a creatinine clear ance of 78 ml/min. Unfortunately, after this period the patient was lost to follow-up.
enon has been a complication rather than the cause, prob ably due to a platelet hyperaggregability condition [9], Laboratory findings, except serum creatinine and creati nine clearance were identical at both hospitalizations. Thrombosis in nephrotic syndrome is probably due to many factors. In this case thrombosis and embolism occurred after an intercurrent hyperpyretic episode and consequent hemoconcentration, factors that in associa tion with severe hypoalbuminemia increase the risk of thrombosis. Whether long-term therapy with anti-platelet agents in nephrotic syndrome is effective to prevent thrombotic phenomena remains an open question [9. 10], Although direct dye injection is the elective diagnos tic instrument in endoluminal vascular pathologic con ditions. in particular cases alternative techniques such as tomography, nuclear magnetic resonance, and color Doppler ultrasound can adequately substitute it.
Discussion
135
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/13/2018 2:27:45 PM
This report documents (1) the rare occurrence of uni lateral renal vein thrombosis and pulmonary embolism in nephrotic syndrome and (2) that the thrombotic phenom-
References 1 Briefel GR. Manis T. Gordon DH. Nicastri AD. Friedman HA: Recurrent renal vein thrombosis consequent to membranous glo merulonephritis. Clin Nephrol 1978:10:32. 2 Cameron JS: The nephrotic syndrome and its complications. Am J Kidney Dis 1987:10 :151 — 171. 3 Llaclt F. KolTler A. Finck E. Massry SG: On the incidence of renal vein thrombosis in the ne phrotic svndrome. Arch Intern Med 1977:137: 333.
4 McCarthy LJ. Titus JL. Daugherty GW: Bilat eral renal vein thrombosis and nephrotic syn drome in adults. Ann Intern Med 1963:58: 837. 5 Trew PA, Biava CG. Jacobs RP. Hopper J Jr: Renal vein thrombosis in membranous glome rulopathy: Incidence and association. Medi cine (Baltimore) 1978:57:69. 6 Kauffmann RH. DeGraal'J, de la Rivière GB. van Es LA: Unilateral renal vein thrombosis and nephrotic syndrome. Report of a case with protein selectivity and antithrombin III clear ance studies. Am J Med 1976:60:1048.
Pasquariello/Camerini
7 Morris JF. Ginn HE. Thompson DD: Unilat eral renal vein thrombosis associated with the nephrotic syndrome. Am J Med 1963:34:867. 8 Richet G. Gillot C, Vayasse J, Meycrovitch A: La thrombose isolée de la veine rénale. Presse Méd 1965:73:2035. 9 Remuzzi G. Mecca G. Marchesi D. Liuio M. de Gaetano G. Donati MB. Silver MJ: Platelet hyperaggregability and nephrotic syndrome. Thromb Res 1979:16:345. 10 RossDL. Lubowitz H: Anticoagulation in renal vein thrombosis. Arch Intern Med 1978:178: 1349-1351.
Unilateral Renal Vein Thrombosis and Embolism in Nephrotic Syndrome
Announcem ent
The National Kidney Foundation 1992 Annual Scientific Meeting November 13-15. 1992. Baltimore. Md.. USA The National Kidney Foundation (NKF) will present its Annual Scientific Meeting this fall. It will offer state-of-the-art presentations on the pathogenesis, diagnosis, cure and pre vention of diseases of the kidney and urinary tract. A computer-assisted audience interactive workshop will address the role of the referring nephrologist in kidney transplantation. Other topics on the program include: pathogenesis of diabetes, benign prostatic hyperplasia, adult polycystic kidney disease, hypertension, renal stone disease, glomerulonephritis, renal diag nostic imaging, reflux nephropathy, nutrition and dialysis care. All events will be held at the Convention Center in Baltimore. Md. For additional infor mation. please contact:
136
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/13/2018 2:27:45 PM
The National Kidney Foundation 30 East 33rd Street New York, NY I0016(USA) TLF: (212) 889-2210; (800) 622-9010.
