Diagnosis of nut‐cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria

Cho, Byoung‐Soo; Choi, You Yeon; Kang, Hyeon-Ho; Park, Seong Jin; Lim, Joo Won; Yoon, Tai Young

doi:10.1093/ndt/16.8.1620

Cited by 42 publications

(59 citation statements)

References 18 publications

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“…The sonographic diagnostic criterion consists of a peak flow velocity ratio between the AMP and hilar portion of the LRV of greater than 5. 40,41 Investigations regarding the use of noninvasive sonographic imaging for the confirmation of the nutcracker phenomenon in children and adults have been performed previously. 10,11,[42][43][44] The scope of this study focused on quantitative description and hemodynamic evaluation of the LRV and on the presence of the nutcracker phenomenon (compression of the LRV between the aorta and superior mesenteric artery) 1,[4][5][6][7][9][10] to establish auxiliary diagnostic leads in the determination of the cause of varicocele using noninvasive sonography.…”

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confidence: 99%

Varicocele and Nutcracker Syndrome

Mohamadi

Ghasemi-Rad

Mladkova

et al. 2010

Journal of Ultrasound in Medicine

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Abbreviations AMP, aortomesenteric portion; ANOVA, analysis of variance; LRV, left renal vein lthough the causes of infertility in men are of various characters and origins (eg, developmental defects and exposure to harmful agents), a substantial proportion, especially secondarily infertile men, have the clinically detectable and correctable vascular abnormality varicocele.Despite various theories, the underlying cause of varicocele remains enigmatic. The role of intrinsic anatomic differences between the left and the right renal vein drainage systems has been implicated in the development of this condition. A greater length of the left internal spermatic vein in comparison with the right system and higher venous pressure on the left side caused by the junction of the left internal spermatic vein with the left renal vein (LRV) at a right angle are the most commonly considered factors because they lead to subsequent propagation of the elevated pressure to the left scrotal vein 1 and possibly determine the onset of varicocele. A ArticleObjective. Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome. Methods. A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured. Results. A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both). Conclusions. Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.

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Varicocele and Nutcracker Syndrome

Mohamadi

Ghasemi-Rad

Mladkova

et al. 2010

Journal of Ultrasound in Medicine

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“…15 For diagnosing pediatric patients, we prefer to use the combined cutoff level as described above 5 because this approach has been used to diagnose children in previous studies and has the highest reported sensitivity and specificity. 5,8 Our patient experienced a sudden onset of gross hematuria, without proteinuria, after exercise. Causes of hematuria other than NCP, such as infection, urolithiasis, and glomerulonephritis, were excluded by the clinical and laboratory findings.…”

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confidence: 87%

“…Conservative treatment is adequate if the symptoms are mild, but in cases of massive hematuria and abdominal and flank pain, which are probably caused by ureteral passage of blood clots, surgical intervention is indicated. 2 The hematuria accompanying NCP is sometimes associated with proteinuria [7][8][9] and may result from increased pressure on the LRV, causing microruptures of thin-walled veins into the renal collecting system or the caliceal fornix or communication between dilated venous sinuses and adjacent renal calyces. 8,10 Because the hematuria caused by NCP is nonglomerular, erythrocytes in the urine are isomorphic on phase-contrast microscopic examination.…”

Section: Discussionmentioning

confidence: 99%

“…2 Erect posture of a patient with NCP can close this angle even further, leading to renal congestion and orthostatic proteinuria or hematuria. 8 In the past, the most widely used means of diagnosing NCP was renal venography, and an increased pressure gradient between the LRV and the inferior vena cava (normal, < 1 mm Hg) was considered to indicate clinically significant NCP. 13 More recently, Doppler sonography has been used for the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…8 Thus, the sampling area of the LRV is smaller and the Doppler angle larger in children than in adults, making Doppler measurements in pediatric patients difficult. To date, diagnostic criteria for childhood NCP have not been established.…”

Section: Discussionmentioning

confidence: 99%

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Doppler sonographic indices in diagnosing the nutcracker phenomenon in a hematuric adolescent

Kavukçu

Kasap

Göktay

et al. 2003

J of Clinical Ultrasound

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Compression of the left renal vein between the aorta and the superior mesenteric artery, known as the nutcracker phenomenon, may cause gross or microscopic hematuria, pain in the flank, proteinuria, or a combination of these symptoms. We report the case of a hematuric adolescent diagnosed with a high index of suspicion by noninvasive Doppler sonography using the diagnostic indices of Doppler sonography established for adults with hematuria. Compression of the patient's left renal vein at the aortomesenteric portion and dilatation at the hilar portion were visualized by magnetic resonance angiography, which verified the diagnosis.

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Abdominal Vessels

Rasmussen¹

2015

Diagnostic and Interventional Ultrasound in Pediatrics and Pediatric Surgery

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Diagnosis of nut‐cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria

Abstract: NCP may be one of the leading causes of orthostatic proteinuria, and non-invasive renal Doppler US may be a useful diagnostic tool in the screening of NCP. In the future, the diagnostic criteria of NCP must be redefined in children.

Cited by 42 publications

References 18 publications

Varicocele and Nutcracker Syndrome

Varicocele and Nutcracker Syndrome

Doppler sonographic indices in diagnosing the nutcracker phenomenon in a hematuric adolescent

Abdominal Vessels

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