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Maharaj D, Mohammed SR, Caesar K, Dindyal S. Nutcracker syndrome: a case-based review. Ann R Coll Surg Engl 2024; 106:396-400. [PMID: 38038139 PMCID: PMC11060856 DOI: 10.1308/rcsann.2023.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
The nutcracker phenomenon, also known as left renal vein entrapment, occurs when there is extrinsic compression of the left renal vein, most often between the abdominal aorta and the superior mesenteric artery. Nutcracker syndrome refers to the constellation of clinical symptoms that may arise from the nutcracker phenomenon, typically inclusive of haematuria, flank/pelvic pain, orthostatic proteinuria and (in male patients) varicocele. We provide a short review of the nutcracker syndrome including various diagnostic and therapeutic modalities. We utilise our own experience with a patient as a case study and highlight the modern management option of endovascular stenting.
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Affiliation(s)
- D Maharaj
- St Clair Medical Centre, Trinidad and Tobago
| | - SR Mohammed
- University of the West Indies, Trinidad and Tobago
| | - K Caesar
- St Clair Medical Centre, Trinidad and Tobago
| | - S Dindyal
- Mid and South Essex NHS Foundation Trust, UK
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Sarikaya S, Altas O, Ozgur MM, Hancer H, Yilmaz F, Karagoz A, Ozer T, Aksut M, Ozen Y, Kirali K. Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting. Ann Vasc Surg 2024; 102:110-120. [PMID: 38296038 DOI: 10.1016/j.avsg.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 02/26/2024]
Abstract
BACKGROUND Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. METHODS The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. RESULTS Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. CONCLUSIONS Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.
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Affiliation(s)
- Sabit Sarikaya
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey.
| | - Ozge Altas
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Mert Ozgur
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Hakan Hancer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Fatih Yilmaz
- Department of Cardiology, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ali Karagoz
- Department of Cardiology, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Tanıl Ozer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Aksut
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Yucel Ozen
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Kaan Kirali
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
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Akdemir I, Mekik Akar E, Yılmaz S, Çakar N, Fitöz S, Özçakar ZB. Nutcracker syndrome in pediatrics: initial findings and long-term follow-up results. Pediatr Nephrol 2024; 39:799-806. [PMID: 37733097 DOI: 10.1007/s00467-023-06150-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Nutcracker syndrome (NCS) describes a set of symptoms and signs resulting from compression of the left renal vein (LRV). There is a lack of knowledge about its natural course, diagnosis, and management, especially in children. Herein, we present our single-center experience with a large number of patients who have long-term follow-up results. METHODS All patients with NCS diagnosed between January 2011 and March 2021 were included and their data were obtained retrospectively. RESULTS A total of 123 NCS patients (85 females) were included. The median age at the time of diagnosis was 12 (IQR 10-14) years, and BMI percentiles were below 5% in 38% of the cases. At the time of diagnosis, two-thirds of the patients were asymptomatic. The most common laboratory finding was nephritic proteinuria (98%), followed by microscopic hematuria (16%). Signs of LRV compression were significantly more evident in upright position Doppler ultrasonography (DUS) examination. All patients have been followed conservatively; hematuria and/or proteinuria resolved in 43 of the 108 patients (40%) within 35.8 ± 25.8 months of follow-up. Control DUS was performed in 52 patients after a mean period of 39.1 ± 21.3 months. The median peak velocity and diameter ratios of the LRV in the upright position were found to be decreased significantly when compared to the initial assessment (p < 0.05). Normal DUS findings were noted in 13 patients at the final evaluation. CONCLUSIONS In unexplained proteinuria and/or hematuria, NCS should be considered, especially in asthenic adolescents. Our results support conservative management in children as the first-line treatment approach.
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Affiliation(s)
- Iryna Akdemir
- Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Ece Mekik Akar
- Division of Pediatric Nephrology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Songül Yılmaz
- Division of Pediatric Nephrology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Nilgün Çakar
- Division of Pediatric Nephrology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Suat Fitöz
- Division of Pediatric Radiology, Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Zeynep Birsin Özçakar
- Division of Pediatric Nephrology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey.
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Lin L, Zhang K, Yang X, Lin L, Li X, Qiu L. Orthostatic proteinuria due to inferior vena cava interruption without nutcracker phenomenon in an old obese female: a case report and literature review. BMC Nephrol 2023; 24:225. [PMID: 37525103 PMCID: PMC10391862 DOI: 10.1186/s12882-023-03279-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 07/21/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Nutcracker syndrome (NCS) caused by left renal vein (LRV) entrapment, is one of the most common causes of orthostatic proteinuria. In stereotype, orthostatic proteinuria is often accompanied by left renal vein obstruction and is found in young and underweight individuals. Here, we report a rare case with orthostatic proteinuria in an old obese female caused by a rare type of congenital inferior vena cava (IVC) interruption. CASE PRESENTATION A 65-year-old obese woman, who suffered from fluctuated proteinuria, had been misdiagnosed as chronic glomerulitis for 30 years. Instead of having any sign of NCS, she had a unique type of IVC interruption. Most venous blood from infrarenal IVC and right kidney drained into her LRV, and then through the expanded communicating vessel, drained into the left ascending lumbar vein which extended as hemiazygos vein. To the best of our knowledge, this is one of the first cases reported of orthostatic proteinuria attributed to the subsequent hemodynamic irregularity caused by IVC interruption without nutcracker phenomenon. CONCLUSION Adult-onset orthostatic proteinuria is relatively rare, hard to be recognized and could be misdiagnosed as chronic glomerulonephritis. The case provided a novel differential diagnostic condition for those who suffered from fluctuated proteinuria of unknown causes.
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Affiliation(s)
- Liling Lin
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifu Yuan, Dongcheng District, Beijing, 100730, PR China
| | - Kai Zhang
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifu Yuan, Dongcheng District, Beijing, 100730, PR China
| | - Xiao Yang
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lu Lin
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ling Qiu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifu Yuan, Dongcheng District, Beijing, 100730, PR China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Cioffi S, Di Domenico F, Russo G, De Nigris A, Guarino S, Miraglia del Giudice E, Marzuillo P, Di Sessa A. Diagnostic Clues in Pediatric Nutcracker Syndrome: From Two Clinical Cases to Current Literature Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121988. [PMID: 36553431 PMCID: PMC9777484 DOI: 10.3390/children9121988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Revised: 12/10/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Nutcracker syndrome (NCS) is a rare pediatric disease caused by left kidney vein compression. Besides the "Triade's symptoms", including hematuria, proteinuria, and flank pain, a wide spectrum of clinical manifestations has been reported. As the significant hemodynamic changes secondary to the dilatation of the left renal vein, serious consequences such as renal vein thrombosis and severe anemia might occur in these children. NCS diagnosis includes a variety of invasive and non-invasive imaging tools, but cutoff values need to be further validated. A conservative treatment represents the most common therapeutic approach for these patients, but operative options are available in selected cases. To complicate matters, a standard diagnostic and treatment algorithm is currently lacking and scientific pediatric evidence in this field is still poor and limited. In this perspective, early recognition of NCS is crucial but challenging for pediatricians. Therefore, a better knowledge of the disease is recommended. Starting from two different clinical presentations of NCS, we aimed to provide a comprehensive overview of the disease in children.
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Wang F, Zhu H, Bao S, Qi H, Xu L, Liu X, Zhai C, Yang X, Wang R. Associations of left renal vein entrapment with IgA nephropathy and Henoch-Schönlein purpura nephritis. Ren Fail 2022; 44:1519-1527. [PMID: 36069515 PMCID: PMC9467612 DOI: 10.1080/0886022x.2022.2118065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives The aims of the study were to identify whether left renal vein (LRV) entrapment was more prevalent in IgA nephropathy (IgAN) and Henoch–Schönlein purpura nephritis (HSPN) compared with other types of renal diseases, and the association of LRV entrapment with glomerular incidental IgA and galactose-deficient-IgA1 (Gd-IgA1) deposition. Methods A total of 797 patients with biopsy-proven kidney diseases have been screened for LRV entrapment by color Doppler ultrasound, and the prevalence of LRV entrapment in different types of renal diseases were then analyzed. Propensity score matching analysis was used to adjust for age, gender, and body mass index. Immunostaining of Gd-IgA1 with KM55 was performed in paraffin-embedded sections of renal biopsy specimens. Results LRV entrapment was diagnosed in 47 patients (6%) with several kinds of renal diseases in our cohort. A total of 32 (68%) LRV entrapments were combined with expanded IgAN (idiopathic IgAN and HSPN). The prevalence of LRV entrapment in expanded IgAN was significantly higher than that in non-expanded IgAN (17 vs. 2%, p < 0.001), even after adjustment for age, gender, and body mass index by propensity score matching analysis (13 vs. 2%, p < 0.001). Removing expanded IgAN and LN, glomerular incidental IgA deposition was observed to be significantly more common in patients with LRV entrapment compared with patients without it (43 vs. 9%, p < 0.001). Furthermore, in glomerular diseases with incidental IgA deposits, significantly much larger proportion of patients with LRV entrapment were positive for glomerular Gd-IgA1 in contrast to patients without LRV entrapment (5/5 vs. 5/17, p = 0.01). Conclusions LRV entrapment coexisted with several kinds of renal diseases, with a significantly higher prevalence in patients with idiopathic IgAN and HSPN. In patients of LN and IgAN-unrelated disease with LRV entrapment, glomerular IgA and Gd-IgA1 deposition was more common compared with patients without LRV entrapment.
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Affiliation(s)
- Fengmei Wang
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, P. R. China
| | - Huizi Zhu
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, P. R. China
| | - Shougang Bao
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Hengtao Qi
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Liang Xu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Xiang Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Xiaowei Yang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, P. R. China.,Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P. R. China
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Gulleroglu NB, Gulleroglu K, Uslu N, Baskin E. Left renal vein entrapment in postural proteinuria: the diagnostic utility of the aortomesenteric angle. Eur J Pediatr 2022; 181:3339-3343. [PMID: 35789292 DOI: 10.1007/s00431-022-04551-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
Nutcracker syndrome related to the left kidney vein compression is a cause of orthostatic proteinuria during childhood. Some studies have shown that the ratios between maximum velocities and anterior-posterior diameters of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions must be more than 4 in order to make a Nutcracker syndrome diagnosis. Our aim was to investigate whether the use of a decrease in aortomesenteric angle between upright and supine positions in the presence of isolated orthostatic proteinuria can be a criterion for the diagnosis of Nutcracker syndrome. Relevant patient information, which included demographic data, clinical examination findings, laboratory data, urinary system ultrasound, and kidney color flow Doppler ultrasound results, were prospectively collected. Thirty-nine pediatric patients with orthostatic proteinuria were included in the study. Left kidney vein compression findings were demonstrated in 31 patients. The ratio of maximum velocities of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions was above 4 in only 7 of our patients. Ratio of aortomesenteric angle between upright and supine positions was significantly decreased for patients with left kidney vein compression findings. Conclusion: The use of a decrease in the ratio of aortomesenteric angle between upright and supine positions in the presence of orthostatic proteinuria, instead of the ratios for maximum velocities and anterior-posterior diameters of hilar and aortomesenteric segments, can be more helpful for the diagnosis of Nutcracker syndrome in the differential diagnosis of orthostatic proteinuria. What is Known: • Proteinuria may be a sign of an impending kidney disease • Nutcracker syndrome is a cause of orthostatic proteinuria. What is New: • Ratio of aortomesenteric angle between upright and supine positions > 0.6 can be used for Nutcracker syndrome diagnosis.
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Affiliation(s)
| | | | - Nihal Uslu
- Radiology, Baskent University, Ankara, Turkey
| | - Esra Baskin
- Pediatric Nephrology, Baskent University, Ankara, Turkey
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Montorfani-Janett VML, Montorfani GE, Lavagno C, Gualco G, Bianchetti MG, Milani GP, Lava SAG, Cristallo Lacalamita M. External Male Genitalia in Henoch-Schönlein Syndrome: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081154. [PMID: 36010045 PMCID: PMC9406875 DOI: 10.3390/children9081154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/16/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022]
Abstract
The external genitalia are notoriously implicated in every fifth male with Henoch−Schönlein syndrome. Nonetheless, the underlying conditions are poorly categorized. To characterize the involvement of the external male genitalia in this vasculitis, we performed a systematic review of the literature. For the final analysis, we selected 85 reports published between 1972 and 2022, which reported on 114 Henoch−Schönlein cases (≤ 18 years, N = 104) with a penile (N = 18), a scrotal (N = 77), or both a penile and a scrotal (N = 19) involvement. The genital involvement mostly appeared concurrently with or after the cutaneous features of Henoch−Schönlein syndrome, while it preceded the presentation of Henoch−Schönlein syndrome in 10 cases. Patients with penile involvement (N = 37) presented with swelling (N = 26), erythema (N = 23), and purpuric rash (N = 15). Most patients were otherwise asymptomatic except for transient micturition disorders (N = 2) or priapism (N = 2). Patients with scrotal involvement (N = 96) presented with pain (N = 85), swelling (N = 79), erythema (N = 42), or scrotal purpura (N = 22). The following scrotal structures were often involved: scrotal skin (N = 83), epididymis (N = 49), and testes (N = 39). An ischemic testicular damage was noted in nine patients (four with torsion and five without). The scrotal skin involvement was mostly bilateral, while that of the epididymis and testis were mostly (p < 0.0001) unilateral (with a significant predilection for the left side). In conclusion, this analysis allows for better categorization of the involvement of external male genitalia in Henoch−Schönlein vasculitis. Scrotal involvement can result from skin inflammation, epididymitis, orchitis, or testicular ischemia.
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Affiliation(s)
- Valentina M. L. Montorfani-Janett
- Family Medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (V.M.L.M.-J.); (G.E.M.); (M.G.B.)
| | - Gabriele E. Montorfani
- Family Medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (V.M.L.M.-J.); (G.E.M.); (M.G.B.)
| | - Camilla Lavagno
- Pediatric Emergency Department, University Children’s Hospital Zurich, 8032 Zurich, Switzerland;
| | - Gianluca Gualco
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland;
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Mario G. Bianchetti
- Family Medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (V.M.L.M.-J.); (G.E.M.); (M.G.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Gregorio P. Milani
- Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Sebastiano A. G. Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, 1011 Lausanne, Switzerland
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London WC1N 3JH, UK
- Correspondence:
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Nutcracker syndrome: a potentially underdiagnosed cause of proteinuria in children with familial Mediterranean fever. Pediatr Nephrol 2022; 37:1615-1621. [PMID: 34796389 DOI: 10.1007/s00467-021-05337-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Familial Mediterranean fever (FMF) is the most common hereditary autoinflammatory disease with an increased risk for secondary amyloidosis. Since lifelong colchicine has been the treatment of choice that prevents renal amyloidosis, non-amyloid kidney diseases are more frequently considered in the differential diagnosis of proteinuria. Nutcracker syndrome (NCS) can be one of the confounding causes. This long-term retrospective study aimed to evaluate the causes of proteinuria in a pediatric cohort of patients with FMF and discuss changing trends in recent years . METHODS Demographic, clinic, and laboratory data were extracted from electronic medical records of patients with FMF. All urine tests of the study population were reviewed. Patients were evaluated for persistent proteinuria and grouped according to the etiology of proteinuria. RESULTS A total of 576 patients with FMF were identified with a mean follow-up of 6.3 years in the last 10 years; 8% had persistent proteinuria. The etiology was NCS in 67.5% of the patients with proteinuria, and renal amyloidosis was less commonly encountered (15%) without any new diagnosis for the last 8 years. Non-amyloid kidney diseases were also diagnosed in 17.5% of the patients. Patients with NCS had significantly lower BMI than other patients in the cohort and less subclinical inflammation, higher hemoglobin concentration, and milder levels of proteinuria with normal serum albumin and eGFR than other patients with proteinuria. CONCLUSION Nutcracker syndrome is the leading cause of proteinuria in children with FMF nowadays, and it should be kept in mind during the evaluation of proteinuria in these patients. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Proteinuria from first-morning urine in a child due to brace treatment for adolescent idiopathic scoliosis. CEN Case Rep 2022; 11:490-493. [DOI: 10.1007/s13730-022-00708-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/20/2022] [Indexed: 10/18/2022] Open
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Kolber MK, Cui Z, Chen CK, Habibollahi P, Kalva SP. Nutcracker syndrome: diagnosis and therapy. Cardiovasc Diagn Ther 2021; 11:1140-1149. [PMID: 34815965 DOI: 10.21037/cdt-20-160] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain, or even renal dysfunction. Long-standing venous compression can encourage collateral drainage pathways through gonadal and pelvic veins, which may explain reported symptom and syndrome overlap with pelvic congestion syndrome. Diagnosis can be challenging and variable, frequently involving a combination of ultrasound Doppler, cross-sectional, and invasive imaging. Often, intravascular pressure measurements are required to prove a renocaval pressure gradient to aid in a definitive diagnosis. Conservative management is appropriate, especially in children, who tend to outgrow the disorder. In the interim, medical management with angiotensin converting enzyme inhibitors (ACEIs) is a useful therapy to manage orthostatic hypotension in the pediatric population. In adults, invasive therapies are more frequently pursued. These are aimed at relieving the extrinsic compression on the LRV. The standard of care is renal vein transposition, with renal autotransplantation reserved for recalcitrant cases. Endovascular stenting is a less invasive option. Laparoscopic placement of an exovascular stent is a newer therapy intended to minimize trauma to the LRV. In this review, we will discuss the clinical manifestations, diagnostic criterion, imaging features, and conservative and surgical therapies for this condition.
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Affiliation(s)
- Marcin K Kolber
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhonghao Cui
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Christine K Chen
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Habibollahi
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Waldrop RD, Henning P. Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report. Clin Pract Cases Emerg Med 2021; 5:415-418. [PMID: 34813432 PMCID: PMC8610464 DOI: 10.5811/cpcem.2021.6.52140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Abdominal pain and flank pain cause a significant proportion of emergency department (ED) visits. The diagnosis often remains unclear and is frequently associated with repeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank pain is compression of the left renal vein between the aorta and the superior mesenteric artery known as nutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameter proximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describe such a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the final diagnosis and intervention occurred. Case Report A 16-year-old female, long-distance runner presented four times complaining of intractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visit urinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomography revealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred to vascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements and eliminated symptoms. Conclusion Emergency physicians must maintain a large list of possible diagnoses during the evaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndrome may mimic other causes of abdominal and flank pain such as renal colic and requires appropriate referral.
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Affiliation(s)
- Ron D Waldrop
- USA Health Systems, Department of Pediatric Emergency Medicine, Mobile, Alabama
| | - Paul Henning
- USA Health Systems, Department of Emergency Medicine, Mobile, Alabama
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A case of painless exercise-induced gross hematuria in a 9-year-old boy: Answers. Pediatr Nephrol 2021; 36:1969-1971. [PMID: 33090254 DOI: 10.1007/s00467-020-04807-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
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14
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Yin X, Blumenfeld JD, Riyahi S, Luo X, Rennert H, Barash I, Prince MR. Prevalence of Inferior Vena Cava Compression in ADPKD. Kidney Int Rep 2020; 6:168-178. [PMID: 33426396 PMCID: PMC7783582 DOI: 10.1016/j.ekir.2020.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Kidney and liver cysts in autosomal dominant polycystic kidney disease (ADPKD) can compress the inferior vena cava (IVC), but IVC compression prevalence and its risk factors are unknown. Methods Patients who have ADPKD (n = 216) with abdominal magnetic resonance imaging (MRI) studies and age-/sex-matched controls (n = 216) were evaluated for IVC compression as well as azygous vein diameter (a marker of collateral blood flow) and IVC aspect ratio (left-to-right dimension divided by anterior-to-posterior dimension with a value of 1 corresponding to a circular (high pressure) IVC caudal to compression. Results Severe IVC compression (≥70%) was observed in 33 (15%) ADPKD subjects and mild compression (≥50% to <70%) was observed in 33 (15%) subjects; whereas controls had no IVC compression (P < 0.001). Severe IVC compression was associated with larger azygous vein (4.0 ± 1.3 mm versus 2.3 ± 0.8 mm without IVC compression; P < 0.001) and a more circular IVC cross-section upstream (mean IVC aspect ratio: 1.16 ± 0.27 vs. 1.69 ± 0.67, P < 0.001), suggesting higher pressure upstream from the compression. IVC compression was associated with older age, lower estimated glomerular filtration rate (eGFR), greater height-adjusted total kidney volumes, greater height-adjusted liver volume (ht-LV), and greater liver and renal cyst fractions (P < 0.001). No subject younger than 30 years had IVC compression, but ADPKD subjects ≥40 years old had 12-fold higher risk of IVC compression (95% confidence interval [CI]: 4.2–42.4), with highest predicted probability for Mayo Clinic classes 1D (59%; 95% CI: 39%–76%) and 1E (74%; 95% CI: 49%–90%) after adjustment (P < 0.001). Women with ht-LV ≥ 2000 ml/m had 83% (95% CI: 59%–95%) prevalence of IVC compression. Complications of IVC compression included deep vein thrombosis (DVT) and symptomatic hypotension. Conclusions IVC compression is common in ADPKD patients >40 years old, with Mayo Clinic class 1D/E, and in females with ht-LV > 2000 ml/m.
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Affiliation(s)
- Xiaorui Yin
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA.,Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jon D Blumenfeld
- The Rogosin Institute, New York, New York, USA.,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sadjad Riyahi
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Xianfu Luo
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Hanna Rennert
- Department of Pathology, Weill Cornell Medicine, New York, New York, USA
| | - Irina Barash
- The Rogosin Institute, New York, New York, USA.,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Martin R Prince
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA.,Department of Radiology, Columbia College of Physicians and Surgeons, New York, New York, USA
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Tanaka H. Orthostatic proteinuria revisited: new clinical impact of the "old" clinical entity? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:814. [PMID: 32793659 PMCID: PMC7396241 DOI: 10.21037/atm.2020.02.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hiroshi Tanaka
- Department of School Health Science, Hirosaki University Faculty of Education, Hirosaki, Japan.,Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
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Niu XL, Wu Y, Hao S, Wang P, Kang YL, Kuang XY, Zhu GH, Huang WY. Value of micro-proteinuria in combination with ultrasonography of the left renal vein in the diagnosis of orthostatic proteinuria. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:780. [PMID: 32042796 DOI: 10.21037/atm.2019.11.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to evaluate the clinical value of micro-proteinuria in combination with ultrasonography of the left renal vein (LRV) in the diagnosis of orthostatic proteinuria (OP). Methods The patients with suspected OP received West test, upright lordotic position test, Robinson test, ultrasonography of the LRV, and detection of morning urine micro-proteinuria and micro-proteinuria after activity. The sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (PLR and NLR) and Youden's index (YI) for micro-proteinuria, ultrasonography of the LRV and both of them in the diagnosis of OP were analyzed. Results From January 2013 to January 2018, 75 patients (M/F: 38/37) were recruited. Sixty patients were diagnosed with OP (M/F: 29/31, median age at onset: 10.6±2.80 years); 15 patients had no OP (M/F: 9/6, median age at onset: 10.9±3.25 years); the LRV entrapment, urine Alb/Cr, IgG/Cr, and NAG/Cr after activity were significantly different between OP group and non-OP group (Z=-3.55, -4.10, -4.01, -3.04, P<0.05). The area under the curve (AUC) of urine Alb/Cr, IgG/Cr, NAG/Cr, and the ratio of anteroposterior (AP) for LRV in the hilar and narrow portions (a/b) was 0.84, 0.84, 0.76 and 0.58, respectively, and the best cut-off value was 13.2 mg/mmol, 2.52 mg/mmol, 0.64 U/mmol and 4.06, respectively. The combination of ultrasonography of the LRV and elevated micro-proteinuria after activity could achieve the Se, Sp, PPV, NPV, PLR (weighted by prevalence, W), NLR (W) and YI at 93.3% (95% CI: 0.83-0.98), 66.7% (95% CI: 0.39-0.87), 91.8% (95% CI: 0.81-0.97), 71.4% (95% CI: 0.42-0.90), 11.2 (95% CI: 4.82-26.00), 0.40 (95% CI: 0.17-0.97) and 60%, respectively, in the diagnosis of OP. Conclusions The micro-proteinuria in combination of ultrasonography of the LRV is helpful for the preliminary screening of OP in patients with suspected OP.
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Affiliation(s)
- Xiao-Ling Niu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Ying Wu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Sheng Hao
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Ping Wang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Yu-Lin Kang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Xin-Yu Kuang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Guang-Hua Zhu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Wen-Yan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
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Bin Dahman HA, Aljabry AO. A case report of a young girl with recurrent hematuria: a missed diagnosis - renal nutcracker syndrome. BMC Nephrol 2019; 20:349. [PMID: 31488074 PMCID: PMC6727525 DOI: 10.1186/s12882-019-1508-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/31/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Nutcracker syndrome is an easily missed cause of hematuria in children. It is characterized by left renal vein entrapment between the abdominal aorta and the superior mesenteric artery causing renal venous hypertension. Intermittent hematuria and orthostatic proteinuria with or without abdominal or flank pain are the common clinical manifestations. Presence of variable non-specific symptoms and non-significant physical findings results in a delayed diagnosis. CASE PRESENTATION We present a ten -year -old girl with four episodes of painless gross hematuria and recurrent microscopic hematuria since the age of two years. Doppler ultrasound showed left renal vein compression while 3 D computerized tomography angiography confirmed the diagnosis of an anterior nutcracker. The patient was conservatively treated with nutritional support (pediasure complete formula and high calorie food), iron supplements and followed up, monitored for anemia, hypertension and renal insufficiency. CONCLUSION Nutcracker syndrome is a rare cause of recurrent gross hematuria in children. A high index of suspicion and proper imaging is needed to reach a proper diagnosis and avoid the psychological and financial stress on the family.
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Affiliation(s)
- Haifa Ali Bin Dahman
- Pediatric Department, Hadhramout University College of Medicine, Mukalla, Hadhramout governorate, Yemen.
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18
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Tanaka H. High prevalence of underlying orthostatic proteinuria in young Japanese women. Pediatr Int 2019; 61:306-307. [PMID: 30834612 DOI: 10.1111/ped.13781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/19/2018] [Accepted: 12/27/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Hiroshi Tanaka
- Department of School Health Science, Hirosaki University Faculty of Education, Hirosaki, Japan.,Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
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Kanai H, Sawanobori E, Kobayashi A, Goto M, Higashida K, Sugita K. Urinary fibrin/fibrinogen degradation products measured using an anti-fibrinogen antibody predict orthostatic proteinuria. Pediatr Int 2018; 60:639-644. [PMID: 29654610 DOI: 10.1111/ped.13576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to assess the diagnostic value of urinary fibrin/fibrinogen degradation products (uFDP) measured using an anti-fibrinogen antibody in patients with orthostatic proteinuria (OP), and their use in differentiating between OP and glomerulonephritis (GN). METHODS uFDP were measured using first urine in the morning (supine) and non-first urine during a hospital visit (upright) and then normalized to urine creatinine (uFDP/Cr, ng/mgCr). We compared (i) OP patients (n = 16); (ii) those in remission from nephrotic syndrome (NS, n = 14) and from GN (IgA nephropathy [IgAN], n = 14; Henoch-Schönlein purpura nephritis [HSPN], n = 12); and (iii) those with active GN (IgAN, n = 12; HSPN, n = 19). RESULTS The uFDP/Cr ratio increased from supine to upright urine in patients with OP (P < 0.001), but decreased in one case. uFDP were excreted in supine urine in 94% of OP patients, with no excretion in NS remission patients or in 92% of GN remission patients (P < 0.001 for both). uFDP/Cr in supine urine was similar between the OP and active GN patients (P = 0.40), whereas proteinuria in supine urine was in the normal range in all OP patients, but was significantly higher in upright urine in the OP patients (P < 0.001). In upright urine, urinary protein/creatinine ratio was significantly lower in patients with OP than in those with active GN (P = 0.005). A uFDP/Cr ratio cut-off of 1,108 ng/mgCr in upright urine correctly differentiated OP from active GN, with a sensitivity of 87.5% and a specificity of 100%. CONCLUSION Comparison of uFDP levels in supine/upright urine can be reliable for diagnosing OP and for differentiating it from active GN.
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Affiliation(s)
- Hiroaki Kanai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Anna Kobayashi
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Miwa Goto
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kosuke Higashida
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kanji Sugita
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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21
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Nutcracker Syndrome and Sickle Cell Trait: A Perfect Storm for Hematuria. J Gen Intern Med 2017; 32:585-588. [PMID: 28210918 PMCID: PMC5400767 DOI: 10.1007/s11606-017-4008-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/08/2016] [Accepted: 01/26/2017] [Indexed: 10/20/2022]
Abstract
We describe the case of a 27-year-old woman with a history of sickle cell trait (SCT) who presented with several months of hematuria and was found to have nutcracker syndrome (NCS). While SCT is a common cause of hematuria resulting from renal papillary necrosis, our patient had concomitant abdominal pain and anemia, prompting further evaluation and the subsequent diagnosis of NCS. Interestingly, the anoxia in the left renal vein from NCS predisposes patients with SCT to sickling. Our case highlights key clinical features of both NCS and SCT and the relationship between the two disease processes.
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22
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Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature. Pediatr Nephrol 2016; 31:175-84. [PMID: 25627663 DOI: 10.1007/s00467-015-3045-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews. METHODS We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria". RESULTS We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava. CONCLUSIONS In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.
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Gurecká R, Koborová I, Šebek J, Šebeková K. Presence of Cardiometabolic Risk Factors Is Not Associated with Microalbuminuria in 14-to-20-Years Old Slovak Adolescents: A Cross-Sectional, Population Study. PLoS One 2015; 10:e0129311. [PMID: 26046923 PMCID: PMC4489371 DOI: 10.1371/journal.pone.0129311] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 05/07/2015] [Indexed: 01/19/2023] Open
Abstract
Introduction In adults, microalbuminuria indicates generalized endothelial dysfunction, and is
an independent risk factor for cardiovascular and all cause mortality. Slovak
adults present one of the highest cardiovascular mortality rates in Europe. Thus
Slovak adolescents are on a high-risk to develop cardiovascular afflictions early,
and screening for microalbuminuria might be useful in early assessment of their
cardiovascular risk. We aimed to study the prevalence of microalbuminuria in
Slovak adolescents, and the association of urinary albumin-to-creatinine ratio
(ACR) to cardiovascular risk factors. Subjects and methods Anthropometric data, blood pressure, blood count, glucose homeostasis, lipid
profile, renal function, inflammatory status, concentrations of homocysteine and
uric acid were determined and associated with ACR in 2 666 adolescents (49.4%
boys, 51.6% girls) aged 14-to-20 years. Microalbuminuria was classified as ACR
2.5–25.0 mg/mmol in boys and 3.5–35.0 mg/mmol in girls. Results Prevalence of microalbuminuria in both genders reached 3.3%, and did not differ
significantly between lean and centrally obese subjects. Girls presented higher
ACR than boys (normoalbuminuric: 0.6±0.5 mg/mmol vs. 0.5±0.4
mg/mmol, p>0.001; microalbuminuric: 9.3±7.3 mg/mmol vs.
5.0±3.8 mg/mmol; p>0.001). Microalbuminuric adolescents and those
presenting normoalbuminuria within the upper ACR quartile were slimmer than their
normoalbuminuric counterparts or adolescents with normoalbuminuria within the
lower quartile, respectively. No association between microalbuminuria and
cardiovascular risk markers was revealed. Conclusion Results obtained in this study do not support our assumption that ACR associates
with cardiometabolic risk factors in apparently healthy adolescents. Follow-up
studies until adulthood are needed to estimate the potential cardiometabolic risk
of apparently healthy microalbuminuric adolescents.
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Affiliation(s)
- Radana Gurecká
- Institute of Molecular BioMedicine, Faculty of Medicine, Comenius University,
Bratislava, Slovakia
- * E-mail:
| | - Ivana Koborová
- Institute of Molecular BioMedicine, Faculty of Medicine, Comenius University,
Bratislava, Slovakia
| | - Jozef Šebek
- Institute of Technology, Slovak Academy of Sciences, Bratislava,
Slovakia
| | - Katarína Šebeková
- Institute of Molecular BioMedicine, Faculty of Medicine, Comenius University,
Bratislava, Slovakia
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Quevedo HC, Arain SA, Abi Rafeh N. Systematic review of endovascular therapy for nutcracker syndrome and case presentation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:305-7. [DOI: 10.1016/j.carrev.2014.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/11/2014] [Accepted: 04/14/2014] [Indexed: 01/29/2023]
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Uehara K, Tominaga N, Shibagaki Y. Adult orthostatic proteinuria. Clin Kidney J 2014; 7:327-8. [PMID: 25852903 PMCID: PMC4377758 DOI: 10.1093/ckj/sfu040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/17/2014] [Indexed: 12/04/2022] Open
Affiliation(s)
- Keita Uehara
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine , St. Marianna University Hospital , Kawasaki, Kanagawa , Japan
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Should screening of renal markers be recommended in a working population? Int Urol Nephrol 2014; 46:1601-8. [PMID: 24771473 DOI: 10.1007/s11255-014-0718-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 04/09/2014] [Indexed: 01/27/2023]
Abstract
INTRODUCTION It is debated whether the general population should be screened for kidney disease. This study evaluated whether screening of albuminuria and estimated glomerular filtration rate (eGFR) in a working population should be recommended to detect subjects with chronic kidney disease. METHODS The unreferred renal insufficiency study is a cross-sectional study in 1,398 workers aged 17-65. Markers of cardiovascular and renal disease were measured. Cardiovascular risk (CVR) was defined by hypertension (n = 416), diabetes (n = 45), dyslipidemia (n = 159) and/or history of a cardiovascular event (n = 10). RESULTS In our population, 5 % of the workers had microalbuminuria, 0.5 % had macroalbuminuria and <0.1 % had eGFR <60 ml/min/1.73 m(2). All workers with an eGFR <60 ml/min/1.73 m(2) and/or macroalbuminuria (8/8) had at least one CVR factor, whereas this was the case in only half of workers with microalbuminuria (36/73, p = 0.007). In workers without CVR factors, the presence of microalbuminuria was associated with low body mass index (BMI, p < 0.001) or physiochemical exposure risk (p < 0.001). CONCLUSIONS Screening of renal markers in a working population, identified only a few subjects with an eGFR <60 ml/min/1.73 m(2) or macroalbuminuria. Although microalbuminuria was more prevalent, it might not necessarily indicate kidney disease, as it may have a completely different meanings depending of the phenotype of the screened subjects. Besides underlying CVR factors, microalbuminuria was also associated with low BMI in absence of any risk factor, suggesting presence of benign postural proteinuria. In addition, microalbuminuria also seemed to be related to physicochemical exposure. In view of the impossibility to further analyze this finding in the present study, the meaning of this observation needs to be further investigated.
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Jin M, Hu P, Ding R, Chen P, Qiu Q, Wu J, Liu S, Xie Y, Chen X. Effectiveness of supine/standing urinalysis for differential diagnosis of left renal vein entrapment syndrome combined with or without glomerulopathy. Nephrology (Carlton) 2014; 19:332-8. [PMID: 24629105 DOI: 10.1111/nep.12227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 01/29/2023]
Abstract
AIM To assess the effectiveness of supine/standing urinalysis for differential diagnosis of left renal vein entrapment syndrome (LRVES) combined with or without glomerulopathy. METHODS The enrolled patients with abnormal urinalysis and LRVES demonstrated by Doppler sonography were guided to perform a supine/standing urinalysis. RESULTS Fifty-two patients were enrolled. Most of them were adolescents (aged 14-29 years, 73.1%) and with low body mass index (BMI, mean BMI, 19.8 ± 2.4 kg/m(2)). Seventeen cases (32.7%) manifested orthostatic urine abnormalities (OUA, proteinuria and/or haematuria show negative in supine while positive after 15 min standing), two patients who had undergone renal biopsies both showed no evidence of kidney lesions, another two patients were changed from abnormal to normal urinalysis after weight gain. The remaining 35 cases (67.3%) manifested non-orthostatic urine abnormalities (NOUA, proteinuria and/or haematuria show positive both in supine and standing), 15 patients had undergone renal biopsies and showed different degrees of glomerulopathy. After prednisone/immunosuppression therapy, four patients with glomerulonephritis were changed from the NOUA to the OUA classification. Statistics analyses showed that serum total protein and albumin levels were significantly lower (P = 0.028, 0.007, respectively) and urinary protein was significantly higher (P = 0.007) in the NOUA group than in the OUA group. CONCLUSION After the indication of LRVES by ultrasound, patients with OUA likely have only LRVES, while patients with NOUA likely also have glomerulopathy. Supine/standing urinalysis combined with Doppler sonography can be helpful for differential diagnosis of LRVES combined with or without glomerulopathy.
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Affiliation(s)
- Meiling Jin
- State Key Laboratory of Kidney Disease, Institute of Nephrology, Chinese PLA General Hospital, Beijing, China; Medical College, Nankai University, Tianjin, China
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He Y, Wu Z, Chen S, Tian L, Li D, Li M, Jin W, Zhang H. Nutcracker syndrome--how well do we know it? Urology 2013; 83:12-7. [PMID: 24139744 DOI: 10.1016/j.urology.2013.08.033] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 08/12/2013] [Accepted: 08/17/2013] [Indexed: 02/07/2023]
Abstract
Nutcracker syndrome (NCS), which is caused by compression of the left renal vein between the abdominal aorta and the superior mesenteric artery, leads to a series of clinical symptoms including hematuria, proteinuria, flank pain, and varicocele. The diagnosis of NCS is difficult due to variations in normal anatomy. Treatment, which ranges from observation to nephrectomy, remains controversial. We conducted a review based on the related literature and our experience with hundreds of cases. We summarize the characteristics of NCS, the different measurements used in diagnosis, and the current treatment options. We present our diagnostic criteria and recommend endovascular stenting as the primary option for NCS.
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Affiliation(s)
- Yangyan He
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Ziheng Wu
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Shanwen Chen
- Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Lu Tian
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Donglin Li
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Ming Li
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Wei Jin
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Hongkun Zhang
- Department of Vascular Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China.
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Waseem M, Upadhyay R, Prosper G. The nutcracker syndrome: an underrecognized cause of hematuria. Eur J Pediatr 2012; 171:1269-71. [PMID: 22696107 DOI: 10.1007/s00431-012-1761-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/16/2012] [Indexed: 11/29/2022]
Abstract
UNLABELLED Nutcracker syndrome (NCS) is an uncommon cause of hematuria. It refers to the compression of the left renal vein between the aorta and superior mesenteric artery. It can cause both microscopic and gross hematuria. Hematuria may be associated with left flank pain. The diagnosis of NCS is often delayed. Most patients may have symptoms for many years and non-diagnostic evaluations before accurate diagnosis can be established. It should be included in the differential diagnosis of unexplained hematuria. The diagnosis and treatment of nutcracker syndrome are discussed. CONCLUSION NCS is a rare but treatable clinical condition. An inclusion of this entity in the differential diagnosis of patients with unknown cause of hematuria and flank pain can achieve efficient management of this condition.
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Affiliation(s)
- Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical & Mental Health Center, 234 East 149th Street, Bronx, NY 10451, USA.
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Shin JI, Park SJ, Cho MH, Kim JH. Left renal venographic findings in children with orthostatic proteinuria. Nephrol Dial Transplant 2011; 26:2715. [PMID: 21636825 DOI: 10.1093/ndt/gfr299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Modern medicine has experienced a tremendous explosion in knowledge about disease pathophysiology, gained largely from understanding the molecular biology of human disease. Recent advances in mass spectrometry and proteomics now allow for simultaneous identification and quantification of thousands of unique proteins and peptides in complex biological tissues and fluids. In particular, proteomic studies of urine benefit from urine's less complex composition as compared to serum and tissues, and have been used successfully to discover novel markers of a variety of infectious, autoimmune, oncological, and surgical conditions. This perspective discusses the challenges of such studies that stem from the compositional variability and complexity of human urine, as well as instrumental sampling limitations and the effects of noise and selection bias. Strategies for the design of observational clinical trials, physical and chemical fractionation of urine specimens, mass spectrometry analysis, and functional data annotation are outlined. Rigorous translational investigations using urine proteomics are likely to discover novel and accurate markers of both rare and common diseases. This should aid the diagnosis, improve stratification of therapy, and identify novel therapeutic targets for a variety of childhood and adult diseases, all of which will be essential for the development of personalized and predictive medicine of the future.
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Affiliation(s)
- Alex Kentsis
- Division of Hematology/Oncology, Children's Hospital Boston, and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA.
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