Bilateral Renal Vein Research Articles

503 Phospholipase A2 receptor associated membranous nephropathy complicated with a bilateral renal vein thrombosis, a case report

503 Phospholipase A2 receptor associated membranous nephropathy complicated with a bilateral renal vein thrombosis, a case report

Predictors of renal outcomes and mortality in patients with renal vein thrombosis: a retrospective multicenter study.

Studies on renal vein thrombosis have been conducted as case reports or case series. The renal outcomes and mortality risk of renal vein thrombosis have not been fully established. We aimed to investigate the clinical characteristics, treatment modalities, and predictors of renal outcomes and mortality in patients with renal vein thrombosis in a large multicenter cohort. We retrospectively assessed 182 patients with renal vein thrombosis diagnosed between January 2011 and May 2023 using either Doppler ultrasonography or computed tomography venography. The main outcomes analyzed were all-cause mortality, and worsening kidney function. We evaluated 182 patients comprising 76 males (41.8%) and 106 females (58.2%). Nephrotic syndrome was the most common cause (51.6%) followed by malignancy (33%) and post-trauma or surgery (11%). Kidney function worsened in 126 patients (69.2%). Acute kidney injury (AKI) was identified in 72 patients (39.6%), whereas 54 patients (29.7%) developed chronic kidney disease (CKD). Multivariatelogistic regression showed that declining kidney function was reliably predicted by nephrotic syndrome (Odds ratio (OR): 6.41, P = 0.004), serum albumin (OR: 0.31, P = 0.003), and diabetes mellitus (OR: 14.04, P < 0.001). Eighty-two patients (45.1%) died while being monitored. Sepsis accounted for the majority of deaths (25.3%). Bilateral renal vein thrombosis (Hazard Ratio (HR): 5.61, P < 0.001), malignancy (HR: 6.15, P = 0.004), serum albumin (HR: 0.12, P < 0.001), hemoglobin (Hb) level (HR: 0.102, P < 0.001) and diabetes mellitus (HR: 2.42, P = 0.007) were all reliable predictors of all-cause mortality using multivariate Cox regression. Renal vein thrombosis is associated with a higher risk of mortality and worsening kidney function. It is essential to promptly identify high risk patients and start early treatment to prevent unfavorable outcomes.

Perioperative Anaesthetic Management of a Large Paraganglioma Compressing Abdominal Aorta and Inferior Vena Cava: A Case Report

Paragangliomas (PGs) are rare neuroendocrine tumors that originate in the autonomic nervous system. Functionally, they are highly vascular and may be parasympathetic or sympathetic. Parasympathetic tumors are usually asymptomatic and inactive, located mostly in the skull base in the distribution of IX and X cranial nerves. In contrast, sympathetic tumors are highly active (secretes norepinephrine) and symptomatic and mainly located in the abdomen and pelvic regions. Surgical removal of these tumors is curative and key to favorable outcomes. Some of these tumors have malignant potential as well. Meticulous preoperative preparation is needed but many patients may still land up in hypertensive crises intraoperatively which should be managed promptly and cautiously by the anesthesia team to reduce morbidity and mortality during surgery. Here, we describe the successful anesthetic management of a patient diagnosed with large aortocaval PG abutting the aorta and compressing the inferior vena cava and bilateral renal veins.

Ratlarda Oluşturulan Renal İskemi Reperfüzyon Hasarında Epibatidinin Etkileri

Objective: The attenuation of renal ischemia reperfusion (I/R) injury by stimulating cholinergic antiinflamatory pathway has been demonstrated in the literature. The purpose of this study is to investigate the protective effects of epibatidine, a non selective nicotinic acethycholine receptor agonist, administered before ischemia on renal ischemia-reperfusion injury. Methods: After Ethics Committee approval, 24 Wistar Albino rats were randomly allocated into 4 groups. Group S: Sham (n=6), Group I/R: Ischemia/reperfusion (n=6), Group I/R-E: Ischemia/ reperfusion-Epibatidine (n=6), Group E: Epibatidine (n=6). All groups underwent laparotomy and bilateral renal artery and vein dissection under anesthesia. No further action was taken in Group S. In Group I/R and Group I/R-E, renal ischemia was applied for 25 minutes and then reperfusion for 24 hours. A single dose of 5 μg kg-1 epibatidine was administered subcutaneously before the laparotomy in Group I/R-E and Group E. At the end of the reperfusion period, blood and urine samples were taken for plasma BUN, creatine, plasma and urinary neutrophil gelatinase associated lipocalin (NGAL) and cystatin C, plasma IL-6 and TNF-α assessment. Results: Plasma BUN, creatine, NGAL, cystatin C, IL-6 and TNF-α levels were significantly higher in Group I/R when compared to Group S (p&lt;0.05). All the levels of the above biomarkers were comparable in Group S and Group I/R-E. Conclusion: These results indicate that epibatidine administration before ischemia has a protective effect on kidney in renal I/R injury induced rats. Keywords: Renal ischemia-reperfusion injury, cholinergic antiinflammatory pathway, n7AchR, epibatidine, NGAL

Inferior Vena Cava Agenesis, Bilateral Double Renal Veins, and Left Circumaortic Renal Vein: A Rare Case and Brief Review of the Literature

Abstract The improper embryologic development of the inferior vena cava (IVC) is a rare congenital defect that affects about 4% of the population. IVC agenesis is one of the less common variations, with an estimated prevalence ranging from 0.005% to 1%. We present a rare instance of IVC agenesis, bilateral double renal veins, and left circumaortic renal vein that manifested as lower extremities deep vein thrombosis. While anomalies of the IVC and renal veins are exceedingly rare, they should be considered during retroperitoneal procedures to avoid major consequences, particularly venous bleeding caused by incorrect damage. Anatomical variance of the IVC and renal veins is critical for procedures such as ureteral surgery, sympathectomy, radical nephrectomy, and organ transplantation. The clinical significance of these aberrations stems from the possibility of mistakes during imaging. They play a significant role in the diagnosis and treatment of venous thromboembolic disease.

Knockdown of histone deacetylase 1 in fibroblasts and pericytes prevents renal interstitial fibrosis after ischemia-reperfusion injury.

Ischemia-reperfusion injury (IRI), one form of acute kidney failure, often occurs after cardiovascular or renal surgery where there is a decline in blood flow through the kidney. This injury causes damage to renal cells and can lead to the formation of interstitial fibrosis, which will increase the risk of chronic kidney disease. The histone deacetylases (HDAC) protein family controls the expression of genes via epigenetic regulation of deacetylating histone lysine residues. We published that within an hour of bilateral IRI, in male mice, there was an increase of HDAC1 in the epithelium and interstitial cells. Moreover, inhibition of HDAC1 prior to IRI resulted in attenuated interstitial fibrosis. Myofibroblasts secrete collagen contributing significantly to wound healing as well as the development of interstitial fibrosis and these cells are predominantly differentiated fibroblasts and pericytes. We hypothesized that the knockdown of HDAC1 in fibroblasts and pericytes will attenuate interstitial fibrosis in the kidney after IRI. Male control (HDAC1fl/fl) and iFibroblastHDAC1KO (HDAC1fl/fl, Col1A2-CreER, hemizygous mice) were used in the experiment. The mice underwent bilateral renal artery and vein clamping for 18 minutes to induce IRI or sham surgery. Acute kidney injury was confirmed by serum creatinine measurements and determination of glomerular filtration rate (GFR) by transcutaneous FITC-sinistrin clearance 24 hours after injury. GFR was measured weekly for 4 weeks at which point the blood and kidneys were collected for analysis. Renal interstitial fibrosis was quantified by measuring the percentage coverage area of collagen stained by picrosirius red staining. 24 hours after surgery, IRI mice serum creatinine levels were greater in control mice 0.53 mg/dl ± 0.17, n = 9, and iFibHDAC1KO IRI mice 0.25 mg/dl ± 0.053, n = 10, compared to sham mice (control 0.084 mg/dl ± 0.008, n = 5, KO 0.098 mg/dl ± 0.006, n = 4, Pgenotype = 0.3, Psurgery = 0.028, Pinteraction = 0.25). This agreed with the measured GFR that was significantly reduced in the IRI mice (control IRI = 426 ul/min/100g ± 132, KO IRI = 529 ul/min/100g ± 116, Sham control = 1180 ul/min/100g ± 178, sham KO = 1188 ul/min/100g ± 156, Pgenotype = 0.71, Psurgery = 0.0003, Pinteraction = 0.75). The percentage of the collagen-positive area was significantly higher in control than in sham mice (p = 0.0011), while there was no noticeable difference (p = 0.9) between iFibHDAC1KO and sham mice (control IRI = 1.2 % ± 0.2, KO IRI = 0.47% ± 0.12, sham control = 0.35% ± 0.085, sham KO = 0.401% ± 0.073). In conclusion, HDAC1 is activated by IRI in the myofibroblast and promotes interstitial fibrosis. Funding resources: NIH NIDDK R01DK126664, UAB-UCSD O'Brien Center, and the Priya Nagar M.D. Foundation. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Bilateral Renal Vein Thrombosis in Membranous Nephropathy: Hypoalbuminemia Predictive of Venous Thromboembolism in Nephrotic Syndrome

Nephrotic syndrome is a known clinical syndrome in which there is increased permeability in the glomerular basement membrane leading to proteinuria, >3.5g/24h, and hypoalbuminemia. The primary causes of nephrotic syndrome include membranous nephropathy, focal segmental glomerulosclerosis, and minimal change disease. Secondary causes include lupus nephritis, diabetes mellitus, multiple myeloma, amyloidosis, and other systemic conditions.Clinically, nephrotic syndrome presents with edema, hyperlipidemia, and increased risk of thromboembolism, the primary focus of this paper. Nephrotic syndrome is often associated with thromboembolic events, especially in patients with membranous nephropathy. It has been shown that hypoalbuminemia is the most significant independent predictor of venous thromboembolic risk. We present the case of a 32-year-old male who first presented with pleuritic chest pain and was found to have multiple bilateral pulmonary emboli treated with oral anticoagulation. On subsequent visits, prompted by either chest pain or edema, he was found to have increasing pulmonary emboli, as well as downtrending serum albumin levels at each visit. Eventually, bilateral non-occlusive renal vein thrombi were discovered. Lab work indicatedmembranous nephropathy as the most likely etiology secondary to the patient's presentation. Serum anti-phospholipase A2 receptor antibody positivity confirmed the diagnosis, and the patient was treated appropriately.

Double trouble - management of perinephric hematoma and renal vein thrombosis post percutaneous renal biopsy

BackgroundPerforming percutaneous renal biopsy procedures in lupus nephritis (LN) and nephrotic syndrome presents a unique challenge to the nephrologist because of the risk of bleeding from the procedure and the hypercoagulable state in hypoalbuminemia. The management of a patient with venous thrombosis with perinephric hematoma post renal biopsy can be difficult if occurred.Case presentationWe are presenting a case of perinephric hematoma following percutaneous renal biopsy in a 23-year-old man with lupus nephritis, nephrotic syndrome, and lower limbs deep vein thrombosis (DVT). The patient developed persistent frank haematuria, flank pain and acute urinary retention post-procedure. We have withheld his oral warfarin three days before the procedure, and no anticoagulation was given subsequently. Initial CT Angiography (CTA) renal showing stable hematoma and no visible evidence of vascular injury. Three weeks later, the patient still has persistent frank haematuria and a repeated CTA renal revealed new bilateral renal vein thrombosis. Considering the high risk of worsening symptomatic venous thrombosis, we gave subcutaneous enoxaparin sodium and restart oral warfarin despite ongoing haematuria. The frank haematuria resolved within two days of anticoagulation with no radiological evidence of worsening of the perinephric hematoma. The follow-up ultrasonography a month later showed resolution of the hematoma and renal vein thrombosis with no adverse effect.ConclusionOur experience, in this case, highlighted the importance of case selection for percutaneous renal biopsy among high-risk patients. Additionally, a prolonged frank haematuria in post-renal biopsy with nephrotic syndrome warranted a reassessment, as a clinical presentation of post-procedure perinephric hematoma and renal vein thrombosis can overlap. We also demonstrated that restarting anticoagulation earlier than four weeks in a patient with renal vein thrombosis and post-renal biopsy perinephric hematoma can be safe in the selective case.

Variations of Renal Vasculature in Multi Detector Computed Tomography Evaluation of Abdomen

Introduction: Normal vascular supply to each kidney is by a single artery and vein on each side. This normal pattern is not found in all cases. Arterial variations can be accessory renal arteries which can be hilar, upper polar or lower polar and early branching. Venous variations can be late confluence, multiple renal veins and on left there can be retroaortic or circumaortic course of the left renal vein.&#x0D; Aims: To evaluate renal vasculature variations in patients who undergo contrast enhanced MultiDetector Computed Tomography of the abdomen.&#x0D; Methods: This was a hospital based cross sectional study done in 290 consecutive patients who underwent contrast enhanced Multi Detector Computed Tomography abdomen in Nepalgunj Medical College. Normal as well as variations in renal vasculature was evaluated.&#x0D; Results: Total of 158 (54.48%) cases had normal arterial supply. Out of 132 cases with renal arterial variation, 96 cases (72.7%) were unilateral and early branching was the most common unilateral renal arterial variation (36.4%) followed by upper polar (20.8%), lower polar (20.8%) and hilar (16.6%) arteries. Concurrent upper and lower polar arteries and combined early branching and lower polar arterial system were the most common multiple unilateral renal arterial variation seen in 2.08% cases respectively. 36 (27.27%) cases had bilateral renal arterial variations. Most cases had early branching in bilateral renal arteries seen in 9.09% cases. Venous variations were seen in 11.03%.Late confluence was the most common variation seen in 62.5% cases with variations. Rest were multiple renal veins. Left sided retroaortic and circumaortic course and bilateral renal vein variations were not found in our study.&#x0D; Conclusion: Renal vasculature variations were frequently observed in routine contrast enhanced Multi Detector Computed Tomography evaluation of abdomen. Renal arterial variation was more common than venous variations. Unilateral variations were more common than bilateral.

The value of repeat kidney biopsy during an atypical course of membranous nephropathy

BackgroundThe clinical trajectory for patients with primary membranous nephropathy ranges widely from spontaneous remission to a rapid decline in kidney function. Etiologies for rapid progression with membranous nephropathy include concurrent bilateral renal vein thrombosis, malignant hypertension, and crescentic membranous nephropathy. Given the wide heterogeneity in prognosis, timing of immunosuppressive therapy is often challenging and centers around an individual patient’s perceived risk for rapidly progressive disease.Case presentationHerein, we describe the clinical course of a young patient who initially developed a typical presentation of membranous nephropathy with consistent kidney biopsy findings. Given clinical stability, a six month observation period was undertaken prior to initiating immunosuppression. Within this observation window, the patient developed community acquired pneumonia followed several weeks later by a sudden, rapid decline in kidney function requiring dialysis. Repeat kidney biopsy revealed post-infectious glomerulonephritis superimposed upon a background of membranous nephropathy. Immunosuppressive therapy resulted in a favorable long-term outcome with normalization of kidney function and remission of nephrotic syndrome. To our knowledge, this is the first report of the simultaneous occurrence of these two glomerular disease processes.ConclusionThis case illustrates the value of repeat kidney biopsy during an atypical course of membranous nephropathy. Superimposed glomerular disease processes should be considered during a course of rapidly progressive membranous nephropathy.

Evaluation of renal vascular variations with computed tomography

BackgroundIt is important to know the renal vascular variations before renal surgeries and invasive procedures. The aim of this study is to evaluate the prevalence and types of variation of renal arteries and veins.MethodsThe abdominal CT images of 460 patients, taken between 2019 and 2021, were retrospectively analyzed in axial and coronal planes. The presence and number of accessory renal arteries and early branching in the main renal artery were evaluated. Then, bilateral renal vein variations were investigated. Finally, the compression of the left renal vein by different anatomical structures was evaluated.ResultsOf the 450 patients included in the study, the mean age was 53 years. No variations were detected in 378 renal arteries on the right side (84%) and 392 renal arteries on the left side (87.1%). The most common variation in renal arteries was an accessory inferior hilar artery in 7.5% and 6% rates on the right and left, respectively. An accessory inferior renal polar artery was observed at an overall rate of 1.3%. An accessory superior renal hilar artery was found at 3.3% and 2% rates on the left and the right, respectively. An accessory superior renal polar artery was found at an overall rate of 3.5%. Multiple variations in the renal arteries were observed at a rate of 6.4%. Early branching was observed at a rate of 4.9% on the right and 2.2% on the left. The presence of two and three right renal veins was observed at rates of 13.1% and 0.6%, respectively. Retroaortic and circumaortic left renal veins were found at 3.5% and 4.4% rates, respectively. The compression on the anterior and posterior left renal veins was observed at 4.6% and 0.9% rates, respectively.ConclusionConsidering that variations in renal arteries and veins are too many and of different types to underestimate, a CT examination for the renal vascular anatomy before and at the planning phase of renal surgery or interventional procedures will be of great benefit to avoid potential complications.

MP20-02 PROTECTIVE ROLE OF METFORMIN IN ACUTE RENAL ISCHEMIC REPERFUSION INJURY

You have accessJournal of UrologyCME1 May 2022MP20-02 PROTECTIVE ROLE OF METFORMIN IN ACUTE RENAL ISCHEMIC REPERFUSION INJURY Junrong Zou, Xiaofeng Zou, Guoxi Zhang, Kecheng Lou, Shangzhi Feng, Guancheng Xiao, and Hailan He Junrong ZouJunrong Zou More articles by this author , Xiaofeng ZouXiaofeng Zou More articles by this author , Guoxi ZhangGuoxi Zhang More articles by this author , Kecheng LouKecheng Lou More articles by this author , Shangzhi FengShangzhi Feng More articles by this author , Guancheng XiaoGuancheng Xiao More articles by this author , and Hailan HeHailan He More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To figure out the role of metformin in acute renal ischemic reperfusion (IR) injury. METHODS: HK-2 cell was treated with, PBS, metformin, 3MA and rapamycin. Western-blot was used to observe cell autophagy and apoptosis level. 15 C57 mice were divided randomly into Control group, IR group, IR+ 3-MA group, IR+ rapamycin group, IR+ metformin group, with 3 mice in each group. In this research, the IR mouse model was established through clamping the bilateral renal artery and vein for 20min. The above mice were treated with PBS, metformin (200mg/kg), 3-MA (30mg/kg) and rapamycin (1mg/kg) by intraperitoneal injection respectively. All the mice were sacrificed after anesthesia 24h later, serum, the kidney was obtained for sequent experiments. The kidney was divided into two parts, one of which was fixed by 2.5% glutaraldehyde for autophagosome and apoptosis body observation under electron microscope, the other part was fixed by 10% formalin for the later histological experiments, including IHC, TUNEL staining and H&E.This study was approved by the Hospital Ethics Committee. RESULTS: Metformin inhibits autophagy and apoptosis level in HK-2 cell. In the IR model, metformin showed a more effective protective role compared to 3-MA and control group. After metformin treatment, IHC staining showed less LC3B and cleaved-caspase3 expression, and LAMP2 (lysosome) expression was inhibited. Metformin decreased serum creatinine and β2-microglobulin. TUNEL staining showed apoptosis level decreased after metformin treatment. We also observed decreased autophagosome and apoptosis body in metformin group through electron microscope scan. In addition, H&E staining showed kidney necrosis was inhibited after metformin treatment. CONCLUSIONS: Altogether, in this research, we established IR mouse model of kidney stone. We firstly found metformin inhibits autophagy and apoptosis in renal cell, which indicated metformin plays a protective role of metformin in acute renal ischemic reperfusion injury. Source of Funding: National Natural Science Foundation of China (81860456, 81760462) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e317 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Junrong Zou More articles by this author Xiaofeng Zou More articles by this author Guoxi Zhang More articles by this author Kecheng Lou More articles by this author Shangzhi Feng More articles by this author Guancheng Xiao More articles by this author Hailan He More articles by this author Expand All Advertisement PDF DownloadLoading ...

Bilateral extra‐renal pelvises and calyxes with additional renal blood vessel variations identified in a single prosected medical school donor body

While there are relatively commonly observed, reported anatomical variations associated with the posterior abdominal wall, especially with the kidneys, we report here over a dozen variations in one prosected medical school donor body (Caucasian, male, age 87, cause of death: sepsis). These variations could contribute significantly to negative outcomes, especially in surgical procedures. During a routine dissection, we found bilateral extra‐renal pelvises. In the right kidney, there were two extra‐renal major calyxes, and five extra‐renal minor calyxes (two extra‐renal minor calyxes from the superior major calyxes, and three extra‐renal minor calyxes from inferior major calyxes). In the left kidney, there were four extra‐renal major calyxes and two extra‐renal minor calyxes off the most inferior major calyx. In addition, we found four venous variations and four arterial anomalies including one in a major artery. Namely, there were bilateral accessory renal veins found at the hilum that drained into the posterior aspect of the inferior vena cava. There was an additional accessory left renal vein that drained into the left renal vein, at the junction of the left testicular and left suprarenal veins. There was also a left lumbar vein that drained into one of the accessory left renal veins. Regarding the arterial supply to the kidneys, there were two polar right renal arteries directly off the abdominal aorta in addition to two long hilar right renal arteries, and three left hilar renal arteries that branched individually from the abdominal aorta. Finally, there was a long left common iliac artery compared to the right common iliac artery. Anatomical variations within patients can be of no significance or can turn a routine surgical procedure into a hazardous process if unrecognized at the time of intervention. Further documentation of such anatomical variations in prosected donor bodies can further inform surgeons for the need for imaging prior to various surgical procedures.

POS-100 THE VALUE OF REPEAT KIDNEY BIOPSY WHEN THE COURSE OF MEMBRANOUS NEPHROPATHY IS ATYPICAL

The clinical trajectory for patients with primary membranous nephropathy ranges widely from spontaneous remission to rapid declining kidney function. Etiologies for rapid progression with membranous nephropathy include concurrent bilateral renal vein thrombosis, malignant hypertension, and crescentic membranous nephropathy. Given the wide heterogeneity in prognosis, timing of immunosuppressive therapy is often challenging and centers around an individual patient’s perceived risk for rapidly progressive disease.

Case of COVID-19 and Acute Pancreatitis: A Case Report

Background: Respiratory symptoms, including cough, shortness of breath, and fever, have been reported to be the most common symptoms of Coronavirus disease (COVID-19). However, extra respiratory symptoms, such as gastrointestinal manifestations, have also been reported. Case Presentation: In our paper, we report a case of a 32-year-old African female patient with no previous medical history who presented to the emergency department with altered mental status for one day. The patient had a history of fever, epigastric pain, decreased oral intake, vomiting, and diarrhea. Initial laboratory findings revealed elevated blood glucose, amylase, lipase, blood urea nitrogen, and creatinine levels. Urine ketones were also positive, and blood gases demonstrated severe metabolic acidosis. The patient was admitted to the intensive care unit as a case of diabetic ketoacidosis, acute kidney injury and acute pancreatitis that was later confirmed by computed tomography imaging, where it revealed bilateral renal vein thrombosis with left kidney infarction. Additionally, reverse transcriptasepolymerase chain reaction (RT‒PCR) confirmed COVID-19. The patient improved significantly following conservative management and anticoagulation and was discharged home. Conclusion: Our case demonstrates the importance of considering COVID-19 as a possible cause of acute pancreatitis and that acute kidney infarctions should be part of the differential diagnosis of acute kidney injury in patients who are COVID-19 positive.

A Novel Use of Suction Thrombectomy for Embolic Protection During Mechanical Ileocaval Thrombectomy

We have reported on a novel use of the AngioVac suction thrombectomy device (AngioDynamics, Latham, NY) for vacuum-assisted embolic protection in a case of extensive mechanical thrombectomy of a caval–visceral deep vein thrombosis (DVT) that was refractory to standard catheter-directed thrombolysis. To the best of our knowledge, this is the first report of the use of a vacuum-assisted suction thrombectomy device for successful embolic protection. A 15-year-old girl had developed extensive, symptomatic bilateral ileocaval and renal vein DVTs refractory to outpatient management with anticoagulation therapy after pharmacomechanical thrombectomy and catheter-directed lysis. Initially, she had been treated successfully with overnight lytic therapy for the ileocaval DVT, and she was discharged with anticoagulation therapy. However, she had presented again with worsening bilateral lower extremity symptoms and kidney injury due to progression of the DVT. To prevent end-organ failure, extensive endovascular mechanical thrombectomy was planned. With the patient's significant thrombus burden through the visceral and retrohepatic inferior vena cava (IVC), pulmonary embolic protection during mechanical thrombectomy was our chief concern. Given the extent of the clot, IVC filter placement was impossible. Therefore, an AngioVac suction thrombectomy cannula and circuit was established via bilateral internal jugular vein access in an attempt to debulk the thrombus from a superior approach and provide pulmonary embolic protection. Mechanical thrombectomy (ClotTriever; Inari Medical, Irvine, Calif) was used to successfully debulk the IVC and bilateral ileofemoral venous segments from the bilateral popliteal veins. Although the use of the AngioVac from above proved unable to debulk the thrombus, it was successful in preventing significant embolism during ClotTriever mechanical thrombectomy (Fig 1). After mechanical thrombectomy (Fig 2), the patient's creatinine had returned to normal. She continued anticoagulation therapy, with Doppler ultrasound imaging showing reduction of the DVT and improvement of her lower extremity symptoms. We believe the present case has illustrated successful pulmonary embolic protection using a large-bore suction thrombectomy device with venoveno bypass during endovascular mechanical thrombectomy of caval, visceral, and bilateral ileofemoral DVTs. The AngioVac cannula and circuit can be safely and effectively used for central embolic protection in the case of large-volume caval mechanical thrombectomy.Fig 2Doppler ultrasound image showing reduction of the deep vein thrombosis (DVT) after mechanical thrombectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

MO322VENOUS THROMBOEMBOLISM AND NEPHROTIC SYDROME: A FAMOUS BUT STILL SURPRISING COUPLE

Abstract Background Venous thromboembolism (VTE) is a multifactorial disorder, accounting for high morbidity and mortality rates, due to a complex interplay of several variables classifiable as inherited (mutated Leiden V factor, prothrombin, protein C, protein S and antithrombin) and acquired (lupus anticoagulants, pregnancy, major surgery procedures, cancer and inflammatory diseases) risk factors. The association of VTE with the nephrotic syndrome, particularly deep vein and renal vein thrombosis (DVT and RVT, respectively) is tightly established. This risk is particularly high in patients with idiopathic membranous nephropathy. In fact, thromboembolic events occur with a frequency between &amp;lt;10% and 45% in this disease. The reason(s) underlying the hypercoagulable status in nephrotic patients are not clearly understood. Multiple hemostatic abnormalities have been described, including decreased levels of antithrombin and plasminogen (due to urinary losses), increased platelet activation, reduced plasminogen activation, overproduction of fibrinogen and factors V and VIII as a compensatory response to hypoalbuminemia. The risk of thrombosis seems to be related to the severity and duration of the nephrotic status and seems to be particularly increased with serum albumin concentrations ≤2.0 g/dl (20 g/L). Case report We report the case of a 28 year-old male with nephrotic syndrome due to membranous nephropathy positive for serum anti-phospholipase-A2 receptor antibody. The patient was asymptomatic for VTE, but abdominal ultrasound showed endoluminal obstruction of both renal veins. Abdominal Computer Tomography confirmed the extensive bilateral renal vein thrombosis and also revealed an extension of the thrombosis to the inferior cava vein and the left common iliac vein. He was treated with low-molecular weight heparin for six months. According to our internal protocol, a complete Thrombophilia Molecular Study was performed and showed a normal Leiden V factor, but a rare homozygous mutation of the G20210A gene encoding for prothrombin. The prevalence of this is less than 5% in the general population, but is highly variable with ethnicity. The G20210A mutation confers a mildly increased thrombotic risk that is amplified by the presence of other risk factors, such as nephrotic syndrome. Conclusions In our case report, the association of a nephrotic syndrome secondary to a primitive membranous glomerulonephritis and the mutation in homozygous of the G20210A prothrombin, a rare mutation associated with a high thrombotic risk, led to a severe VTE in an still asymptomatic 28-year-old patient. Based on this experience, we would highlight the importance of the genetic screening for polymorphisms associated with inherited thrombophilia in nephrotic patients complicated with VTE.

Lycopene Attenuates Hypoxia-Induced Testicular Injury by Inhibiting PROK2 Expression and Activating PI3K/AKT/mTOR Pathway in a Varicocele Adult Rat.

Purpose The aim of this study was to evaluate the effect of lycopene on hypoxia-induced testicular injury in rat model and explore the underlying mechanism. Methods Six-week-old male Wistar rats (n = 36) were randomly divided into three groups (n = 12/group): a normal group (NG, sham control), a varicocele group (VG), and a varicocele treated by lycopene group (VLG). Bilateral renal veins constriction was performed on rats in VG and VLG. Simultaneously, rats in VLG were treated to lycopene by intragastric administration. Four weeks later, sperm was collected for sperm analysis. Testes and epididymides were harvested for morphological change analysis, histologic analysis, ELISA, qRT-PCR, and western blot. Results Our observations were that lycopene improved the hypoxia-induced testicular injury in vivo. Prokineticin 2(PROK2) and prokineticin receptor 2 (PROKR2) were overexpressed in VG (P < 0.01), and lycopene inhibited the PROK2 expression (P < 0.01). Proliferating cell nuclear antigen (PCNA) and sex hormones were increased by lycopene in VLG (P < 0.05). Lycopene restored the quality and activity of sperm by blocking PROK2 expression (P < 0.05). The expression of VEGF was increased, as HIF-1/NF-κB pathway was upregulated in VLG (P < 0.05). Meanwhile, expression of pAKT/AKT in VLG was higher than that in VG (P < 0.05). In addition, lycopene reduced levels of interleukin-1β (IL-1β) and interleukin-2 (IL-2) in VLG (P < 0.05), compared to NG. Conclusions Lycopene improved the hypoxia-induced testicular injury by inhibiting the expression of PROK2 and decreasing levels of IL-1β and IL-2, which might show us a novel and promising treatment for varicocele testicular injury.

Renal Clearance of FGF23 and its Fragments in Humans

Background: Relative abundance of fibroblast growth factor-23 (FGF23) measured by the C-terminal (cFGF23, which measures both intact FGF23 & c-terminal fragments) vs intact (iFGF23, measures only intact hormone) assays varies by kidney function in humans. Differential kidney clearance may explain this. Methods: We measured cFGF23 and iFGF23 in the aorta and bilateral renal veins of 162 patients with essential hypertension undergoing renal angiography. Using multivariable linear regression models, we examined factors associated with aorta to renal vein reduction of FGF23 using both assays. Similar, parameters and urine concentrations were measured in 6 Wistar rats. Results: Mean age was 54±12 years, 54% percent were women, and mean creatinine clearance was 72±48 ml/min/100g. The human kidney reduces the concentrations of both cFGF23 (16±12%) and iFGF23 (21±16%) compared to aorta, but reduction was higher for iFGF23. Greater kidney creatinine and PTH reduction were each independently associated with greater reductions of both cFGF23 and iFGF23. The relative kidney reduction of iFGF23 and cFGF23 appeared stable and consistent across the range of creatinine clearance. Kidney clearance was similar, and urine concentrations of both assays were low in the rat models, suggesting kidney metabolism of both cFGF23 and iFGF23. Conclusions: Renal reduction of iFGF23 is higher than that of creatinine and cFGF23.FGF23 is likely metabolized and cleared through the human kidney tubules, above and beyond glomerular filtration. Kidney clearance of FGF23 does not explain differences in C-terminal and intact moieties across the range of kidney function. Funding: This work was supported by National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) Grants R01DK119528 and K24DK110427 (J.H.I). P30 DK079328, R01 DK091392, R01 DK092461 and R01 DK119528 (O.W.M). Veterans Health Administration IK2-CX002195 (SS). Declaration of Interest: Dr. Ix is principal investigator of an investigator-initiated research grant from Baxter International, serves as a data safety monitoring board member for Sanifit International, and has served on advisory boards for Alpha Young, AstraZeneca, Ardelyx Inc., and Jnana Inc. Dr. Moe has served on advisory boards and received compensations in the last 5 years for Allena, Alnylam, Ardelyx, Applied Therapeutics, Dicerna, Janssen, Genzyme-Sanofi, and Tricida. Remaining authors have declared no conflicts of interest. Ethical Approval: The human renal angiography studies were approved by the medical ethical committee of the Maastricht University Hospital. Animal studies were performed in accordance with the National Institutes for Health’s Guide for Care and Use of Laboratory Animals, and the experimental protocols had gained approval by the VA San Diego Health Care Systems and conducted under their guidelines.

An Extremely Rare Case of Intestinal Malrotation with an Absent Inferior Vena Cava.

We present a case of intestinal malrotation with an absent inferior vena cava, which was found in a cadaver during a dissection course in our medical school. The intestinal malrotation was Amir-Jahed type 2, with the large intestine on the right side and the small intestine on the left side of the abdominal cavity. The descending colon was fixed on the right side of the posterior abdominal wall and continued into the pelvic cavity from the right side. The cadaver also had a venous system anomaly. The pre-renal segment of the inferior vena cava, which is a section between the renal vein and the hepatic vein, was absent. The inferior vena cava connected to the azygos vein after being joined by bilateral renal veins. The only hepatic segment of the inferior vena cava, which was posterior to the liver and received hepatic veins, penetrated the diaphragm and flowed into the right atrium. To our knowledge, this is the first report of these two anomalies appearing concurrently. We discuss the details of this case and the embryological considerations.