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Renal function after ligation of right renal vein
RENAL FUNCTION
AFTER LIGATION
OF RIGHT RENAL VEIN U. S. PATY, M.D.
L. R. ABEYATUNGE,
M.D.
M. L. KAMATH, M.D. G. K. LINDSAY, G. J. WISE,
M.D.
M.D.
From the Division of Urology, Department of Surgery, Coney Island Hospital/Affiliated with Maimonides Medical Center, Brooklyn, New York
- Renal function following the ligation of the right renal vein has never been reported in man. This case report shows adequate renal function after ligation of the right renal vein fm trauma. The functional recovery of the kidney because of adequate collaterals gives an ample testimony fn- not sacri$cing the kidney.
ABSTRACT
It is widely believed that the sudden occlusion of the main renal vein will result in hemorrhagic infarction and loss of kidney function, particularly on the right side where there is minimal collateral circulation.‘*Z This has not necessarily been the case with the left kidney which has more extensive collateral circulation. l-4 There have been no clinical reports as to the function of the right kidney following sudden occlusion of the right renal vein. The following case report documents the effect of sudden right renal vein ligation on the kidney function. Case Report A twenty-year-old Chinese boy was brought to the Coney Island Hospital with a gunshot wound of the abdomen, On arrival the patient was conscious and oriented. His pulse rate was 96 per minute, respiration 22 per minute, blood pressure of llW80 mm. Hg, central venous pressure 14 to 15 cm.; peripheral pulses were palpable. The bullet was felt under the subcutaneous tissue on the right paraspinous region. Laboratory investigation showed urine analysis from the Foley catheter to be clear, no sugar or acetone, white blood cells 10 to 15, red blood cells 10 to 15,
UROLOGY
/
JANUARY 1975
/
VOLUME V, NUMBER 1
specific gravity 1.021, hemoglobin 14.8 Gm. per 100 ml., hematocrit 41.1. X-ray study revealed a foreign body (bullet) in the abdomen. The right psoas shadow was indistinctly seen in its upper part. Intravenous pyelogram revealed a normally functioning urinary tract (Fig. 1A). Because of the acute abdominal signs, an exploratory laparotomy was performed the same day, and the following conditions were noted: (1) A through-and-through laceration of the left lobe of the liver and laceration of the inferior surface of the liver, (2) a through-andthrough laceration of the second part of the duodenum (Fig. lB), (3) a nonexpanding retroperitoneal hematoma, and (4) laceration of the inferior vena cava and the right renal vein. The tear was about 2 to 3 cm. in size at the junction of the renal vein with the inferior vena cava (Fig. 1C). The renal vein was the single main vein, and there were no accessory veins joining the kidney with the inferior vena cava. Repair of the lacerations of the liver and duodenum and of the inferior vena cava were made. Every attempt was made to suture the right renal vein to the inferior vena cava, but technically this was not possible. The right renal
95
(A) Foreign body in abdomen and normally functioning urinary tract. (B) Laceration of second part of duodenum and inferior surface of liver; (C) tear of renal vein atjunction of inferior vena cava.
~111wa\ irgated cjl)\, to the inferior vena cava, illaving tlrchright kidn: y in situ; the right sperma!ic vein drained direc*tly into the vena cava. The patient’s postoperative course was satisfactory. Laboratory dat;i on the fifth postoperative day revealed hematocrit 34.7, blood urea nitrogen 21 nrg. and creatinine 1.3 mg. per 100 ml. The urinary output was 1,775 ml. on the first postoperative day, 2,200 on the second, and 1,100
FIGURE 2. lntravenous pyelogram on ninth postoperative day showing no right kidney function.
on the fourth day. Urine analysis on the second postoperative day revealed a specific gravity of 1.022, protein 3 plus, glucose negative, ketone moderate, white blood cells 0 to 4, red blood cells 10 to 15, and few epithelial cells. Electrolytes done on the third postoperative day of the twenty-four-hour urine showed a volume of 3,240 ml., sodium 147 mEq. and chloride 120 mEq. A drip intravenous pyelogram on the third postoperative day and an intravenous pyelogram on the ninth postoperative day showed no right kidney function (Fig. 2). Renal flow study with 15 mc. 99Tc 04 showed some activity in the right _renal area which probably represents the right kidney uptake (Fig. 3A). Renal scan on the ninth postoperative day with 220 mc. lv7Hg showed absence of the right renal uptake (Fig. 3B). The bullet was removed from the subcutaneous tissue on the ninth postoperative day under local anesthesia, and the patient was discharged three days later on an outpatient basis. Intravenous pyelogram performed after three-and-one-half months showed the right kidney to be smaller than the left and well outlined (Fig. 4A). A prompt excretion of dye on both sides and no obstructive uropathy in either kidney were noted. The patient was admitted again approximately four-and-one-half months after injury for further work-up. At the time of this admission his general condition was good, blood pressure 110170 mm. Hg, hematocrit 39.6, blood urea nitrogen 18.1 mg. per 100 ml., electrolytes were within normal limits. Urinalysis showed a specific gravity of 1.025, no protein, no sugar, no ketone, white and red blood cells 0 to 1, and few epithehal cells. Renal arteriogram showed a contracted right kidney (Fig. 4B and C); the venous return
UROLOGY
i JANUARY1975
i VOLUME~,NUMBEH
I
FIGURE 3. (A) Rend jbw study with 15 mc. gSrc 04 showing some activity in right renal area which probably represents right kidney uptake. (B) Renal scan on ninth postoperative day showing absence of right renal uptake (anterior view). through the lumbar venous plexus, An excretory urogram showed a normal collecting system. A renal scan with 220 mc. lg7Hg showed a normal left kidney, poorly functioning right kidney, with changes probably secondary to surgical intervention (Fig. 5A). A renal flow study with 15 mc. ‘STc 04 showed the circulation occurring promptly to the right kidney, compared with the study of August, 1973; the left side was normal (Fig. 5B). The pattern of perfusion to the right kidney showed a rapidly filling central area and a delayed filling of the rest of the parenchyma. A cystoscopic examination revealed a normal bladder. The ureteric orifices were normal in shape, size, and position, with clean effhrx. A right retrograde catheterization with a no. 5 ureter catheter up to 18 cm. was done without difficulty; a normal drip was obtained. A twenty-four-hour urine collection from the right ureter showed a creatinine clearance of 54 ml. per minute. was
Anatomy Normally, the right renal vein is smaller than the left; usually it is one, rarely multiple. The venous return from the right kidney is through the following ways:5 (1) the right renal vein joining the inferior vena cava; (2) the capsular veins of the right kidney from the right suprarenal vein which in turn drains into the inferior vena
UROLOGY
/ JANUARY1975
/ VOLUMEV,NUMBER~
cava; (3) capsular veins of the kidney join the internal spermatic vein (ovarian) which drain into the inferior vena cava; (4) the renal vein receives one or two small ureteral veins running along the upper portion of the ureter. The right ureteric veins also get communication from the internal spermatic vein and capsular vein, and (5) the capsular vein communicates with the subcapsular veins of the kidney and also with the lumbar veins. Comment Infarction of the kidney may occur following acute thrombosis of the renal vein. 4 Rupture of the renal capsule and retroperitoneal extravasation of blood is common. The thrombosis usually extends, involving the tributary veins of the collateral venous circulation. A similar sequence of events is expected following surgical ligation of the renal vein6 but this may not be so because of collateral venous circulation adequate enough for maintaining normal renal function. This has been shown in the past where the left renal vein has been ligated without causing any damage to the left kidney.4 This could be possible because of adequate collateral venous communications of the left kidney entering lateral to the tip of the transverse processes. The collateral communications of the right kidney with the inferior vena
97
pyelogram performed three-and-one-half months postoperatively showing right FIGURE 4. (A) lntravenous (R i kidney to be smaller than left, well outlined; prompt excretion of dye on both sides, no obstructive uropathy Flush study showing contracted right kidney. (C) Selective angiogram showing contracted tight kidney, note venous phase of filling and venous collaterals.
FIGXJRE 5. (A) Renal scan showing normal left kidney, sho wing circulation occurring promptly to right kidney.
pool ply functioning
right kidney.
(B) Renal flow study
include the internal spermatic (ovarian), ureteral, lumbar, and capsular veins of the kidney. The capsular veins in turn communicate with the subcapsular veins of the kidney. This shows that the collateral circulation of the right kidney is much less extensive compared with the left kidney; thus the site of ligation of the right renal vein, either at the hilum or immediately adjacent to the inferior vena cava, is of little significance. Surgical ligation of the right renal vein, as seen in this case, has shown us that even though there were some structural changes in the right kidney, the function of that kidney was retained. This kidney was fortuitously not sacrificed.
cava
vein has been ligated in man without producing renal death or extensive functional changes. and it is ample testimony for not sacrificing the kidney. v
Brooklyn,
References 1. ANSON,B., CAIJLDWELL, E., and PICU, J.:
2. 3.
Conclusion
4.
The left kidney will continue to function even after ligation of the left renal vein, presumably because of collateral effect.4 The right renal function following renal vein ligation in man has never before been reported in the world literature. This is the first case in which the right renal
UROLOGY / JANUARY1975 /
VOLUMEV, NUMBER 1
909 49th Street New York 11219 (DR. PATY)
5.
The blood supply of the kidney, suprarenal gland and associated structures, Surg. Gynecol. Obstet. 85: 313 (1947). IDEM: The anatomy of the pararenal system of veins with comments on renal arteries, J. Urol. 60: 714 (1948). ERLIK, D., BARZILAI, A., and SHRAMEK,A.: Renal function after left renal vein ligation, ibid. 93: 540 (1965). GONZALEZ,E., LEITER, E., JEMERIN,E. E., andBm~~LER, H.: Renal survival after renal vein ligation, J.A.M.A. 200: 259 (1967). HOLLINSHEAD,H., and MCFARLANE, J. A.: The collateral venous drainage from the kidney following occlu-
sion of renal vein in the dog, Surg. Gynecol. Obstet. 97: 213 (1953). 6. COX, J., et al. : Collateral circulation after renal vein occlusion, Surgery, 52: 875 (1962).
99
AFTER LIGATION
OF RIGHT RENAL VEIN U. S. PATY, M.D.
L. R. ABEYATUNGE,
M.D.
M. L. KAMATH, M.D. G. K. LINDSAY, G. J. WISE,
M.D.
M.D.
From the Division of Urology, Department of Surgery, Coney Island Hospital/Affiliated with Maimonides Medical Center, Brooklyn, New York
- Renal function following the ligation of the right renal vein has never been reported in man. This case report shows adequate renal function after ligation of the right renal vein fm trauma. The functional recovery of the kidney because of adequate collaterals gives an ample testimony fn- not sacri$cing the kidney.
ABSTRACT
It is widely believed that the sudden occlusion of the main renal vein will result in hemorrhagic infarction and loss of kidney function, particularly on the right side where there is minimal collateral circulation.‘*Z This has not necessarily been the case with the left kidney which has more extensive collateral circulation. l-4 There have been no clinical reports as to the function of the right kidney following sudden occlusion of the right renal vein. The following case report documents the effect of sudden right renal vein ligation on the kidney function. Case Report A twenty-year-old Chinese boy was brought to the Coney Island Hospital with a gunshot wound of the abdomen, On arrival the patient was conscious and oriented. His pulse rate was 96 per minute, respiration 22 per minute, blood pressure of llW80 mm. Hg, central venous pressure 14 to 15 cm.; peripheral pulses were palpable. The bullet was felt under the subcutaneous tissue on the right paraspinous region. Laboratory investigation showed urine analysis from the Foley catheter to be clear, no sugar or acetone, white blood cells 10 to 15, red blood cells 10 to 15,
UROLOGY
/
JANUARY 1975
/
VOLUME V, NUMBER 1
specific gravity 1.021, hemoglobin 14.8 Gm. per 100 ml., hematocrit 41.1. X-ray study revealed a foreign body (bullet) in the abdomen. The right psoas shadow was indistinctly seen in its upper part. Intravenous pyelogram revealed a normally functioning urinary tract (Fig. 1A). Because of the acute abdominal signs, an exploratory laparotomy was performed the same day, and the following conditions were noted: (1) A through-and-through laceration of the left lobe of the liver and laceration of the inferior surface of the liver, (2) a through-andthrough laceration of the second part of the duodenum (Fig. lB), (3) a nonexpanding retroperitoneal hematoma, and (4) laceration of the inferior vena cava and the right renal vein. The tear was about 2 to 3 cm. in size at the junction of the renal vein with the inferior vena cava (Fig. 1C). The renal vein was the single main vein, and there were no accessory veins joining the kidney with the inferior vena cava. Repair of the lacerations of the liver and duodenum and of the inferior vena cava were made. Every attempt was made to suture the right renal vein to the inferior vena cava, but technically this was not possible. The right renal
95
(A) Foreign body in abdomen and normally functioning urinary tract. (B) Laceration of second part of duodenum and inferior surface of liver; (C) tear of renal vein atjunction of inferior vena cava.
~111wa\ irgated cjl)\, to the inferior vena cava, illaving tlrchright kidn: y in situ; the right sperma!ic vein drained direc*tly into the vena cava. The patient’s postoperative course was satisfactory. Laboratory dat;i on the fifth postoperative day revealed hematocrit 34.7, blood urea nitrogen 21 nrg. and creatinine 1.3 mg. per 100 ml. The urinary output was 1,775 ml. on the first postoperative day, 2,200 on the second, and 1,100
FIGURE 2. lntravenous pyelogram on ninth postoperative day showing no right kidney function.
on the fourth day. Urine analysis on the second postoperative day revealed a specific gravity of 1.022, protein 3 plus, glucose negative, ketone moderate, white blood cells 0 to 4, red blood cells 10 to 15, and few epithelial cells. Electrolytes done on the third postoperative day of the twenty-four-hour urine showed a volume of 3,240 ml., sodium 147 mEq. and chloride 120 mEq. A drip intravenous pyelogram on the third postoperative day and an intravenous pyelogram on the ninth postoperative day showed no right kidney function (Fig. 2). Renal flow study with 15 mc. 99Tc 04 showed some activity in the right _renal area which probably represents the right kidney uptake (Fig. 3A). Renal scan on the ninth postoperative day with 220 mc. lv7Hg showed absence of the right renal uptake (Fig. 3B). The bullet was removed from the subcutaneous tissue on the ninth postoperative day under local anesthesia, and the patient was discharged three days later on an outpatient basis. Intravenous pyelogram performed after three-and-one-half months showed the right kidney to be smaller than the left and well outlined (Fig. 4A). A prompt excretion of dye on both sides and no obstructive uropathy in either kidney were noted. The patient was admitted again approximately four-and-one-half months after injury for further work-up. At the time of this admission his general condition was good, blood pressure 110170 mm. Hg, hematocrit 39.6, blood urea nitrogen 18.1 mg. per 100 ml., electrolytes were within normal limits. Urinalysis showed a specific gravity of 1.025, no protein, no sugar, no ketone, white and red blood cells 0 to 1, and few epithehal cells. Renal arteriogram showed a contracted right kidney (Fig. 4B and C); the venous return
UROLOGY
i JANUARY1975
i VOLUME~,NUMBEH
I
FIGURE 3. (A) Rend jbw study with 15 mc. gSrc 04 showing some activity in right renal area which probably represents right kidney uptake. (B) Renal scan on ninth postoperative day showing absence of right renal uptake (anterior view). through the lumbar venous plexus, An excretory urogram showed a normal collecting system. A renal scan with 220 mc. lg7Hg showed a normal left kidney, poorly functioning right kidney, with changes probably secondary to surgical intervention (Fig. 5A). A renal flow study with 15 mc. ‘STc 04 showed the circulation occurring promptly to the right kidney, compared with the study of August, 1973; the left side was normal (Fig. 5B). The pattern of perfusion to the right kidney showed a rapidly filling central area and a delayed filling of the rest of the parenchyma. A cystoscopic examination revealed a normal bladder. The ureteric orifices were normal in shape, size, and position, with clean effhrx. A right retrograde catheterization with a no. 5 ureter catheter up to 18 cm. was done without difficulty; a normal drip was obtained. A twenty-four-hour urine collection from the right ureter showed a creatinine clearance of 54 ml. per minute. was
Anatomy Normally, the right renal vein is smaller than the left; usually it is one, rarely multiple. The venous return from the right kidney is through the following ways:5 (1) the right renal vein joining the inferior vena cava; (2) the capsular veins of the right kidney from the right suprarenal vein which in turn drains into the inferior vena
UROLOGY
/ JANUARY1975
/ VOLUMEV,NUMBER~
cava; (3) capsular veins of the kidney join the internal spermatic vein (ovarian) which drain into the inferior vena cava; (4) the renal vein receives one or two small ureteral veins running along the upper portion of the ureter. The right ureteric veins also get communication from the internal spermatic vein and capsular vein, and (5) the capsular vein communicates with the subcapsular veins of the kidney and also with the lumbar veins. Comment Infarction of the kidney may occur following acute thrombosis of the renal vein. 4 Rupture of the renal capsule and retroperitoneal extravasation of blood is common. The thrombosis usually extends, involving the tributary veins of the collateral venous circulation. A similar sequence of events is expected following surgical ligation of the renal vein6 but this may not be so because of collateral venous circulation adequate enough for maintaining normal renal function. This has been shown in the past where the left renal vein has been ligated without causing any damage to the left kidney.4 This could be possible because of adequate collateral venous communications of the left kidney entering lateral to the tip of the transverse processes. The collateral communications of the right kidney with the inferior vena
97
pyelogram performed three-and-one-half months postoperatively showing right FIGURE 4. (A) lntravenous (R i kidney to be smaller than left, well outlined; prompt excretion of dye on both sides, no obstructive uropathy Flush study showing contracted right kidney. (C) Selective angiogram showing contracted tight kidney, note venous phase of filling and venous collaterals.
FIGXJRE 5. (A) Renal scan showing normal left kidney, sho wing circulation occurring promptly to right kidney.
pool ply functioning
right kidney.
(B) Renal flow study
include the internal spermatic (ovarian), ureteral, lumbar, and capsular veins of the kidney. The capsular veins in turn communicate with the subcapsular veins of the kidney. This shows that the collateral circulation of the right kidney is much less extensive compared with the left kidney; thus the site of ligation of the right renal vein, either at the hilum or immediately adjacent to the inferior vena cava, is of little significance. Surgical ligation of the right renal vein, as seen in this case, has shown us that even though there were some structural changes in the right kidney, the function of that kidney was retained. This kidney was fortuitously not sacrificed.
cava
vein has been ligated in man without producing renal death or extensive functional changes. and it is ample testimony for not sacrificing the kidney. v
Brooklyn,
References 1. ANSON,B., CAIJLDWELL, E., and PICU, J.:
2. 3.
Conclusion
4.
The left kidney will continue to function even after ligation of the left renal vein, presumably because of collateral effect.4 The right renal function following renal vein ligation in man has never before been reported in the world literature. This is the first case in which the right renal
UROLOGY / JANUARY1975 /
VOLUMEV, NUMBER 1
909 49th Street New York 11219 (DR. PATY)
5.
The blood supply of the kidney, suprarenal gland and associated structures, Surg. Gynecol. Obstet. 85: 313 (1947). IDEM: The anatomy of the pararenal system of veins with comments on renal arteries, J. Urol. 60: 714 (1948). ERLIK, D., BARZILAI, A., and SHRAMEK,A.: Renal function after left renal vein ligation, ibid. 93: 540 (1965). GONZALEZ,E., LEITER, E., JEMERIN,E. E., andBm~~LER, H.: Renal survival after renal vein ligation, J.A.M.A. 200: 259 (1967). HOLLINSHEAD,H., and MCFARLANE, J. A.: The collateral venous drainage from the kidney following occlu-
sion of renal vein in the dog, Surg. Gynecol. Obstet. 97: 213 (1953). 6. COX, J., et al. : Collateral circulation after renal vein occlusion, Surgery, 52: 875 (1962).
99