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microhaematuria was always present&#46; Also&#44; haematuria was not correlated with respiratory tract infections at any level&#46; The patient did not have oedema&#44; abdominal pain&#44; or any other symptoms&#46;</p><p class="elsevierStylePara">A physical examination revealed the following&#58; weight&#58; 65kg&#59; height&#58; 1&#46;80m&#59; body mass index&#58; 20kg&#47;m<span class="elsevierStyleSup">2</span>&#59; blood pressure&#58; 110&#47;60mm Hg&#59; all other measurements were normal&#46; A laboratory analysis revealed the following values&#58; C-reactive protein&#58; 0&#46;9mg&#47;dl&#59; proteinuria&#58; 1g&#47;24 hours&#59; urinary sediment &#62;30&#160;000 red blood cells per field&#44; with no casts or dysmorphic blood cells&#46; The patient also had normal renal ultrasound images&#46; An axial computed tomography angiography &#40;CTA&#41; &#40;Figure 1 and Figure 2&#41; was used to evaluate renal vascularisation&#44; and led us to the diagnosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Nutcracker syndrome consists of haematuria originating from the left collecting system secondary to compression of the left renal vein&#44; between the superior mesenteric artery and the aorta and is due to a reduced angle between these two arteries&#46; This compression translates into increased pressure on the left renal vein system&#44; which causes varicosities in the renal pelvis and ureter&#44; which can in turn communicate with the urinary tract and cause haematuria&#46; The predisposing factors include&#58; nephroptosis&#44; lumbar hyperlordosis&#44; and reduced peri-renal fat &#40;which was present in our patient&#41;&#46; Clinically&#44; this condition can be silent or involve episodes of macroscopic or microscopic haematuria&#44; which can be accompanied by pain in the left renal fossa and&#47;or abdominal pain&#46; The haematuria is usually more intense during orthostasis and exercise&#44; which occurred in our patient&#46; It can also be accompanied by mild proteinuria and can even be associated with other entities such as IgA glomerulonephritis&#44; although there is no evidence that associates these two conditions&#46;<span class="elsevierStyleSup">1-3</span></p><p class="elsevierStylePara">This disease is difficult to diagnose using routine methods&#46; Initially&#44; a haematuria analysis must be carried out in order to rule out other&#44; more common causes&#46; Cystoscopy will reveal unilateral emission of haematuric urine from the left ureter&#44; in the case of macroscopic haematuria&#46; A retrograde venography and angiography with renocaval pressure gradient &#40;difference in pressure between the distal portion of the renal vein and the inferior vena cava&#41; is accepted as the gold standard for establishing a definitive diagnosis of nutcracker syndrome&#59; however&#44; since these are invasive testing methods&#44; there are other diagnostic alternatives&#44; such as CTA scans and 3D reconstructions that also facilitate diagnosis&#46; Depending on the severity of the bleeding&#44; treatment varies between observation and monitoring and surgical techniques for correcting the anatomical anomaly&#44; such as autologous transplantation and left renal vein transposition&#46;<span class="elsevierStyleSup">4-5</span></p><p class="elsevierStylePara">In conclusion&#44; given a young patient with haematuria&#44; and negative diagnostic tests suggesting haematuria of a renal origin&#44; we must keep in mind the possibility of this urological pathology&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11423&#95;19157&#95;33374&#95;en&#95;ref&#46;1142315089&#95;11423&#95;12122&#95;27809&#95;es&#95;corte&#95;transversal&#46;jpg" class="elsevierStyleCrossRefs"><img src="11423_19157_33374_en_ref.1142315089_11423_12122_27809_es_corte_transversal.jpg" alt="Computed tomography angiography of the abdomen"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Computed tomography angiography of the abdomen</p><p class="elsevierStylePara"><a href="grande&#47;11423&#95;16025&#95;33375&#95;en&#95;f2&#95;4114232&#46;jpg" class="elsevierStyleCrossRefs"><img src="11423_16025_33375_en_f2_4114232.jpg" alt="Computed tomography angiography of the abdomen"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Computed tomography angiography of the abdomen</p>"
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Gross haematuria in patients with nutcracker syndrome
Hematuria macroscópica en paciente con síndrome del cascanueces
Manuel Polaina-Rusilloa, Leticia Liébana-Carpiob, Josefa Borrego-Hinojosaa, Antonio Liébana-Cañadaa
a Servicio de Nefrología, Complejo Hospitalario Ciudad de Jaén, Jaén,
b Servicio de Radiología, Complejo Hospitalario Ciudad de Jaén, Jaén,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Among the different diagnostic algorithms that are commonly used in outpatient nephrology consultations&#44; nutcracker syndrome&#47;phenomenon is a very rare cause of haematuria&#46; This type of haematuria originating from the left collecting system and is secondary to compression of the left renal vein between the superior mesenteric artery and the aorta&#46;</p><p class="elsevierStylePara">We herein report the case of a 22-year-old male with no personal or family history of relevance&#44; who was referred to a nephrological department for haematuria&#46; Laboratory analyses confirmed the presence of haematuria that ranged between gross &#40;macroscopic&#41; haematuria and microhaematuria&#44; depending on the measurement&#46; This condition arose both with and without physical exercise&#46; During periods in which urine samples came up clear&#44; microhaematuria was always present&#46; Also&#44; haematuria was not correlated with respiratory tract infections at any level&#46; The patient did not have oedema&#44; abdominal pain&#44; or any other symptoms&#46;</p><p class="elsevierStylePara">A physical examination revealed the following&#58; weight&#58; 65kg&#59; height&#58; 1&#46;80m&#59; body mass index&#58; 20kg&#47;m<span class="elsevierStyleSup">2</span>&#59; blood pressure&#58; 110&#47;60mm Hg&#59; all other measurements were normal&#46; A laboratory analysis revealed the following values&#58; C-reactive protein&#58; 0&#46;9mg&#47;dl&#59; proteinuria&#58; 1g&#47;24 hours&#59; urinary sediment &#62;30&#160;000 red blood cells per field&#44; with no casts or dysmorphic blood cells&#46; The patient also had normal renal ultrasound images&#46; An axial computed tomography angiography &#40;CTA&#41; &#40;Figure 1 and Figure 2&#41; was used to evaluate renal vascularisation&#44; and led us to the diagnosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Nutcracker syndrome consists of haematuria originating from the left collecting system secondary to compression of the left renal vein&#44; between the superior mesenteric artery and the aorta and is due to a reduced angle between these two arteries&#46; This compression translates into increased pressure on the left renal vein system&#44; which causes varicosities in the renal pelvis and ureter&#44; which can in turn communicate with the urinary tract and cause haematuria&#46; The predisposing factors include&#58; nephroptosis&#44; lumbar hyperlordosis&#44; and reduced peri-renal fat &#40;which was present in our patient&#41;&#46; Clinically&#44; this condition can be silent or involve episodes of macroscopic or microscopic haematuria&#44; which can be accompanied by pain in the left renal fossa and&#47;or abdominal pain&#46; The haematuria is usually more intense during orthostasis and exercise&#44; which occurred in our patient&#46; It can also be accompanied by mild proteinuria and can even be associated with other entities such as IgA glomerulonephritis&#44; although there is no evidence that associates these two conditions&#46;<span class="elsevierStyleSup">1-3</span></p><p class="elsevierStylePara">This disease is difficult to diagnose using routine methods&#46; Initially&#44; a haematuria analysis must be carried out in order to rule out other&#44; more common causes&#46; Cystoscopy will reveal unilateral emission of haematuric urine from the left ureter&#44; in the case of macroscopic haematuria&#46; A retrograde venography and angiography with renocaval pressure gradient &#40;difference in pressure between the distal portion of the renal vein and the inferior vena cava&#41; is accepted as the gold standard for establishing a definitive diagnosis of nutcracker syndrome&#59; however&#44; since these are invasive testing methods&#44; there are other diagnostic alternatives&#44; such as CTA scans and 3D reconstructions that also facilitate diagnosis&#46; Depending on the severity of the bleeding&#44; treatment varies between observation and monitoring and surgical techniques for correcting the anatomical anomaly&#44; such as autologous transplantation and left renal vein transposition&#46;<span class="elsevierStyleSup">4-5</span></p><p class="elsevierStylePara">In conclusion&#44; given a young patient with haematuria&#44; and negative diagnostic tests suggesting haematuria of a renal origin&#44; we must keep in mind the possibility of this urological pathology&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11423&#95;19157&#95;33374&#95;en&#95;ref&#46;1142315089&#95;11423&#95;12122&#95;27809&#95;es&#95;corte&#95;transversal&#46;jpg" class="elsevierStyleCrossRefs"><img src="11423_19157_33374_en_ref.1142315089_11423_12122_27809_es_corte_transversal.jpg" alt="Computed tomography angiography of the abdomen"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Computed tomography angiography of the abdomen</p><p class="elsevierStylePara"><a href="grande&#47;11423&#95;16025&#95;33375&#95;en&#95;f2&#95;4114232&#46;jpg" class="elsevierStyleCrossRefs"><img src="11423_16025_33375_en_f2_4114232.jpg" alt="Computed tomography angiography of the abdomen"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Computed tomography angiography of the abdomen</p>"
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ISSN: 20132514
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