Images in Clinical Medicine

Bilateral Renal-Vein Thrombosis Associated with the Nephrotic Syndrome

Surat Phonsombat, M.D., and Marshall L. Stoller, M.D.

N Engl J Med 2006; 354:1402March 30, 2006

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Article

A 61-year-old woman whose medical history was notable for hypertension and type 2 diabetes reported a two-day history of increasing dull pain in the right flank and nonbloody, bilious vomiting. Physical examination revealed no abdominal masses, costovertebral-angle tenderness, or peripheral edema. Laboratory evaluation revealed normal serum creatinine levels (1.0 mg per deciliter [88.4 μmol per liter]); the presence of hyperlipidemia (total cholesterol level, 938 mg per deciliter [24.3 mmol per liter]; triglyceride level, 811 mg per deciliter [9.2 mmol per liter]; and high-density lipoprotein cholesterol level, 44 mg per deciliter [1.1 mmol per liter]); low total-protein and albumin levels (3.9 g per deciliter and <1.0 g per deciliter, respectively); and an abnormal result on urinalysis, showing proteinuria (>300 mg of protein per deciliter), microhematuria (11 to 20 red cells per high-power field on light-microscopical examination), and glucosuria (100 mg of glucose per deciliter [5.5 mmol per liter]). A 24-hour urine test demonstrated proteinuria (8.4 g of protein). Computed tomography of the abdomen demonstrated bilateral renal-vein thrombosis (larger on the right than on the left) (thin arrows), with extension to the inferior vena cava (thick arrow). A renal biopsy revealed membranous glomerulonephritis. Low-molecular-weight heparin was begun, and the patient was given warfarin at discharge. The risk of renal-vein thrombosis is increased in patients with the nephrotic syndrome, owing to the loss of clotting inhibitors in the urine.

Surat Phonsombat, M.D.
Marshall L. Stoller, M.D.
University of California at San Francisco, San Francisco, CA 94143