Abstract
The association of pulmonary thromboembolism with nephrectomy is well documented in malignant conditions. However, the data for incidence of pulmonary thromboembolism following nephrectomy in nonmalignant conditions remains scarce. We report the first case of an incidence of pulmonary thromboembolism following nephrectomy in a patient with a nonfunctional kidney due to multiple renal calculi.
Keywords: Pulmonary thromboembolism, Renal calculi, Nephrectomy
Introduction
Postoperative pulmonary thromboembolism after nephrectomy for malignant tumors is a known but rare complication. There is no reported case of incidence of venous thromboembolism after nephrectomy in a nonfunctional kidney due to renal calculi. Herein, we report a case of pulmonary thromboembolism (PTE) with right pulmonary infarction and pleural effusion following right nephrectomy after 3 weeks of surgery. The patient was managed with low molecular weight heparin followed by oral anticoagulation, and he made an uneventful recovery.
Case report
A 33-year-old male patient with no known co-morbidities was evaluated by a urologist for a right-sided nonfunctioning kidney due to multiple renal calculi and was electively operated under general anesthesia, and right nephrectomy was done by subcostal retroperitoneal incision. The duration of surgery was 120 min. Preoperatively, the nonfunctional kidney was confirmed on renal diethylene triamine penta-acetic acid (DTPA) scan, and his preoperative coagulation profile were normal. The patient made a good recovery postoperatively and was ambulant. He was discharged on the 5th postoperative day. The histopathology of the resected specimen of the kidney showed features of chronic pyelonephritis, and there was no evidence of malignancy. On the 14th postoperative day, the patient developed right pleuritic chest pain, and subsequently, there was cough with scanty mucoid sputum. There was no history of fever, diarrhea, or abdominal pain. The clinical examination was normal at that time and he was given symptomatic therapy with an oral nonsteroidal anti-inflammatory drug (tablet diclofenac 50 mg twice a day), oral antibiotic (tablet amoxycillin plus clavulanate 625 mg thrice a day). He had not received any postoperative thromboprophylaxis. One week later, he had complained of right-sided chest pain and two episodes of streaky hemoptysis. Hence he was referred for a pulmonology consult when he was found to have clinical signs of right pleural effusion. The chest radiograph showed moderate right pleural effusion. Due to the clinical profile of postabdominal surgery state with unexplained pleuritic chest pain and hemoptysis, the possibility of pulmonary thromboembolism (PTE) was considered. In view of the postoperative setting, the d-dimer assay was not done while his electrocardiogram (ECG) was normal. An urgent computed tomography pulmonary angiography (CTPA) confirmed the presence of PTE of the right descending branch of the pulmonary artery and pulmonary infarction of the right lower lobe with pleural effusion (Fig. 1, Fig. 2, Fig. 3). The Doppler of the inferior vena cava (IVC) and lower limb veins for the source of the PTE revealed no evidence of deep venous thrombosis. The patient was managed with subcutaneous low molecular weight heparin (enoxaparin) 60 mg subcutaneously 12 hourly, followed by oral anticoagulation (tab acitrom 4 mg once a day) to maintain international normalized ratio (INR) between 2.0 and 3.0. The patient made an uneventful recovery. Follow-up CTPA at 3 months, showed complete resolution of the thrombus. He had no recurrence of hemoptysis or chest pain and was discharged on OPD follow up. Patient consent was obtained for images and inclusion in the study.
Fig. 1.
CT pulmonary angiography showing a thrombus in the right descending pulmonary artery with mild right pleural effusion.
Fig. 2.
CT pulmonary angiography lung windows right lower lobe wedge-shaped pleural-based pulmonary infarction.
Fig. 3.
CT Pulmonary angiography coronal reconstruction images showing thrombus in the right descending pulmonary artery with small right pleural effusion.
Discussion
Postoperative PTE is a complication that occurs following major orthopedic surgery on the lower extremity, major abdominal surgery, and cardiothoracic surgery.1 The risk factors for venous thromboembolism following surgery can be categorized as surgery-related factors and patient-related factors.2 The former includes infection, immobilization, and dehydration, in addition to the duration and type of surgery, whereas the latter includes cancer, advancing age, previous VTE, obesity, varicose veins, and the use of estrogen. The incidence of venous thromboembolism in malignancies ranges from 2.9% to 17.1% depending on the stage of malignancy,3 whereas its incidence after chemotherapy stood at 12.6%.4 Patients undergoing surgery for malignant cancers also have a higher risk of postoperative deep vein thrombosis than those having surgery for nonmalignant diseases.3 PTE following radical nephrectomy for malignant renal tumors has been well documented in literature.5 The pulmonary embolism may be due to thrombus formed in such patients due to the prothrombotic effects of a malignant neoplasm. In certain patients with renal cell carcinoma, tumor emboli from the renal vein or IVC have been the cause of the pulmonary embolism. The incidence of pulmonary thromboembolism (PTE) following nephrectomy was studied to be 0.5% among patients undergoing nephrectomy.6 The occurrence of pulmonary thromboembolism (PTE) following nephrectomy for nonfunctioning kidney due to multiple renal calculi is an extremely rare entity and to the best knowledge of the authors and on searching the databases of PubMed using the keywords, pulmonary thromboembolism, renal calculi, and nephrectomy, has not been reported in English literature till date.
In this case of PTE source of the thrombus remained a mystery as there was no clinical evidence of deep vein thrombosis (DVT), and the doppler study of the upper and lower extremity veins and inferior vena cava was unrewarding. The renal veins were also assessed and were found to be clear of the thrombus. The radio-labeled fibrinogen red blood cell (RBC) nuclear imaging was not done in this patient due to lack of facilities for the same. There was no past history of deep vein thrombosis in the patient or first-degree relatives to suggest hereditary thrombophilia such as protein C and S deficiency, antithrombin III deficiency, factor V Leiden, prothrombin gene mutation. He has been reviewed after 12 weeks and has remained asymptomatic on anticoagulation. The plan is to give anticoagulation for 6 months and then stop for two months before doing the workup for hereditary thrombophilias.
Disclosure of competing interest
The authors have none to declare.
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