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Renal Vein Thrombosis


Zhiwei Zhang

, MD, Loma Linda University School of Medicine

Last full review/revision Mar 2021| Content last modified Sep 2022
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Renal vein thrombosis is thrombotic occlusion of one or both main renal veins, resulting in acute kidney injury or chronic kidney disease. Common causes include nephrotic syndrome, primary hypercoagulability disorders, malignant renal tumors, extrinsic compression, trauma, and rarely inflammatory bowel disease. Symptoms of renal failure and sometimes nausea, vomiting, flank pain, gross hematuria, decreased urine output, or systemic manifestations of venous thromboembolism may occur. Diagnosis is by CT, magnetic resonance angiography, or renal venography. With treatment, prognosis is generally good. Treatment is anticoagulation, support of renal function, and treatment of the underlying disorder. Some patients benefit from thrombectomy or nephrectomy.

Etiology of Renal Vein Thrombosis

Other causes include

Less common causes are related to reduced renal vein blood flow and include malignant renal tumors that extend into the renal veins (typically renal cell carcinoma Renal Cell Carcinoma Renal cell carcinoma (RCC) is the most common renal cancer. Symptoms can include hematuria, flank pain, a palpable mass, and fever of unknown origin (FUO). However, symptoms are often absent... read more ), extrinsic compression of the renal vein or inferior vena cava (eg, by vascular abnormalities, tumor, retroperitoneal disease, ligation of the inferior vena cava, aortic aneurysm), oral contraceptive use, trauma, dehydration, and, rarely, thrombophlebitis migrans and cocaine abuse.

Symptoms and Signs of Renal Vein Thrombosis

Diagnosis of Renal Vein Thrombosis

  • Vascular imaging

Renal vein thrombosis should be considered in patients with renal infarction or any unexplained deterioration in renal function, particularly in patients with the nephrotic syndrome or other risk factors.

The traditional diagnostic test of choice and the standard is venography of the inferior vena cava; this test is diagnostic, but it may mobilize clots. Because of the risks of conventional venography, magnetic resonance venography and Doppler ultrasonography Doppler In ultrasonography, a signal generator is combined with a transducer. Piezoelectric crystals in the signal generator convert electricity into high-frequency sound waves, which are sent into... read more Doppler are being used increasingly. Magnetic resonance venography can be done if glomerular filtration rate (GFR) > 30 mL/minute. Doppler ultrasonography sometimes detects renal vein thrombosis but has high false-negative and false-positive rates. Notching of the ureter due to dilated collateral veins is a characteristic finding in some chronic cases.

CT angiography CT angiography CT shows a focal area of osteolysis (arrows) involving the right acetabulum that is consistent with particle disease. In CT, an x-ray source and x-ray detector housed in a doughnut-shaped assembly... read more CT angiography provides good detail with high sensitivity and specificity and is fast but requires administration of a radiocontrast agent, which may be nephrotoxic. Serum electrolytes and urinalysis are done and confirm deterioration of renal function.

Microscopic hematuria is often present. Proteinuria may be in the nephrotic range.

Prognosis for Renal Vein Thrombosis

Treatment of Renal Vein Thrombosis

  • Treatment of underlying disorder

  • Anticoagulation

  • Sometimes percutaneous catheter-directed thrombectomy or thrombolysis

The underlying disorder should be treated.

Treatment options for renal vein thrombosis include anticoagulation with heparin, thrombolysis, and catheter-directed or surgical thrombectomy. Long-term anticoagulation with low molecular weight heparin or oral warfarin should be started immediately if no invasive intervention is planned. Anticoagulation minimizes risk of new thrombi, promotes recanalization of vessels with existing clots, and improves renal function. Anticoagulation should be continued for at least 6 to 12 months and, if a hypercoagulability disorder (eg, persistent nephrotic syndrome Overview of Nephrotic Syndrome Nephrotic syndrome is urinary excretion of > 3 g of protein/day due to a glomerular disorder plus edema and hypoalbuminemia. It is more common among children and has both primary and secondary... read more ) is present, indefinitely.

Use of a percutaneous catheter for thrombectomy or thrombolysis is currently recommended. Surgical thrombectomy is rarely used but should be considered in patients with acute bilateral renal vein thrombosis and acute kidney injury Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more who cannot be treated with percutaneous catheter thrombectomy and/or thrombolysis.

Nephrectomy is done only if infarction is total (in certain cases) or if the underlying disorder warrants it.

Key Points

  • The most common cause of renal vein thrombosis is nephrotic syndrome associated with membranous nephropathy.

  • Consider renal vein thrombosis in patients with renal infarction or any unexplained deterioration in renal function, particularly those who have the nephrotic syndrome or other risk factors.

  • Confirm the diagnosis with vascular imaging, usually magnetic resonance venography (if GFR > 30 mL/minute) or Doppler ultrasonography.

  • Treat the underlying disorder and initiate anticoagulation, thrombolysis, or thrombectomy.

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