Renal Vascular Malformation and Compression
Introduction
Introduction to renal vascular malformation and compression Renal vascular malformation and compression refers to the movement of the bilateral kidneys, the main stem of the vein and its branches in the number of origins, abnormalities in the direction of drainage or compressional deformation of the surrounding organs, resulting in changes in renal hemodynamics, resulting in a series of Pathological damage. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: hematuria, proteinuria, hypertension, heart failure
Cause
Renal vascular malformation and the cause of compression
(1) Causes of the disease
The causes of renal vascular malformation and compression can be divided into two types: congenital and acquired. Congenital renal vascular malformations and mutations are difficult to distinguish. Usually, "abnormality" refers to morphological and structural abnormalities, accompanied by pathological dysfunction. The change means that only the morphological structure is abnormal without affecting the function of the organ, and there is no pathological change. Some renal blood vessel variability may also have pathological changes under certain circumstances, and renal vascular malformation may also occur. Does not constitute pathological changes, such as some small branches of renal arteriovenous fistula, generally does not affect health, and when female patients are pregnant, due to increased blood flow, may lead to high cardiac output heart failure, congenital The etiology of renal vascular malformation is unclear. It may be caused by chromosomal aberrations caused by certain viral infections during embryonic development, or DNA recombination errors during cell division. Acquired factors include trauma and tumors.
(two) pathogenesis
At present, it is generally believed that the mechanism of the disease is as follows: First, when the left renal vein is transferred into the inferior vena cava, it is blocked between the superior mesenteric artery and the abdominal aorta, and is blocked by the clamping of the renal vein. Increased venous system pressure, intrarenal, renal collateral vein collateral formation, varicose veins, severe rupture and hemorrhage, causing hematuria, second, congenital renal artery development is small or absent, renal artery originates from other secondary branches of abdominal aorta Arterial or renal artery fibromuscular dysplasia, acquired renal artery trunk or branch is compressed, renal vein compression causes arterial pressure increase and renal blood flow decrease, all of the above reasons can cause blood flow to decline to varying degrees The ischemic cells in the vicinity of the small arterioles are released to release renin, and the activity of the renin-angiotensin system is increased to cause hypertension.
Renal arteriovenous fistula and renal vein compression caused increased intrarenal venous pressure, renal collecting duct edema or renal trauma, abscess caused by renal vascular rupture, involving the renal collecting duct system, resulting in hematuria and proteinuria.
Prevention
Renal vascular malformation and compression prevention
1. Follow-up observation: Most patients with congenital renal vascular malformation or pressure, without clinical symptoms, do not need treatment, but must be observed with long-term observation, in case of serious organ damage, timely treatment is needed.
2. For the renal vascular malformation and compression caused by acquired factors, the primary disease should be actively treated to relieve the pressure, improve the condition and prevent various complications.
Complication
Renal vascular malformation and compression complications Complications, hematuria, proteinuria, hypertension, heart failure
Often caused by hematuria, proteinuria, renal colic; patients may have hypertension and heart failure due to decreased renal blood flow.
Symptom
Renal vascular malformation and compression symptoms Common symptoms Abdominal vascular murmur Abdominal tenderness Congestion Hypertension Urinary frequency varicocele Urinary urgency Pain swelling Pain
The clinical signs and symptoms of renal vascular malformation and compression are uncharacteristic, generally affected by the severity of hemodynamic changes in the diseased kidney, and also because the lesions damage the renal collecting duct system. The clinical manifestations are as follows. :
1. Lumbar pain in the lumbar ribs: mainly pain, pain and pain, less renal colic, physical examination of the side of the lower back or waist and abdomen tenderness and kidney area sputum pain.
2. Hypertension: Patients may have secondary hypertension due to decreased renal blood flow. Most of them have moderate to severe refractory hypertension 1 to 2 weeks after onset, congenital renal vascular malformation or compression, and the patient may be in infants. Onset or adolescent onset, physical examination in some patients may find vascular murmurs on both sides of the midline of the upper abdomen or at the waist.
3. Renal collecting duct involvement: often cause hematuria, proteinuria, impaired renal function is generally mild, azotemia can occur in severe or advanced cases, cases of uremia are rare, and acquired renal arteriovenous malformations Symptoms and signs of primary disease can exist at the same time as the oppressor.
4.c large renal arteriovenous fistula can cause left to right shunt circulation, increase cardiac preload, renal blood flow decline can increase blood volume and arterial pressure increase, increase the load before and after the heart, severe cases can cause acute heart Functional failure, life-threatening.
5. Some patients have mild or no clinical manifestations, resulting in a high rate of misdiagnosis. Occasionally, varicocele is the only complaint, and the diagnosis is left renal vein compression syndrome.
In general, renal vascular malformation and compression are divided into the following cases: renal artery stenosis is deformed by pressure, and most of them are treated with hypertension; those with renal vein compression are often treated with hematuria and proteinuria; those with small renal arteriovenous fistula are Clinically asymptomatic, and the mouth is huge, the first symptom is heart failure, renal artery malformation or compression caused by secondary hypertension has been described in the relevant chapters, here detailed discussion of renal arteriovenous fistula and renal vein compression deformity The clinical manifestations, other renal vascular malformations, clinically rare and many without clinical symptoms, are not described in detail.
(1) renal arteriovenous fistula: renal arteriovenous fistula deformity can be divided into congenital and post-congenital according to the cause, according to the location of the fistula can be divided into intrarenal and extrarenal, according to clinical symptoms can be divided into veins Varicose type and aneurysm type.
1 Varicose vein type: mostly congenital renal arteriovenous fistula, the fistula is relatively small, the majority of clinically asymptomatic, a small number of patients may have lumbar rib pain, varicose veins may have hematuria, ureter, urethra when rupture Often due to blockage of blood clots, dysuria, frequent urination, urgency, difficulty urinating, pregnant women due to increased blood volume and increased arterial pressure, can induce congestive heart failure, but rare, this type of mouth is mostly located in the kidney outer.
2 aneurysm type: mostly acquired, common in kidney surgery, trauma, renal abscess ulceration, kidney tumors, etc., large fistula, short sacral, large arteriovenous flow, clinically except primary disease In addition to the performance, there are often cardiovascular symptoms and signs, mainly clinical manifestations of congestive heart failure, but also waist, abdominal vascular murmur, blood pressure, etc., but renal biopsy complicated by arteriovenous fistula is often small, 2 Weeks to 18 months, the mouth can heal itself. If there are no serious symptoms, it usually does not require special treatment.
(2) Left renal vein compression syndrome (LRVES): Since Nutcracker described the left renal vein compression syndrome in 1972, many cases have been reported at home and abroad. The disease is mostly caused by children and young adults. Most patients have gross hematuria as the first symptom, some patients have low back pain, and patients with erect proteinuria are the only clinical manifestations.
Examine
Renal vascular malformation and compression examination
1. Blood test: Renal vascular malformation and compression In addition to the performance of the renin-angiotensin system in some patients, there is almost no abnormality in other biochemical tests. The renal function is generally impaired, only severe or advanced. Nitrogenemia can occur in cases.
2. Urine examination: common hematuria, may have proteinuria.
The diagnosis of this disease mainly depends on imaging examination.
1. X-ray inspection:
(1) There may be no abnormalities in the plain film. In the case of severe renal blood supply disorder, one side of the kidney may be reduced, and the left renal vein compression syndrome may have an enlarged left kidney.
(2) intravenous pyelography: generally no positive performance, intraorbital or renal tumor near the tumor mass compression may have renal pelvis compression deformation, contrast agent discharge blocked.
(3) renal angiography: can directly show the location, extent, extent, pathological properties, collateral circulation and abdominal aorta changes of renal vascular malformation or compression, congenital renal arteriovenous fistula is often located in the central renal proximal renal pelvis The site shows a group of curly blood vessels, thickening of the blood supply artery, early renal vein, and even the inferior vena cava can be developed in the arterial phase, obtaining arteriovenous fistula, showing thickening of the blood supply artery, early renal vein and cystic dilatation In the renal parenchymal phase, the renal parenchyma of the diseased side is in a low-density area, indicating that the renal perfusion is insufficient in this area. The patients with renal vascular compression can be seen with a filling defect of the compressed vascular lumen, and the vessel is interrupted when the thrombosis is formed. The kidney of the renal parenchyma is affected. In the cone-shaped low-density area of the lesion site, the left aortic vein compression syndrome can be performed by abdominal aorta or renal artery angiography. In the arterial phase, the position of the abdominal aorta and the superior mesenteric artery and the position of the left renal vein are displayed. Relationship, the extent and location of the left renal vein compression in the venous phase.
2. CT scan: It can show the shape of the kidney, the nature, location, size, shape and renal compression of the kidney and perirenal mass, which has certain significance for differential diagnosis.
3. Abdominal ultrasonography: abnormal color blood flow can be found in renal color Doppler examination. B-mode ultrasound can show the size of the kidney and the condition of the tumor, but the sensitivity is not high.
4. Nuclear medicine examination: radionuclide renal blood pool or renal parenchymal development has no specificity for the diagnosis of renal arteriovenous fistula and renal vascular compression, but it has certain differential diagnostic value. In addition, if 99mTc-RBC blood pool imaging is present Local high-concentration episodes, while 99mTc-calcium gluconate renal imaging showed localized defect in the concentrated area, which is qualitative for the diagnosis of renal aneurysms.
Diagnosis
Differential diagnosis of renal vascular malformation and compression
diagnosis
The clinical manifestations of renal artery malformation and compression are lacking in characteristics, and the rate of missed diagnosis is high. Clinicians must be vigilant. If there are the following clinical manifestations, the possibility of the disease should be considered:
1. Unexplained hematuria or proteinuria.
2. Abdominal vascular murmurs with high-displacement heart failure that cannot be explained.
3. Children or adolescents with high blood pressure.
4. Elderly hypertensive patients with abdominal vascular murmur.
5. Varicocele with left renal enlargement.
The only way to diagnose is renal angiography.
Differential diagnosis
It should be differentiated from other diseases that cause hematuria, proteinuria and hypertension, and high-displacement heart failure.
