Diagnostic Ultrasound - Abdomen and Pelvis

Renal Vein Thrombosis
Diagnoses: Urinary Tract
○ Note, however, that RVT can be a complication of
infection
Urinary Tract Obstruction
• Possible kidney enlargement
• Normal echogenicity maintained acutely
• Dilated pelvis/calyces almost always seen
PATHOLOGY
General Features
• Etiology
○ Nephrotic syndrome: Most common cause of RVT in
adults
– Especially membranous glomerulonephritis
○ Hypovolemia/renal hypoperfusion: Most common cause
of RVT in children
– Dehydration, sepsis, hemorrhage, pericarditis, CHF
○ Risk in neonates is associated with fetal distress,
perinatal asphyxia, diabetic mothers, and volume
contraction
○ Abdominal/renal trauma
○ Mechanical RV compression
○ Postoperative renal transplantation
○ Spontaneous or iatrogenic hypercoagulable states
(malignancy-related, pregnancy, genetic, systemic
diseases, drugs)
Gross Pathologic & Surgical Features
• Congested, enlarged kidney acutely → scarred, small kidney
chronically
Microscopic Features
• Acute: Vascular congestion, edema → tissue necrosis,
hemorrhage
• Chronic: Fibrosis, dystrophic calcification
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Acute
– Flank/abdominal pain, nausea, vomiting
– Mass (enlarged kidney)
– Proteinuria, hematuria, acute renal failure
○ Chronic
– Asymptomatic (if RVT unilateral or with complete
recovery)
– Renal failure/hypertension
• Other signs/symptoms
○ Related to acute pulmonary embolization (most
common RVT complication)
Demographics
• Age
○ Adults (most common) or children < 2 years of age
• Epidemiology
○ Nephrotic syndrome is underlying cause of 16-42% of
RVT
○ Dehydration/sepsis most common cause of RVT in
children < 2 years of age
Natural History & Prognosis
• Sparse data, small anecdotal clinical series
• Outcome depends on cause, time to diagnosis, duration of
occlusion, recanalization, collateralization
• Prognosis overall good; frequent spontaneous recovery
Treatment
• Anticoagulation: Heparin then Coumadin or low molecular
weight heparin for maintenance
• Thrombolysis/surgical thrombectomy: Heroic measure for
life-threatening situations
• Suprarenal caval filter (IVC thrombus)
DIAGNOSTIC CHECKLIST
Consider
• RVT with diffusely enlarged, hypoechoic/heterogeneous
kidney
Image Interpretation Pearls
• Persistent diastolic flow reversal in renal artery suggests
RVT
SELECTED REFERENCES
1. Jones JA et al: Late onset of renal vein thrombosis after renal
transplantation. Ultrasound Q. 30(3):228-9, 2014
2. Moudgil A: Renal venous thrombosis in neonates. Curr Pediatr Rev.
10(2):101-6, 2014
3. Sciascia S et al: Renal involvement in antiphospholipid syndrome. Nat Rev
Nephrol. 10(5):279-89, 2014
4. Horrow MM et al: Immediate postoperative sonography of renal transplants:
vascular findings and outcomes. AJR Am J Roentgenol. 201(3):W479-86,
2013
5. Leschied JR et al: 99mTc MAG3 renography demonstrating return to normal
renal function following resolution of renal vein thrombosis. Clin Nucl Med.
37(4):382-4, 2012
6. Yang GF et al: Thromboembolic complications in nephrotic syndrome:
imaging spectrum. Acta Radiol. 53(10):1186-94, 2012
7. Sidhu R et al: Imaging of renovascular disease. Semin Ultrasound CT MR.
30(4):271-88, 2009
8. Urban BA et al: Three-dimensional volume-rendered CT angiography of the
renal arteries and veins: normal anatomy, variants, and clinical applications.
Radiographics. 21(2):373-86; questionnaire 549-55, 2001
9. Heiss SG et al: Contrast-enhanced three-dimensional fast spoiled gradientecho
renal MR imaging: evaluation of vascular and nonvascular disease.
Radiographics. 20(5):1341-52; discussion 1353-4, 2000
10. Kawashima A et al: CT evaluation of renovascular disease. Radiographics.
20(5):1321-40, 2000
11. Zigman A et al: Renal vein thrombosis: a 10-year review. J Pediatr Surg.
35(11):1540-2, 2000
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