CLINICAL MARKERS OF HYPERTENSION IN THE LEFT RENAL VEIN SYSTEM
Authors: Nestetenko I. R. , Nesterenko V. L. , Pavliak A. Y. 
Published: July 2023

Introduction. Hypertension in the left renal vein (LRV) system is usually a consequence of aorta mesenteric clamp (the so-called “nutcracker syndrome”) and leads not only to venous stasis of the left kidney, but also to the development of pelvic congestion syndrome. The frequency and severity of the “nutcracker syndrome” (NS) symptoms varies from asymptomatic microhematuria to severe forms of pelvic venous congestion. Some patients indicate distinct and constant clinical symptoms, some patients, especially children, note an asymptomatic course

The objective was to study the prevalence and degree of hypertension clinical symptoms manifestations in the LRV system.

Materials and methods. The study included 248 patients (156 men and 92 women, an average age constituted 28.24±2.74) with suspicion of NS who underwent examination and treatment from 1999 to 2022. All patients were interviewed for specific complaints, pain syndrome in particular (questionnaire according to VAS) and underwent laboratory diagnostic tests, color Doppler ultrasound of the reno-caval segment, kidneys, pelvis, and CT angiography, if necessary.

Results. According to the conducted patient questionnaire, one third of patients with AMC without critical LRV stenosis did not have a pain syndrome, and when present, mild and moderate pain prevailed. However, pain syndrome was indicated by 93.1% of respondents in the group of patients with critical LRV stenosis (II group) and the structure of its intensity also changed.

Apparently, macrohematuria lasting more than 2 years with a frequency of more than 2 times in 2 months (32.84%) prevailed in the patients with critical LRV stenosis (group II), whereas this indicator in the patients of groups I and III constituted 4.26% and 4 .56%, respectively.

Evidently, a significant decrease in BMI was observed in the patients with critical LRV stenosis (16.2±1.08 vs. 23.8±1.12 and 24.7±2.38 in the patients of groups I and III, respectively). As a result of the examination, a distinct correlation was established between the decrease in BMI and the pain syndrome intensity according to VAS in the patients of group II: Spearman’s rank correlation coefficient was 0.948, P<0.0001, CI 95% for Rs from -0.972 to -0.906 constituted 18.2% in group I, 46.3% in group II, 12.4% in group III, respectively.

Left sided varicocele was diagnosed in 48 (54.5%) examined men of groups I and II: stage I was diagnosed in 12 (25%) cases, stage II was observed in 31 (64.5%) cases, stage III was found in 5 (10.5%) patients and in 12 (13.4%) patients of group III (control).

However, analysis of the varicocele frequency, taking into account its stage, found no connection between the degree of varicocele and the presence of LRV critical stenosis.

Conclusions. NS is characterized by distinct polymorphism of clinical manifestations and a variety of clinical forms. The main hypertension markers in the LRV system are pain syndrome and hematuria. Color Doppler ultrasound of the reno-caval segment is recommended to the patients with left sided varicocele / left sided pudendal varicose veins, hematuria, proteinuria, with a diagnosis of pelvic congestion; with dyspareunia, algodysmenorrhea, the appearance of blood during coitus / hemospermia, with chronic epigastric pain of unknown etiology, with anorexia, idiopathic infertility, in order to exclude pathology of the reno-caval segment.