Thread by @gag_aggarwal

#ECNeph we chickened out-> went with MR Urography - here are the images. Don't we hate interpreting MRI, any takers?

https://twitter.com/gag_aggarwal/status/1324385824662716416

#ECNeph MRI -> Possible Thrombus in the infrahepatic IVC extending into Bilateral renal veins. Mod to marked HDN of Rt Kidney showing heterogenous filling defects with Haemorrhage and fluid levels in the dilated system. Rest Abd- unremarkable

#ECNeph MRI findings confirmed with a Venous doppler->Infrahepatic IVC and B/l renal veins visualized with absent colour flow s/o Thrombus. Portal Vein, Rt and Lt portal Branches, Splenic veins were all normal.
Now what? Please suggest further workup?

#ECNeph Causes of B/L Veinous Thrombosis. ACUTE RVT ->trauma, severe dehydration or genralized hypercoagulable state. Uncommonly- Nephrotic Syndrome. The work up list is endless
Source uptodate.com/contents/overv…

#ECNeph B/L Renal Vein Thrombosis work up on this patient

#ECNeph B/L RVT -> No cause found. Possibly Traumatic?
Treatment options, LETS DISCUSS #ECNeph Oral and parenteral Direct Thrombin inhibitors/Factor Xa inhibitors have not been well studied in the setting of Nephrotic syndrome or AKI

#ECNeph Treated with Unfractionated Heparin -> AKI improved, Creat 4.2 to 2.0mg/dl, No hematuria. Planned to Discharge on Warfarin
Patient lives in a remote village in Bihar, cannot get repeated INR tests done for Warfarin monitoring.

#ECNeph Started him on Apixaban 2.5mg twice a day
ahajournals.org/doi/10.1161/CI…
ncbi.nlm.nih.gov/pmc/articles/P…
in clinical practice we do what we do

Have you tried OACs other than Warfarin in your CKD population? #ECNeph

#ECNeph Follow up-> Pt returned 3 months later -> Loss of weight, Persistent Hematuria, Drop in Hemoglobin (Hb-6.0g/dl); Worsening renal functions (Creatinine-2.5mg/dl). We missed something! maybe you were all right

#ECNeph Repeat MR Urography -> Expansile enhancing thrombus in IVC extending in bilateral renal veins and showing interval progression with extension into RA upto sinoatrial junction superiorly and upto 40mm below the level of renal vein inferiorly-likely TUMOR THROMBUS.

#ECNeph Here are the PET images @anandthedoc Like the Rad described it "it lit up"

@anandthedoc #ECNeph Tumors affecting the inferior vena cava
Tumor thrombus-Renal Cell Carcinoma 4-15% of cases of RCC
Leiomyosarcoma rarediseases.org/rare-diseases/…
Renal Angiomyolipoma
Pheochromocytoma
Adrenal carcinoma
Hepatocellular Carcinoma
Excellent review webcir.org/revistavirtual…

@anandthedoc #ECNeph the most difficult part now was to get the tissue for diagnosis. Uro said nothing in the kidney to biopsy. Cardiothoraic said it'll be an open heart surgery to biopsy

@anandthedoc #ECNeph yes we did get a little help from friends in Vascular intervention. Went in through the femoral route and grabbed some tissue

@anandthedoc #ECNeph and we had our diagnosis

@anandthedoc #ECNeph - it turned out to be a Metastatic RCC- All the RCC naysayers kept saying you can't have no tumor in the IVC without a mass lesion in the kidney. But here we were. It left its origin(possibly Rt Kidney?) and was travelling all over the IVC upto the heart!

@anandthedoc #ECNeph Maybe it was there all along. Patient was inoperable due to co-morbidities. Went for Tyrosine Kinase Inhibitors (off label)

@anandthedoc #ECNeph Patient remained stable on TKIs for 1 yr- and then succumbed as he could not tolerate the drug. Thats all for tonight folks!! Thank you for a lovely chat