Nutcracker syndrome

Varying clinical presentations of nutcracker syndrome: a case report

INTRODUCTION

The term nutcracker syndrome was initially established in 1972 to refer to the compressive effects on the left renal vein due to a narrow angle between the abdominal aorta and the superior mesenteric artery. Although the precise prevalence of nutcracker syndrome remains unknown, an incidence of up to 4% has been described in patients presenting with hematuria. The peak age of incidence is between 10 and 30 years, and it is equally prevalent among both genders, though earlier studies showed a predominantly female preponderance. About 70-80% of patients present initially with hematuria, though left flank pain and proteinuria may also be presenting symptoms. A high index of suspicion and appropriate imaging often helps in aiding diagnosis.

CASE PRESENTATION

In this case report, we present here two South Asian young females aged 23 and 30 years old. They presented with gross painless hematuria of a duration of 2 years (Case 1) and nonspecific symptoms of abdominal pain (Case 2), and they were diagnosed with nutcracker syndrome on investigation. Both patients were diagnosed by computed tomography angiography with defined aortomesenteric angles diagnostic of nutcracker syndrome. Patient 1 underwent saphenous venous bypass grafting and repositioning of left renal vein with symptomatic improvement, while patient 2 was managed conservatively and continues to be on close follow-up. In addition, we present a brief review of this syndrome so that better insight is obtained regarding diagnosis and management.

CONCLUSION

The diagnosis of nutcracker syndrome needs to be considered in patients who present with unexplained hematuria or proteinuria. Diagnosis by appropriate imaging studies is necessary, and treatment is dictated by the severity of symptoms. Surgical therapy remains the front-line treatment; however, endovascular techniques are becoming favored owing to advancements in stent technology.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

A unique case report of wilkie syndrome in a middle-aged female with posterior nutcracker syndrome

Nutcracker syndrome and Wilkie syndrome are rare and often diagnosed incidentally during imaging investigations for other conditions and, on occasion, together. In this paper, we present the case of a 36-year-old patient with quasi-permanent symptoms including epigastralgia, loss of appetite, early satiety, left lumbar colic pain, normal stool and dysuria. The clinical examination revealed a non-distended abdomen, sensitivity to palpation in the epigastrium and hypogastrium regions, frequent urination in small amounts, and a body mass index (BMI) of 15 kg/m2, indicating severe protein calorie malnutrition. Laboratory tests indicated persistent microscopic hematuria without proteinuria with repeated urinary infections. Abdominal-pelvic ultrasound with Doppler revealed a left renal vein dilated up to 10 mm in the left paraaortic region (Nutcracker syndrome) and distal duodenal obstruction with distension in the same region, which was also confirmed by gastroduodenoscopy (Wilkie syndrome). Abdominal‒pelvic computed tomography angiography revealed a malformed and dilated left renal vein that was compressed as a result of aorto-mesenteric obstruction and communicating with an aberrant left paravertebral and paraspinal network extending to L1 and L5 and thrombosis of the left ovarian vein. The patient benefitted from conservative treatment, which intended to correct the malabsorption syndrome with the help of a nutritionist, who suggested a personalized diet to help gain weight. As a result, the patient was able to avoid surgical treatment. The case is peculiar in that the patient presented with a very rare form of Nutcracker syndrome (posterior type) associated with another rare syndrome, Wilkie syndrome.

Clinical advances in kidney autotransplantation: a review

Kidney autotransplantation is a surgical procedure with multiple indications and advancing technological approaches. Kidney autotransplantation is used to address complex kidney-related diseases including renal vascular lesions, ureteral diseases, tumors, loin pain-hematuria syndrome, and conditions affecting a solitary kidney or both kidneys. Renal artery lesions, including aneurysms and stenoses, often necessitate kidney autotransplantation in cases involving renal artery bifurcation or distant failure of endovascular repair. Complex ureteral lesions such as ureteral avulsions are commonly treated with kidney autotransplantation. Renal tumors, especially centrally located tumors or those involving the renal hilum, are treated using this technique while preserving renal function. It is worth emphasizing that this would be a rarely used last-resort technique in the modern era of minimally invasive nephron-sparing surgery. Kidney autotransplantation may be indicated for the rare condition of loin pain-hematuria syndrome when conservative measures fail. Additionally, individuals with solitary or bilateral kidney disease benefit from kidney autotransplantation to preserve their renal function. Traditional open-kidney autotransplantation involves renal extraction, workbench repair, and renal reimplantation. Technological advancements have introduced minimally invasive techniques including laparoscopic- and robot-assisted kidney autotransplantation, which reduce surgical trauma and recovery times. These techniques have shown promising outcomes, and robotic platforms have the potential to further reduce complications. In this study, we reviewed diverse indications and recent technological innovations in the field of kidney autotransplantation.

Coexisting nutcracker phenomenon and refractory hypertension in a patient with IgA nephropathy: A case report and literature review

The entrapment of the left renal vein (LRV) may contribute to changes in hemodynamics within kidney and could also be associated with IgA nephropathy (IgAN). Although the relationship between the nutcracker phenomenon and IgAN has not yet been elucidated, it is speculated that this patient's refractory hypertension is a combined effect of nutcracker syndrome (NCS) and IgAN.

The Diagnosis of Wilkie's Syndrome Associated with Nutcracker Syndrome: A Case Report and Literature Review

Superior mesenteric artery (SMA) syndrome or Wilkie's syndrome is a vascular compression disorder that causes the abnormal compression of the third portion of the duodenum by the SMA. It has a low incidence rate, which is higher in young women, and is rarely associated with the Nutcracker phenomenon: a condition of the compression of the left renal vein between the SMA and the aorta, which manifests as pain in the left flank and pelvis. Here, we report on the case of a 54-year-old woman with a history of repeated episodes of abdominal pain caused by the Nutcracker syndrome and Wilkie's syndrome.

Concurrent Encounter of Superior Mesenteric Artery Syndrome and Nutcracker Syndrome in a Young Female Patient: A Case Report and Literature Review

Superior mesenteric artery (SMA) syndrome causes duodenal obstruction between the SMA and aorta, which culminates into bowel obstruction. Meanwhile, nutcracker syndrome (NCS) involves left renal vein compression between the aorta and SMA, categorized by the compression site. We present a 15-year-old female with no prior medical or surgical history who displayed early signs of the rarely coexisting SMA and nutcracker phenomena, which were managed symptomatically along with nutritional support to reach her optimal body mass index.

Outcomes of conservative management in patients with nutcracker syndrome

OBJECTIVE

This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions.

METHODS

This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms.

RESULTS

Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged.

CONCLUSIONS

This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.

Venous Compressive Disorders

Venous compressive disorders are a heterogenous group of vascular syndromes characterized by extrinsic venous compression that can lead to complications of venous hypertension or venous thrombosis. Endovascular damage secondary to deep venous thrombosis (DVT) can result in post-thrombotic syndrome (PTS), a potentially debilitating condition that can be associated with significant morbidity in the pediatric population. Here we discuss 4 venous compressive disorders: iliac vein compression (May-Thurner syndrome [MTS]); subclavian vein compression at the venous thoracic inlet (Paget-Schroetter syndrome); left renal vein compression (nutcracker syndrome); and popliteal vein compression (popliteal entrapment syndrome) with a focus on clinical evaluation and diagnostic methods. Where endovascular therapy is appropriate, specific procedural considerations including procedure indications, equipment, procedural steps, technical challenges, complications, clinical follow-up and expected outcomes are discussed.

Nutcracker syndrome: a case-based review

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.

Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting

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.

Atypical case of coexistent vascular compression syndromes: median arcuate ligament syndrome and nutcracker syndrome

Vascular compression syndromes, including median arcuate ligament syndrome (MALS) and nutcracker syndrome (NCS), are poorly understood and frequently delayed diagnoses. This case describes a young adult female presenting with chronic vomiting, abdominal pain and weight loss, with dependence on nasogastric feeding. Subsequent to her gastrointestinal symptoms, she developed haematuria and orthostatic intolerance. Investigations confirmed NCS and possible MALS, with superadded gastroparesis and bradygastria. Under the joint care of general and vascular surgeons, she underwent a gastrojejunostomy and panelled renocaval bypass which led to partial resolution of her symptoms. It is hypothesised that gastroparesis may have been caused by MALS via a neurogenic mechanism, or coexistent compression of the duodenum by the superior mesenteric artery. This case highlights the difficulty in diagnosis of vascular compression syndromes, the overlap between the conditions and the potential for multiple coexistent conditions which complicate diagnosis and lead to increased lead-time and morbidity for patients.

Anterior Nutcracker syndrome in a young male patient: a case report and review of literature

INTRODUCTION AND IMPORTANCE

The left renal vein (LRV) is affected by a venous compression syndrome called Nutcracker syndrome (NCS). This syndrome is characterized by extrinsic compression of the LRV, which usually occurs between aorta and superior mesenteric artery. It is a rare and under-diagnosed condition, more prevalent in females and that, if left untreated, can lead to severe problems. There are no clear guidelines regarding management. Therefore, the authors report this rare case and its symptoms in male patient and they display current management options.

CASE PRESENTATION

NCS was observed during computer tomography in a male patient presented with persistent left flank pain and associated haematuria. Ultrasound for left scrotum demonstrated left moderate-sized varicocele. The left varicocele testis unit was 1.6 mm and during the Valsalva manoeuvre in the supine position the testis unit was 2 mm. LRV compression between abdominal aorta and superior mesenteric artery was identified by computer tomography imaging and therefore, diagnosis of NCS was confirmed.

CLINICAL DISCUSSION

The actual prevalence is unclear, and incidence rates have been observed to fluctuate among age group and more prevalent in women. Main symptoms include haematuria, left flank discomfort, varicocele in men, proteinuria and anaemia. Depending on severity of symptoms, management might range from conservative care to surgery.

CONCLUSION

This treatment strategy was effective in reducing the symptoms of the patients. In young patients, conservative treatment is advised for a fair amount of time. However, more studies on how much the authors should wait before considering surgery is important.

Nutcracker Syndrome in a 77-Year-Old Female With Bilateral May-Thurner Syndrome: A Case Report

Nutcracker syndrome (NCS) is an uncommon condition that predominantly affects the left renal vein (LRV) because of its entrapment between the aorta and superior mesenteric vein. It can result in pain in the left flank or back, hematuria, and proteinuria. May-Thurner syndrome (MTS) is described as a condition in which the left common iliac vein is compressed by the right common iliac artery, causing swelling, fullness, venous ulcers, or varicose veins in the leg. We present a case of a 77-year-old female who had these symptoms for over a decade, until she was diagnosed in 2017. Initially, she experienced swelling and pain in her left leg, which began in 2005; however, treatment did not begin until she had her left ovarian vein embolized in 2017. Her symptoms returned the following year, leading to the diagnosis of bilateral MTS. Owing to recurring symptoms in 2022, a repeat venogram revealed bilateral external iliac vein constriction, requiring intervention. She presented to our clinic in 2023 after being referred by her cardiologist because of persistent back pain and venous congestion. This led to the findings and diagnosis of NCS with bilateral MTS.

Nutcracker syndrome: challenges in diagnosis and surgical treatment

BACKGROUND

Nutcracker syndrome (NCS) is an uncommon syndrome that presents with signs and symptoms caused by compression of the left renal vein (LRV), whereas 'nutcracker phenomenon' is solely used to refer to the anatomical configuration without clinical symptoms. Treatment for NCS may include non-operative management, open surgical intervention and in some instances endovascular stenting. We present a single-center retrospective case series of patients who presented with NCS managed with open surgical interventions.

METHODS

Single-center, retrospective review of patients managed from 2010-2021. We diagnosed NCS via a thorough clinical examination and additional cross-sectional imaging studies including magnetic resonance venography (MRV) and/or computed tomography venography (CTV). For further confirmation of the diagnosis, duplex ultrasound was frequently combined with contrast venography.

RESULTS

Thirty-eight patients were included in our study from 2010-2021 . Twenty-one (55.3%) patients presented with symptoms including flank pain, abdominal pain, hematuria and fatigue. The remaining 17 (44.7%) patients had nutcracker phenomenon. Within the group of patients diagnosed with NCS, 11 patients underwent LRV transposition. Symptoms related to NCS improved in 10 patients. Hematuria in one patient did not improve.

CONCLUSION

Transposition of the LRV is an effective treatment for NCS. Non-operative management is an option for those patients experiencing less severe or nonspecific clinical symptoms.

Scrotal Pain after Varicocelectomy: A Narrative Review

Varicocele is a frequently encountered urological disorder, which has a prevalence rate of 8 to 15% among healthy men. However, the incidence is higher in male patients with primary or secondary infertility, with up to 35 to 80% of varicocele cases occurring in this population. The clinical manifestations of varicocele typically include the presence of an asymptomatic mass that feels like a “bag of worms”, chronic scrotal pain, and infertility. Most patients with varicocele only undergo varicocelectomy after conservative treatments have failed. Unfortunately, some patients may still experience persistent scrotal pain due to a recurrence of varicocele, the development of hydrocele, neuralgia, referred pain, ureteral lesions, or nutcracker syndrome. Therefore, clinicians should consider these conditions as potential causes of postoperative scrotal pain, and take measures to address them. Several factors can assist in predicting surgical outcomes for patients with varicocele. Clinicians should consider these factors when deciding whether to perform surgery and what type of surgical intervention to use. By doing so, they can increase the likelihood of a successful surgical outcome and minimize the risk of complications such as postoperative scrotal pain.

Albuminuria as a marker of systemic congestion in patients with heart failure

AIMS

Albuminuria is common in patients with heart failure and associated with worse outcomes. The underlying pathophysiological mechanism of albuminuria in heart failure is still incompletely understood. The association of clinical characteristics and biomarker profile with albuminuria in patients with heart failure with both reduced and preserved ejection fractions were evaluated.

METHODS AND RESULTS

Two thousand three hundred and fifteen patients included in the index cohort of BIOSTAT-CHF were evaluated and findings were validated in the independent BIOSTAT-CHF validation cohort (1431 patients). Micro-albuminuria and macro-albuminuria were defined as urinary albumincreatinine ratio (UACR) 30 mg/gCr and 300 mg/gCr in spot urines, respectively. The prevalence of micro- and macro-albuminuria was 35.4 and 10.0, respectively. Patients with albuminuria had more severe heart failure, as indicated by inclusion during admission, higher New York Heart Association functional class, more clinical signs and symptoms of congestion, and higher concentrations of biomarkers related to congestion, such as biologically active adrenomedullin, cancer antigen 125, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) (all P 0.001). The presence of albuminuria was associated with increased risk of mortality and heart failure (re)hospitalization in both cohorts. The strongest independent association with log UACR was found for log NT-proBNP (standardized regression coefficient 0.438, 95 confidence interval 0.350.53, P 0.001). Hierarchical clustering analysis demonstrated that UACR clusters with markers of congestion and less with indices of renal function. The validation cohort yielded similar findings.

CONCLUSION

In patients with new-onset or worsening heart failure, albuminuria is consistently associated with clinical, echocardiographic, and circulating biomarkers of congestion.

Robotic-assisted combined transposition of left renal vein and gonadal vein as a novel treatment option for renal nutcracker syndrome: A case report

RATIONALE

Renal nutcracker syndrome is a rare phenomenon that often causes various disability symptoms. The treatment protocol has been explored for a long time, but no consensus has been reached.

PATIENT CONCERNS

Here, we report the case of a 19-year-old male suffering with nutcracker syndrome, including left-sided flank pain and intermittent gross hematuria.

DIAGNOSES

The patient was diagnosed with renal nutcracker syndrome, and the pressure gradient between the left renal vein and inferior vena cava was >5 mm Hg.

INTERVENTIONS

The patient underwentrobotic-assisted combined transposition of left renal vein and gonadal vein.

OUTCOMES

Flank pain and gross hematuria ceased spontaneously after surgery without occurrence.

LESSONS

Robotic-assisted combined transposition of the left renal vein and gonadal vein is a safe and promising option for this condition.

Twenty-year analysis of the rarely diagnosed nutcracker syndrome

Aim: Nutcracker syndrome is a very rare cause in patients presenting to the emergency department with abdominal pain. Early consideration in differential diagnosis will reduce the time spent for diagnosis and morbidity, as well as provide the correct treatment. We aimed to contribute to the literature by determining the clinical relations of these cases with laboratory, imaging and treatment data. Material and Method: Twenty-seven patients over the age of 16 who presented to the emergency department with abdominal pain between January 2000 and December 2020 were included in this study. The ages of the patients were between 16-39 and the mean was 25.19±7.00 years. Demographic characteristics, clinical findings, laboratory parameters, radiological evaluations, and treatment modalities of patients were evaluated retrospectively. Results: Abdominal pain and flank pain were the most common reasons for admission to the emergency department of 27 patients included in the study. In the anterior group, 17 (77%) patients had flank pain, 10 (45%) patients had dysmenorrhea, 11 (50%) hematuria, 10 (45%) proteinuria, and 9 (40%) patients hematuria and proteinuria. In the posterior group, there was no hematuria, proteinuria, anorexia, nausea and vomiting, and oral intolerance. In cases with anteior nutcracker syndrome, 12 (54%) doppler ultrasonography, 13 (59%) computed tomography, 5 (22%) magnetic resonance imaging were performed. Conservative treatment was applied to 11 (40%) patients in the anterior group and 3 (11%) patients in the posterior group. Endovascular surgery was performed on 5 (22%) female patients. Conclusion: Nutcracker syndrome should be investigated in adult patients who present to the emergency department with abdominal pain and whose diagnosis is unclear. Early diagnosis is critical in terms of treatment and morbidity.

Diagnostic Clues in Pediatric Nutcracker Syndrome: From Two Clinical Cases to Current Literature Analysis

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.

Evaluation of Proteinuria and Hematuria in Ambulatory Setting

Proteinuria and/or hematuria are common findings in ambulatory settings. Proteinuria can be glomerular and/or tubular in origin and it may be transient, orthostatic, or persistent. Persistent proteinuria may be indicative of a serious kidney pathology. Hematuria, which denotes the presence of an increased number of red blood cells in the urine, can be gross or microscopic. Hematuria can originate from the glomeruli or other sites of the urinary tract. Asymptomatic microscopic hematuria or mild proteinuria in an otherwise healthy child is less likely to be of clinical significance. However, the presence of both requires further workup and careful monitoring.

Nutcracker Phenomenon: A Rare Incidental Finding

The nutcracker phenomenon, or left renal vein (LRV) entrapment syndrome, occurs when there is compression of the LRV, mostly between the abdominal aorta and the superior mesenteric artery. Patients with nutcracker syndrome (NCS) may present with various symptoms, with the most common being hematuria, left flank pain, varicocele in males, proteinuria, and anemia. Our 22-year-old male patient presented with abdominal pain without hematuria. Insidiously, we made the diagnosis of NCS with this unusual presentation. Some studies have proposed a relationship between rapid weight loss in a short period of time and the appearance of NCS. We recommend that healthcare providers suspect NCS in patients who present with abrupt severe abdominal discomfort, particularly in situations that coincide with rapid weight loss for an unknown reason.

Associations of left renal vein entrapment with IgA nephropathy and Henoch-Schönlein purpura nephritis

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.

Nutcracker syndrome, conservative approach: a case report

The nutcracker phenomenon (NCP) refers to the compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery (SMA). Nutcracker syndrome (NCS) should be limited to patients who present with the characteristic clinical signs and symptoms alongside diagnostic imaging of the anatomy associated with the syndrome. We report a case of NCS presenting with painless visible hematuria and left flank pain. Imaging showed a left renal vein stenosis at the origin of the SMA with collateralization. Diagnosis of NCP is made by a variety of imaging techniques; approaches to the treatment of NCS include conservative methods, open surgical, laparoscopic or endovascular techniques. Correlation with symptoms, laboratory results and excluding other causes continues to be important in the workup of NCS. Collaboration with the establishment of an International Consortium database will aid in the understanding of this rare disease.

Left renal vein entrapment in postural proteinuria: the diagnostic utility of the aortomesenteric angle

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.

Endovascular treatment of a patient with nutcracker syndrome and pelvic varices involving anterior and posterior renal veins

We have reported a case of a 36-year-old woman with flank and pelvic pain and hematuria. She had posterior nutcracker syndrome and pelvic varices involving one anterior and three posterior renal veins (including one major vein). We used a complete endovascular approach, which included stent implantation in the major posterior renal vein and left gonadal vein embolization. During a 12-month follow-up period, the patient had had no symptoms and good computed tomography results. Endovascular treatment represents a safe and successful option for patients with nutcracker syndrome and pelvic varices involving the anterior and posterior renal veins.

Nutcracker syndrome: diagnosis and therapy

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.

Atypical Posterior Nutcracker Syndrome in a 17-Year-Old Male Without Hematuria

Retro-aortic left renal vein (RLRV) is an anatomical variation, where the left renal vein (LRV) courses posterior to the aorta and anterior to the vertebrae before it eventually drains into the inferior vena cava (IVC). RLRV is a rare finding, with a prevalence of around 1%-2%, and only a small minority of RLRVs cause symptoms. RLRV symptoms occur secondary to compression of the LRV between the abdominal aorta and vertebrae, otherwise known as posterior nutcracker syndrome (PNCS). The most common symptoms of PNCS are hematuria and flank pain. We present a 17-year-old male, who came in with recurring left flank pain without hematuria, initially thought to be renal colic secondary to nephrolithiasis. On further investigations, an aberrant posterior renal vein was seen on CT suggestive of PNCS. The patient was treated successfully with RLRV vascular stent placement by interventional radiology. This case report adds to the limited number of PNCS cases observed in children and to the even rarer cases of PNCS without hematuria. This case also acts as a reminder for pediatricians to keep a wide scope of differentials in patients presenting with flank pain and provides an outline of both diagnostic and treatment modalities available for these patients.

[Diagnosis of arteriovenous compression in small pelvic varicose veins]

AIM

The study was aimed at assessing the incidence of arteriovenous compression in women with chronic venous insufficiency of the inferior vena cava and at developing an optimal diagnostic algorithm.

PATIENTS AND METHODS

During the period 2019-2020, we performed a cross-sectional study including a total of sixty-six 18-to-55-year-old (mean 33.5±5.0) women with clinical manifestations of chronic venous insufficiency of the basin of the inferior vena cava. A diagnostic algorithm included questionnaire, transvaginal ultrasound examination, multislice computed tomography, direct phlebography in combination with phlebotonometry.

RESULTS

Chronic venous insufficiency of lower limbs was diagnosed in 66 (100%) cases and was presented by the following clinical classes according to the CEAP classification: C0 - 4.5%, C1 - 60.6%, C2 - 27.2%, C3 - 3%. Symptoms of pelvic venous plethora were revealed in 36 (55.5%) examined patients. Arteriovenous compression syndrome according to the findings of multislice computed tomography was verified in 16 (24%) women, including May-Turner syndrome in 5 (7.6%), aortomesenteric compression syndrome in 8 (12%) women, with a combination of both syndromes observed in 3 cases; the frequency of their detection did not differ statistically in subgroups of women with and without clinical signs pelvic varicose veins. Direct phlebography in combination with phlebotonometry was performed in 9 women, the diagnosis of arteriovenous compression (May-Thurner syndrome) was confirmed in 1 case only.

CONCLUSION

In women with signs of chronic venous insufficiency in the system of the inferior vena cava the frequency of detecting arteriovenous compression on multislice computed tomography may reach 24% and does not depend on the presence of symptoms of pelvic venous plethora. The proportion of arteriovenous compression according to the findings of direct phlebography and phlebotonometry in the structure of causes of the development of pelvic varicose veins did not exceed 11%. An algorithm for diagnosing arteriovenous compression syndromes should obligatorily include multislice computed tomography, direct phlebography and phlebotonometry.

Coexisting nutcracker phenomenon and superior mesenteric artery syndrome in a patient with IgA nephropathy: A case report

RATIONALE

Nutcracker and superior mesenteric artery (SMA) syndrome share the same pathogenesis, but the simultaneous occurrence of both diseases is quite rare. A combination of the nutcracker syndrome and IgA nephropathy has previously been reported. Herein, we report what we believe is the first case of coexisting nutcracker and SMA syndrome in a patient with IgA nephropathy.

PATIENT CONCERNS

A 15-year-old Chinese boy who was diagnosed with IgA nephropathy at 8 years of age presented with gross hematuria, fatigue, anorexia, nausea, and recurrent abdominal distension for 1 week without any obvious evidence of preceding infection. Laboratory data showed macroscopic hematuria, heavy proteinuria, and relatively normal renal function. Doppler ultrasonography and upper gastrointestinal gastrografin study were performed, respectively. Since his renal function deteriorated after admission, repeated renal biopsy was performed.

DIAGNOSES

IgA nephropathy with nutcracker phenomenon and SMA syndrome.

INTERVENTION

Immunosuppressive therapy combined with conservative therapy for superior mesenteric artery syndrome.

OUTCOMES

One month later, his abdomen symptoms such as anorexia and abdominal distension eased a lot with body weight increase of about 3 kg. After 6 months of follow-up, his body weight increased to 57 kg, serum creatinine decreased to 63 μmol/L, and urine microscopy showed 75.5 RBC/high-power field with 0.3 g urine protein per day.

LESSONS

Although the association between vascular compression and IgA nephropathy (IgAN) has not been elucidated yet, combination of nutcracker syndrome and SMA syndrome should be considered in patients with IgAN. The combination may increase the complexity of the disease, and renal biopsy should not be hesitated for differential diagnosis.

Nutcracker Syndrome

We provide a concise review of Nutcracker Syndrome with its history, incidence, clinical presentation and currently available diagnostic criteria and treatment options. This should help any clinician identify and better serve patients with rare venous disorders such as this. Although the literature is scarce, clinicians should be keen to diagnose and treat patients with this potentially debilitating syndrome.

[Abnormal urine color assessment: The urine wheel]

Looking at the urine for diagnostic purposes, once performed by ancient Egyptians, can still provide some valuable clues in modern medicine. Several diseases have been named after their associated urine color and this underlines the clinical value of visual urine inspection: blue diaper disease, purple urine bag syndrome, black urine disease or porphyria. Abnormal urine color could be challenging for the clinician: it may reveal neoplastic disease (urologic cancer; melanoma), cell lysis (rhabdomyolysis; hemolysis), infection (lymphatic filariasis; malaria), enzyme deficiency (porphyria; alkaptonuria), medication or food intake. In this article, we present the diagnostic approach, the mechanisms involved and the main causes of abnormal urine color.

The role of ultrasound imaging in vascular compression syndromes

Vascular compression syndromes are rare alterations that have in common the compression of an arterial and/or venous vessel by contiguous structures and can be congenital or acquired. The best known are the Thoracic Outlet Syndrome, Nutcracker Syndrome, May–Thurner Syndrome, and Dunbar Syndrome. The incidence of these pathologies is certainly underestimated due to the non-specific clinical signs and their frequent asymptomaticity. Being a first-level method, Ultrasound plays a very important role in identifying these alterations, almost always allowing a complete diagnostic classification. If in expert hands, this method can significantly contribute to the reduction of false negatives, especially in the asymptomatic population, where the finding of the aforementioned pathologies often happens randomly following routine checks. In this review, we briefly discuss the best known vascular changes, the corresponding ultrasound anatomy, and typical ultrasound patterns.

Nutcracker syndrome accompanied by hypertension: a case report and literature review

Nutcracker syndrome (NCS) refers to characteristic clinical symptoms that develop secondary to the nutcracker phenomenon (NCP), defined as compression of the left renal vein between the superior mesenteric artery and the aorta. A 22-year-old Chinese man presented with a 2-year history of hypertension and left flank pain after activity; his blood pressure fluctuated within 130–150/90–100 mmHg without treatment. He had microscopic hematuria (2+) and increased plasma renin activity. The findings of both color Doppler ultrasound and computed tomography angiography were consistent with a diagnosis of NCS. The patient had no history of familial hypertension or special medications. Secondary hypertension-related examinations showed no significant abnormalities. After placement of an endovascular stent in the left renal vein, normal blood flow resumed and the collateral circulation was reduced. Both the hypertension and flank pain were alleviated within 3 days after the intervention and did not reappear during the following 11 months. NCP/NCS accompanied by hypertension is very rare. The possibility of NCP/NCS should be considered when secondary hypertension cannot be explained by other factors. The mechanism by which hypertension is caused by NCP/NCS is rather complex and deserves further investigation.

Unusual coexistence of double inferior vena cava with nutcracker syndrome-a case report and review of the literature

Knowledge of vessel anomalies is significant for all specialists in clinical practice and may prevent serious complications following medical interventions. Here, the rare coexistence of a duplicated inferior vena cava (IVC) and nutcracker syndrome in a 42-year-old female patient with atypical abdominal pain is presented, using two complementary radiological techniques (colour Doppler ultrasonography and computed tomography angiography). The right renal vein was found to be compressed when passing between the superior mesenteric artery and the abdominal aorta. The lumen dimensions (width × height) of the right IVC and left IVC at the level of termination were 15.8 × 17.7 mm and 13.4 × 12.4 mm, respectively. Ultrasonography revealed low blood flow in the left IVC that was reversed, and thus blood travelled in the same caudal direction as in the aorta. In the right IVC, however, flow travelled in the cranial direction. The simultaneous existence of a duplicated IVC and nutcracker syndrome is an extremely rare vessel anomaly; nevertheless, this dual presence may result in clinical symptoms and would have an impact on medical operations and even minor medical procedures.

Nutcracker syndrome due to aorto-mesenteric compression in adults: Case report and literature review

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Nutcracker syndrome is characterized by compression of the left renal vein between the abdominal aorta and the superior mesenteric artery, resulting in an obstruction of blood flow from the left renal vein into the inferior vena cava due to extrinsic compression.

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The management of nutcracker syndrome depends on the clinical presentation and severity of hypertension in the left renal vein, ranging from simple monitoring to nephrectomy.

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Surgical techniques used for the treatment of patients with severe symptoms.

Nutcracker syndrome is a rare entity that corresponds to an abdominal pain following compression of the left renal vein during its passage between the aorta and the superior mesenteric artery, with a peak prevalence in adults between 20 and 30 years old, The typical clinical presentation includes hematuria, orthostatic proteinuria with or without flank pain. doppler ultrasound has a sensitivity of 78% and specificity of 100%, Both CT and MRI can show the compression of the left renal vein between the aorta and the superior mesenteric artery.

We report the case of a young patient admitted to the emergency room for abdominal pain mainly localized in the left hypochondrium, with microscopic hematuria, a CT scan was performed showing a reduced aorto mesenteric angle with a compression of the left renal vein and collateralization of venous circulation of left gonadal vein.

Breaking open the case of one patient's acute left flank pain: nutcracker syndrome

Acute flank and abdominal pain represent a common presenting complaint in the emergency department. The etiology can be broad, ranging from the chest to the groin, from benign to catastrophic. There are common causes such as nephrolithiasis and pyelonephritis for which more than 1 million Americans are diagnosed with in the United States each year.1 Other etiologies are more rare and difficult to diagnose. The following case discusses a rare syndrome involving a young man with flank pain and a few other symptoms.

3D-Printed PEEK Extravascular Stent in the Treatment of Nutcracker Syndrome: Imaging Evaluation and Short-Term Clinical Outcome

Minimally invasive options are safe and reliable alternatives for the treatment of nutcracker syndrome (NCS). After continued efforts, our team successfully devised a new and effective therapeutic method: 3D-printed extravascular stenting of the left renal vein. From December 2017 to May 2019, 28 patients (25 men and 3 women) from different parts of China between 18 and 37 years old (mean, 23.6 years) diagnosed with NCS were admitted for laparoscopic 3D-printed extravascular stenting treatment. The post-operative follow-up duration was 6-24 months (median, 16.3 months). Technical success of the operation was achieved in all patients. After treatment, the NCS symptoms all patients resolved or improved during the follow-up period, without relapse. Most symptoms, including macro-/microhematuria, proteinuria, and flank/abdominal pain, tended to resolve within 3-6 months after the surgery; other symptoms, such as left-sided varicocele, also showed varying degrees of improvement at different times post-operatively. Perioperative complications were noted in two patients, including transient and mild lymphatic leakage, without any adverse effects. All extravascular stents were visualized on computed tomography and Doppler ultrasound scans, and no migration or any side effects occurred during the entire follow-up period. Compared to endovascular stenting or polytetrafluoroethylene artificial vessel procedures, 3D-printed polyetheretherketone extravascular stenting has more advantages in terms of stent design and rigidity and approach rationality while successfully preventing stent migration and thrombosis. Therefore, this method may serve as an accurate and effective treatment for NCS patients.

A Case of Nutcracker Syndrome Combined with Wilkie Syndrome with Unusual Clinical Presentation

BACKGROUND Nutcracker syndrome and Wilkie's syndrome are rare vascular diseases due to the abnormal course of the superior mesenteric artery originating from the abdominal aorta with reduced angle (<22°) and consequent compression of the left renal vein (nutcracker) and duodenum (Wilkie). Here, we report the case of a patient with a rare combination of these 2 syndromes and with unusual clinical manifestation of post-prandial pain. CASE REPORT We describe the case of a young male patient with rapid weight loss, coupled with post-prandial abdominal pain, with sub-acute onset, not associated with other symptoms. The ultrasound examination found an aorto-mesenteric angle of 18° and compression of the left renal vein and left varicocele. A CT study was performed to exclude oncological diseases and/or other pathologies responsible for the pain and weight loss, which confirmed the ultrasound findings and showed compression of the third part of the duodenum. The patient underwent endovascular treatment, with stent placement in the left renal vein, which resolved the vascular compression and of the duodenum, with regression of symptoms. CONCLUSIONS The ultrasound scan promptly highlighted the reduction of the aorto-mesenteric angle and the signs of venous congestion of the left renal vein. Based on this experience, in patients with weight loss and post-prandial pain, in our opinion, diagnostic investigations should also be extended to the study of the aorto-mesenteric angle to confirm or exclude any vascular and/or duodenal compression.

Uncracking a case

Nutcracker phenomenon (NCP) refers to compression of the left renal vein (LRV), most frequently between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein. The nutcracker syndrome (NCS) is the terminology used when the nutcracker phenomenon is accompanied by a complex of symptoms such as pain (abdominal, flank, and pelvic), hematuria and orthostatic proteinuria. Diagnosis can be made with Doppler ultrasound (DUS), computed tomography (CT), magnetic resonance imaging (MRI), and venography. We describe a case of a young female adult who was identified with NCP by DUS, after a first CT had found no abnormalities. She presented with flank pain and severe hematuria causing a drastic decrease in hemoglobin levels. The management of NCS depends upon the clinical presentation and the severity of the LRV hypertension. The treatment options range from conservative to nephrectomy. Treatment decision should be based on the age of patients, severity of symptoms, and their expected reversibility. This case describes an underreported disorder that presents with non-specific symptoms, demonstrating the difficulties of the diagnostic approach of NCS, as well as the challenges in the appropriate management, given the lack of standardized treatment.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.