This Article  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (2)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Neonatology and Infant Care  • Cardiovascular System  • Alert me on articles by topic  Social Bookmarking   What's this?

Derek S. Wheeler, MD; W. Bradley Poss, MD; Alton L. Stocks, MD
From the Departments of Pediatrics and Clinical Investigation, Navel Medical Center San Diego, San Diego, Calif.

Arch Pediatr Adolesc Med. 2001;155:415-416.

A 5-DAY-OLD boy was seen for poor feeding, nonbilious vomiting, lethargy, and decreased urine output. The history was notable for an unremarkable pregnancy with normal findings from 16-week fetal ultrasound. Findings from initial physical examination revealed a large, nontender right flank mass. Results of subsequent laboratory analysis revealed acute renal failure, metabolic acidosis, hyperkalemia, azotemia, and hematuria. Anemia and thrombocytopenia were also present. Renal ultrasonography was performed, and results of a subsequent computed tomographic scan of the abdomen are shown in Figure 1 and Figure 2.

Figure 1.

Figure 2.

Denouement and Discussion: Inferior Vena Cava and Renal Vein Thrombosis in a Neonate

Figure 1. Computed tomographic scan of the abdomen demonstrating a markedly enlarged right kidney (thick arrow), calcification of the inferior vena cava (arrowhead), and a small, calcified left kidney (thin arrow).

Figure 2. Computed tomographic scan of the abdomen demonstrating calcifications in the left renal vein extending into the inferior vena cava (arrowhead).

All abdominal masses detected in the neonatal period require further investigation with ultrasonography.¹ Most of these masses originate in the genitourinary tract,^{1, 2} and ultrasonography should be performed to localize and differentiate between cystic and solid structures. The differential diagnosis of cystic abdominal masses includes hydronephrosis; multicystic-dysplastic kidney disease; intestinal duplication; hydrometrocolpos; and choledochal, ovarian, renal, and pancreatic cysts. The differential diagnosis of solid abdominal masses includes neuroblastoma, teratoma, and Wilms tumor. A solid flank mass of a neonate in the presence of hematuria, hypertension, renal failure, and thrombocytopenia suggests a diagnosis of renal vein thrombosis.

Two types of renal vein thrombosis are recognized. In the first, the thrombus begins intrarenally at the level of the arcuate and interlobular veins, successively extending into the larger renal veins and to the inferior vena cava.³ It is thought that this type is more frequent during infancy.^{4, 5} However, Demirci et al⁶ presented a case of bilateral renal vein thrombosis in which the inferior vena cava was completely filled with thrombus, suggesting that the thrombus arose initially in the inferior vena cava with subsequent retrograde extension into the renal veins.

Clinically, renal vein thrombosis is characterized by the presence of a palpable flank mass associated with acute renal failure. Hematuria, proteinuria, and oliguria are usually present. Predisposing factors are dehydration, asphyxia, polycythemia, sepsis, shock, coagulopathies, and maternal diabetes.⁷ Ultrasound examination will show perivascular streaking with increased echogenicity of the renal parenchyma.⁸ Computed tomography will demonstrate persistent parenchymal opacification and enlargement of the affected kidney, dilation of the renal vein, and renal vein and/or inferior vena caval thrombus.⁹

Surgical management with removal of the affected kidney has historically been the treatment of choice,¹⁰ but it has been recognized more recently that with supportive therapy alone, the short-term prognosis of renal vein thrombosis occurring during infancy is good. However, the involved kidney progressively becomes atrophic resulting in a small, scarred kidney.^{11, 12} Treatment with systemic anticoagulation agents may result in a better long-term prognosis.^{13, 14} In our patient, treatment with low-molecular-weight heparin resulted in a return of normal renal function by age 4 months.

AUTHOR INFORMATION
Accepted for publication February 12, 1999.

This report was sponsored by the Chief Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program, report 84-16-1968-665, as required by NSHSBETHINST 6000.41A.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government.

Reprints: Clinical Research Department, Medical Editing Division, Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 5, San Diego, CA 92134-1005 (e-mail: wmacal{at}snd10.med.navy.mil).

REFERENCES
1. Wilson DA. Ultrasound screening for abdominal masses in the neonatal period. AJDC. 1982;136:147-151. 2. Henderson KC, Torch EM. Differential diagnosis of abdominal masses in the neonate. Pediatr Clin North Am. 1977;24:557-578. ISI | PUBMED 3. Metreweli C, Pearson R. Echographic diagnosis of neonatal renal venous thrombosis. Pediatr Radiol. 1984;14:105-108. FULL TEXT | ISI | PUBMED 4. Evans DJ, Silverman M, Bowley NB. Congenital hypertension due to unilateral renal vein thrombosis. Arch Dis Child. 1981;56:306-308. FREE FULL TEXT 5. Patel RB, Connors JJ. In utero sonographic findings in fetal renal vein thrombosis with calcifications. J Ultrasound Med. 1988;7:349-352. ISI | PUBMED 6. Demirci A, Selcuk MB, Yazicioglu I. Bilateral adrenal hemorrhage associated with bilateral renal vein and vena cava thrombosis. Pediatr Radiol. 1991;21:130. FULL TEXT | ISI | PUBMED 7. Orazi C, Fariello G, Malena S, Schingo P, Ferro F, Bagolan P. Renal vein thrombosis and adrenal hemorrhage in the newborn: ultrasound evaluation of 4 cases. J Clin Ultrasound. 1993;21:163-169. ISI | PUBMED 8. Lin G J, Yang PH, Wang ML. Neonatal renal vein thrombosis: a case report describing serial sonographic changes. Pediatr Nephrol. 1994;8:589-591. FULL TEXT | ISI | PUBMED 9. Gatewood OMB, Fishman EK, Burrow CR, Walker WG, Goldman SM, Siegelman SS. Renal vein thrombosis in patients with nephrotic syndrome: CT diagnosis. Radiology. 1986;159:117-122. FREE FULL TEXT 10. Touloukian RJ. Idiopathic venal caval thrombosis with renal infarction in the newborn infant: survival following nephrectomy. Surgery. 1969;65:978-983. ISI | PUBMED 11. Mocan H, Beattie TJ, Murphy AV. Renal venous thrombosis in infancy: long-term follow-up. Pediatr Nephrol. 1991;5:45-49. FULL TEXT | ISI | PUBMED 12. Ricci MA, Lloyd DA. Renal venous thrombosis in infants and children. Arch Surg. 1990;125:1195-1199. FREE FULL TEXT 13. Markowitz GS, Brignol F, Burns ER, Koenigsberg M, Folkert VW. Renal vein thrombosis treated with thrombolytic therapy: case report and brief review. Am J Kidney Dis. 1995;25:801-806. FULL TEXT | ISI | PUBMED 14. Pohl M, Zimmerhackl LB, Heinen F, et al. Bilateral renal vein thrombosis and venous sinus thrombosis in a neonate with factor V mutation (FV Leiden). J Pediatr. 1998;132:159-161. FULL TEXT | ISI | PUBMED

SECTION EDITOR: BEVERLY P. WOOD, MD

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Neonatal Renal Vein Thrombosis: Review of the English-Language Literature Between 1992 and 2006
Lau et al.
Pediatrics 2007;120:e1278-e1284.
ABSTRACT | FULL TEXT