ENAL VEIN ROMBOSIS WHAT WAS IT? DR.JANANI SANKAR UNIT DR. KEDARI NAGARJUNA, DNB P KKCTH
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1 ENAL VEIN ROMBOSIS WHAT WAS IT? DR.JANANI SANKAR UNIT DR. KEDARI NAGARJUNA, DNB P KKCTH
2 RESENTING COMPLAINTS: u 9 ¾ yrs, boy u Fever, Loose stools 10 days back u Right sided Abdominal pain+
3 NVESTIGATIONS u Urea, creatinine - normal u USG Abdomen - right hydronephrosis u CT Abdomen with contrastt -?RIGHT RENAL VEIN THROMBUS EXTENDING INTO IVC u REFERRED FOR FURTHER EVALUATION
4 n examination u Bilateral pedal edema u Free fluid in abdomen u BP - normal
5 elook into history: u Abdominal distension & Progressive leg swelling for 4 days u?oliguria u No hematuria
6 amily history u Father had Bilateral renal calculi - underwent stenting
7 nvestigations: u Creatinine normal (0.5) u Hypoalbuminemia (1.1gm/dl) u Hypercholesterolemia (417mg/dl) u Albuminuria (3+, Spot P/C 24) u Microscopic hematuria (25-30 RBC s/hpf) u C u P u P u M u C u H Counts Normal PCV 36% PT, PTT Normal Mantoux test negative Chest x-ray normal HBsAg negative
8 SG ABDOMEN u Mild bilateral nephromegaly u A clot 4 x 4 x 1.1 cm in the retro hepatic segment of the IVC, extending cranially from the origin of the right renal vein
9 Nephrotic syndrome with thrombotic complication u Low molecular weight Heparin 1mg/kg/dose BD u Prednisolone 2mg/kg/day
10 4hrs later Doppler study normal!!?dislodgement of thrombus (no symptoms)??resolution
11 ourse: u Urine output increased u Edema decreased u Hemodynamically stable u Parents counselled u Discharged on LMWH and Prednisolone u Plan to change to warfarin as outpatient
12 fter 72hrs u Readmitted u Severe epigastric pain and cough u Documented fever u Dyspneic, hypoxic u BP-normal u Anasarca u Diffuse abdominal tenderness
13 ifferential diagnosis: Pulmonary embolism Spontaneous Bacterial peritonitis Pneumonia
14 Shifted to PICU Non invasive ventilation Ceftriaxone Albumin infusion LMWH/steroid continued
15 u Repeat Doppler study no thrombus u USG Abdomen mild b/l nephromegaly, free fluid, dilated bowel loops, no thrombus u ECHO LV dysfunction
16 ultures u Blood culture penicillin resistant Pneumococcus u Changed to Vancomycin u Peritoneal fluid gram stain no organism, culture sterile
17 CT PULMONARY ANGIOGRAPHY Evidence of thrombus in tertiary branch of right pulmonary venules
18 radual improvement: u Started on warfarin (INR 2.19) u Later LMWH stopped u Off oxygen, Hemodynamically stable u Discharged after 2 weeks of vancomycin
19 Follow up: Work up for connective tissue disease ANA negative C3 elevated C4 normal HIV ELISA non eactive Ig profile normal
20 u Persistent proteinuria after completion of 6 weeks of daily steroid steroid resistant u Renal biopsy later u Planned to start on cyclosporine
21 DISCUSSION
22 Hypercoagulable state in Nephrotic syndrome u Vascular stasis u Increase in hepatic production of fibrinogen & other clotting factors u Decreased serum levels of anticoagulation factors u Increased plasma platelet production u Increased platelet aggregation u Increased urinary loss of antithrombin III, protein C, protein S
23 ISK FACTORS: u Risk of VTE is high in patients with membranous nephropathy u HYPOALBUMINEMIA most factor for VTE independent risk u Ratio of proteinuria to serum albumin - risk factor
24 iterature review: u Pulmonary Embolism and Renal Vein Thrombosis in Patients with Nephrotic Syndrome: Prospective Evaluation of Prevalence and Risk Factors with CT Zhang LJ, Zhang Z, Li SJ, Meinel FG, Nance JW Jr, Zhou CS, Zhao YE, Schoepf UJ, Lu GM. Radiology Jul 28: u PE and/or RVT was found in 15 (19%) of 80 children with nephrotic syndrome, while 165 (38%) of 432 adult patients with nephrotic syndrome had PE and/or RVT (P =.001).
25 hy this presentation? u Unusual presentation the child presented with Thrombotic complication and nephrotic syndrome was diagnosed retrospectively u High risk nephrotic syndrome thrombotic complication & penicillin resistant pneumococcal sepsis u Diagnostic dilemma & challenges faced during management
26 cknowledgements: u Dr. Sairam V.K - Consultant Nephrologist u Dr. Muralinath.S - Consultant Radiologist u Dr. Gopinath Consultant Radiologist u Dr. Ramkumar Consultant Dermatologist u Dr. R.Varadarajan Consultantt Hematologist u Dr. Balaji Consultant Vascular surgeon u PICU TEAM
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