Abstract
BackgroundNephrotic-range proteinuria is a common reason for nephrological consultation in clinical practice. The differential diagnosis is wide, and generally focuses on different forms of glomerulonephritis, but other causes should not be overlooked, as illustrated in this article.Case presentationsWe report two female patients with nephrotic-range proteinuria. In the first case, a 46 year old Caucasian patient who suffered from extreme obesity (Body mass index (BMI) 77 kg/m2), acute kidney injury and nephrotic-range proteinuria were discovered during an emergency consultation for acute abdominal pain. The second patient (aged 52, also Caucasian) developed stage 4 chronic kidney disease and nephrotic proteinuria (protein/creatinine ratio 1821 g/mol) after accidental rupture of the inferior vena cava during a gastric bypass operation. On split-urine collection, both had a much higher degree of proteinuria during the day than during the night, compatible with orthostatic proteinuria. At further work-up, inferior vena cava thrombosis was diagnosed in both patients, whereas renal veins were patent.DiscussionAfter simple anticoagulation in the first case, and anticoagulation plus endovascular recanalization in the second, there was almost complete resolution of the orthostatic proteinuria and a strong improvement of the estimated glomerular filtration rate in both patients. These cases highlight that nephrotic-range proteinuria can be linked to inferior vena cava thrombosis, and that a split-urine collection may also be very useful in the diagnostic work-up of proteinuria in adults.
Highlights
DiscussionAfter simple anticoagulation in the first case, and anticoagulation plus endovascular recanalization in the second, there was almost complete resolution of the orthostatic proteinuria and a strong improvement of the estimated glomerular filtration rate in both patients
Nephrotic-range proteinuria is a common reason for nephrological consultation in clinical practice
After simple anticoagulation in the first case, and anticoagulation plus endovascular recanalization in the second, there was almost complete resolution of the orthostatic proteinuria and a strong improvement of the estimated glomerular filtration rate in both patients. These cases highlight that nephrotic-range proteinuria can be linked to inferior vena cava thrombosis, and that a split-urine collection may be very useful in the diagnostic work-up of proteinuria in adults
Summary
We describe the clinical presentation, diagnostic procedures, and treatment of two patients with IVC thrombosis. IVC thrombosis may increase the pressure in the renal veins and increases the transglomerular pressure, leading to proteinuria and reduced glomerular filtration rate The pressure gradient between the thoracic and abdominal vena cava and the intra-abdominal pressure are higher in obese patients than in controls, and increase further in the standing position [15] This phenomenon may explain the fluctuations in proteinuria observed in our patients, despite the fixed IVC thrombosis. Nephrotic syndrome Thrombophilia Factor V Leiden Antiphospholipid syndrome Jak 2 Syndrome protein S/C not recognized as an isolated cause of IVC thrombosis, we believe that the extreme obesity played a major role in the first patient.
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