Management of renal vein thrombosis in a patient with

nephrotic syndrome

Sunil Kumar Daha

Characterized by: Heavy proteinuria (>3.5g in 24 hours) Hallmark Hypoalbuminemia ( serum

albumin<3g/dl) Hypercholesterolemia (serum

cholesterol >300mg/dl) Edema /anasarca Hypertension

Nephrotic syndrome

Lipiduria Hypercoagulabi

lity

Renal vein thrombosis (RVT) is common (around 40%) in patient with nephrotic syndome, as a consequence, in :

a) Membranous nephropathy (more common)

b) Membranoproliferative glomerulonephritis

c) Focal glomerular sclerosis

Renal vein thrombosis

Sickle cell nephropathy Amyloidosis Diabetic nephropathy Renal vasculitis Lupus nephritis Allograft rejection

Differentials for renal vein thrombosis

2/3rd Cases are bilateralEndothelial Damage

HomocystinuriaEndovascular interventionSurgery

Venous stasisDehydrationCompression of renal vein via retroperitoneal fibrosis, abdominal neoplasmHypercoagulable stateProtein C and S deficiency,antithrombin deficiency,factor

V leiden,disseminated malignancy and oral contraceptives.

Etiology

Antiphspholipid antibody syndrome Secondary to nephrotic syndrome Other hypercoagulable stats Protein C deficiency Protein S deficiency Antithrombin deficiency Factor V leiden Disseminated malignancy

Etiology

d/t hemostatic abnormalitiesDecreased level of antithrombin III &

plasminogen (urinary losses)Increased platelet activation Hyperfibrinogenemia Inhibition of plasminogen activation &Presence of high molecular weight

fibrinogen in circulationAltered protein C and protein S

thromboembolic complications Immune-complex injury in glomerulus

increased procoagulant activity

Mechanism of thrombosis in nephropathy

Acute Sudden onset flank or abdominal pain. Gross hematuria Increased proteinuria Left sides varicocele as left testicular vein

drains into renal vein. Acute decline in glomerular filtration rate

Clinical features

Chronic Dramatic increase in proteinuriaEvidence of tubule dysfunctionGlycosuriaAminoaciduria PhosphaturiaImpaired urinary acidification

Contd…..

Definitive diagnosisSelective renal venography with visualization of

occluding thrombus Doppler ultrasound MRI Renal Function Test Urine analysis for protein and RBC

concentration Complete Blood Count (CBC)

Investigations

When symptomatic RVT, treatment anticoagulants low molecular weight heparin and warfarin.

Anticoagulants do not break the preformed clot but can prevent the formation of new clot.

Some patient resistant to heparin therapy d/t severe antithrombin III deficiency.

The effect of oral anticoagulants like warfarin is decreased in nephrotic syndrome as the drug is bound to plasma protein and lost in urine.

Management anticoagulation

The treatment is focused on preventing new clot formation ,improving renal function and reducing the risk of pulmonary embolism.

Both acute and chronic RVT heparin later converted to oral warfarin(coumadin) after 7 to 10 days and maintained long-term

Therapy continued for at least 1 year

In pts with recurrence or continued risk factors indefinite anticoagulation needed

Contd….

In pediatric pts with volume depletion + acute RVT electrolyte balance and fluid restoration essential

In pts with acute RVT associated with acute renal failure fibrinolytic therapy considered

Management of RVT

Harrison’s Principles of Internal Medicine,19th edition

Cecil Textbook of Medicine,22nd edition

References

Thank You