Abstract
Nutcracker syndrome related to the left kidney vein compression is a cause of orthostatic proteinuria during childhood. Some studies have shown that the ratios between maximum velocities and anterior–posterior diameters of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions must be more than 4 in order to make a Nutcracker syndrome diagnosis. Our aim was to investigate whether the use of a decrease in aortomesenteric angle between upright and supine positions in the presence of isolated orthostatic proteinuria can be a criterion for the diagnosis of Nutcracker syndrome. Relevant patient information, which included demographic data, clinical examination findings, laboratory data, urinary system ultrasound, and kidney color flow Doppler ultrasound results, were prospectively collected. Thirty-nine pediatric patients with orthostatic proteinuria were included in the study. Left kidney vein compression findings were demonstrated in 31 patients. The ratio of maximum velocities of hilar and aortomesenteric segments of the left kidney vein between upright and supine positions was above 4 in only 7 of our patients. Ratio of aortomesenteric angle between upright and supine positions was significantly decreased for patients with left kidney vein compression findings.
Conclusion: The use of a decrease in the ratio of aortomesenteric angle between upright and supine positions in the presence of orthostatic proteinuria, instead of the ratios for maximum velocities and anterior–posterior diameters of hilar and aortomesenteric segments, can be more helpful for the diagnosis of Nutcracker syndrome in the differential diagnosis of orthostatic proteinuria.
What is Known: • Proteinuria may be a sign of an impending kidney disease • Nutcracker syndrome is a cause of orthostatic proteinuria. | |
What is New: • Ratio of aortomesenteric angle between upright and supine positions > 0.6 can be used for Nutcracker syndrome diagnosis. |
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Availability of data and material
Not applicable.
Code availability
Not applicable.
Abbreviations
- SMA:
-
Superior mesenteric artery
References
Kovvuru K, Kanduri SR, Thongprayoon C, Cheungpasitporn (2020) Diagnostic approach to orthostatic proteinuria: a combination of urine micro-proteinuria with ultrasonography of the left renal vein. Ann Transl Med 8(12):779. https://doi.org/10.21037/atm.2020.02.50
Pardinas C, do Carmo C, Gomes C, Escada L, Alves R (2021) Nutcracker syndrome: a single-center experience. Case Rep Nephrol Dial 11:48–54
Berthelot JM, Douane F, Maugars Y, Frampas E (2017) Nutcracker syndrome: a rare cause of left flank pain that can also manifest as unexplained pelvic pain. Joint Bone Spine 84:557–562
Gulleroglu K, Gulleroglu B, Baskin E (2014) Nutcracker syndrome. World J Nephrol 3(4):277–281
Granata A, Distefano G, Sturiale A, Figuera M, Foti PV, Palmucci S, Basile A (2021) From Nutcracker phenomenon to Nutcracker syndrome: a pictorial review. Diagnostics 11:101. https://doi.org/10.3390/diagnostics11010101
Kolber MK, Cui Z, Chen CK, Habibollahi P, Kalva SP (2021) Nutcracker syndrome: diagnosis and therapy. Cardiovasc Diagn Ther 11(5):1140–1149
Miro I, Serrano A, Perez-Ardavin J, March JA, Polo A, Conca MA, Sangüesa C, Veiga D, Carazo E, Dominguez C (2020) Eighteen years of experience with pediatric nutcracker syndrome: the importance of the conservative approach. J Pediatric Urology 16:218e1–218e6. https://doi.org/10.1016/j.jpurol.2019.12.003
Orczyk K, Wysiadecki G, Majos A, Stefanczyk L, Topol M, Polguj M (2017) What each clinical anatomist has to know about left renal vein entrapment syndrome (Nutcracker syndrome): a review of the most important findings. BioMed Research International Article ID. https://doi.org/10.1155/2017/1746570
Lee JH, Kim GJ (2010) Significant proteinuria caused by posterior Nutcracker phenomenon. J Korean Soc Pediatr Nephrol 14:84–88
Ananthan K, Onida S, Davies AH (2017) Nutcracker syndrome: an update on current diagnostic criteria and management guidelines. Eur J Vasc Endovasc Surg 53:886–894
Kim SH (2019) Doppler US and CT diagnosis of Nutcracker syndrome. Korean J Radiol 20(12):1627–1637
Alaygut D, Bayram M, Soylu A, Cakmakcı H, Türkmen M, Kavukcu S (2013) Clinical course of children with Nutcracker syndrome. Urology 82:686–690
Meyer J, Rother U, Stehr M, Meyer A (2021) Nutcracker syndrome in children: appearance, diagnostics, and treatment - a systematic review. J Pediatric Surgery. https://doi.org/10.1016/j.pedsurg.2021.12.019
Fitoz S, Ekim M, Ozcakar ZB, Elhan AH, Yalcinkaya F (2007) Nutcracker syndrome in children: the role of upright position examination and superior mesenteric artery angle measurement in the diagnosis. J Ultrasound Med 26:573–578
Ragazzi M, Milani G, Edefonti A, Burdick L, Bianchetti MG, Fossali EF (2008) Left renal vein entrapment: a frequent feature in children with postural proteinuria. Pediatr Nephrol 23:1837–1839
Mazzani MBM, Kottanatu L, Simonetti GD, Ragazzi M, Bianchetti MG, Fossali EF, Milani GP (2011) Renal vein obstruction and orthostatic proteinuria: a review. Nephrol Dial Transplant 26:562–565
Arslan Z, Koyun M, Erengin H, Akbas H, Kaya Aksoy G, Comak E, Akman S (2020) Orthostatic proteinuria: an overestimated phenomenon? Pediatric Nephrol 35:1935–1940
Jin M, Hu P, Ding R, Chen P, Qui Q, Wu J, Liu S, Xie Y, Chen X (2014) Effectiveness of supine/standing urinanalysis for differential diagnosis of left renal vein entrapment syndrome combined with or without glomerulopathy. Nephrology 19:332–338
Guven S, Kalin S, Cicek N (2021) Diagnosis and treatment in children with Nutcracker syndrome: a single-center experience. Acıbadem Universitesi Sağlık Bilimleri Dergisi 12(3):610–615. https://doi.org/10.31067/acusaglik.898335
Nalcacioglu H, Bilgici MC, Tekcan D, Genc G, Bostanci Y, Yakupoglu YK, Sarikaya S, Ozkaya O (2018) Nutcracker syndrome in children: role of Doppler ultrasonographic indices in detecting the pattern of symptoms. J Clin Med 7(8):214. https://doi.org/10.3390/jcm7080214
Author information
Authors and Affiliations
Contributions
Authors’ contributions are listed below;
NBG: the conception and design of the study, acquisition of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted.
KG: the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be submitted.
NU: acquisition of data, and final approval of the version to be submitted.
EB: the conception and design of the study, revising it critically for important intellectual content, and final approval of the version to be submitted.
Corresponding author
Ethics declarations
Ethics approval
This study was approved by Baskent University Institutional Review Board and Ethics Committee (Project no: KA09/97).
Consent to participate
Voluntary written informed consents were obtained.
Consent for publication
Not applicable.
Conflict of interest
The authors declare no competing interests.
Additional information
Communicated by Gregorio Paolo Milani
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Gulleroglu, N.B., Gulleroglu, K., Uslu, N. et al. Left renal vein entrapment in postural proteinuria: the diagnostic utility of the aortomesenteric angle. Eur J Pediatr 181, 3339–3343 (2022). https://doi.org/10.1007/s00431-022-04551-3
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-022-04551-3