The Radiographic Changes in Renal Vein Thrombosis

Thrombosis of the renal veins as a pathological entity was first described by Rayer in 1839 (1). In his Traité des maladies des reins, he gave accounts of 7 patients, 2 of whom apparently had an accompanying nephrotic syndrome. By 1945, when Abeshouse published his review, 228 cases had been reported, chiefly in the European literature (2). Since that time many scattered case reports have appeared (3–5). Campbell and Matthews, in commenting on the prognosis of this condition, have claimed a 90 per cent mortality in infants if prompt nephrectomy is not done (6). It might be expected that the diagnosis could be made radiologically, but only one article on this syndrome was found in the radiological literature (7). An examination of the films in some of the case reports has indicated that there are certain consistent changes which enable the radiologist to make this important diagnosis. The following case shows all the significant roentgen features. Case Report K. S., a 21-year-old white man, who had been treated at home for acute glomerulonephritis, was admitted to the hospital because of persistent flank pain. Clinically there were hypertension, dullness and decreased breath sounds at the left base, tenderness of the costovertebral angle, and peripheral edema. Pertinent laboratory findings included a serum protein of 3.5 gm. per 100 ml. (albumin 1.7, globulin 1.8), proteinuria, microscopic hematuria, and cylindruria. A chest roentgenogram revealed a pulmonary infarct in the left lower lobe. An intravenous pyelogram (Fig. 1) showed diminished function bilaterally, more marked on the left side. The left kidney was enlarged, with distorted calyces and pelvis. A peculiar “beaded” appearance of the proximal ureter was noted. Retrograde pyelography (Fig. 2) again demonstrated these changes. A left nephrectomy was performed, and an extensive collateral venous circulation was noted. The specimen was a swollen, engorged kidney with organized thrombosis of the renal vein to the line of resection. Microscopic examination revealed extensive thrombosis into the smaller venous radicles, with secondary congestive changes of the renal parenchyma. The postoperative course was uneventful, and the patient was discharged, only to be readmitted five weeks later with persistent pedal edema. The right kidney was palpable and tender. An intravenous pyelogram showed only slight concentration on the right side. An inferior vena cavagram (Fig. 3) demonstrated a large irregular filling defect along the right lateral wall of the vena cava near the origin of the renal vein. The right renal shadow at this time was 2.5 cm. longer than it had been six weeks previously. Anticoagulant therapy was instituted and maintained following discharge. The patient is alive and doing well eighteen months after surgery. Discussion Renal-vein thrombosis has been shown to occur most commonly in infants and children and in this age group appears to be related to ileocolitis (4).