Fatal Neonatal Bilateral Renal Vein Thrombosis with Inferior Vena Cava Extension: A Rare Cause of Acute Renal Failure

Fatal Neonatal Bilateral Renal Vein Thrombosis with Inferior Vena Cava Extension: A Rare Cause of Acute Renal Failure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fatal Neonatal Bilateral Renal Vein Thrombosis with Inferior Vena Cava Extension: A Rare Cause of Acute Renal Failure Yasir Khalif Ali, Abdullahi Ahmed Ahmed, Mohamed Nur Ali This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7819752/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 22 You are reading this latest preprint version Abstract Introduction : Neonatal renal vein thrombosis is an uncommon condition that can result in acute renal failure and long-term complications, particularly in cases of bilateral involvement extending to the inferior vena cava (IVC). This case report underscores the challenges of managing neonatal bilateral renal vein thrombosis in resource-limited settings. Case presentation: We report a 15-day-old neonate who presented with a 10-day history of gross hematuria and acute renal failure. Ultrasound confirmed the presence of bilateral renal vein thrombosis extending to the inferior vena cava and the right hepatic artery. The infant was managed with supportive care and unfractionated heparin. However, due to the challenges in critical care management, the condition deteriorated, resulting in a fatal outcome. Conclusion: Bilateral neonatal renal vein thrombosis is a rare, life-threatening condition with high morbidity and mortality. Although other factors may have contributed to the poor outcome, this case also may suggest that the absence of thrombolysis in severe bilateral cases played a role. Further research is needed to guide effective management and improve outcomes in low-resource settings like Somalia. Neonatal renal vein thrombosis renal failure anticoagulant thrombolysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Neonatal renal vein thrombosis (RVT) is an uncommon yet critical condition in newborns where blood clots develop in the veins responsible for draining the kidneys. RVT stands as the leading non-catheter-associated thromboembolism in newborns, representing 16–20% of all thromboembolic cases in this group. Unlike older children, neonates are more prone to experiencing thrombosis. In cases where a central venous catheter is not inserted, prior research has shown that up to 80% of neonates diagnosed with RVT exhibited other associated risk factors. The identified risk factors include infections, perinatal asphyxia, maternal diabetes, polycythemia, dehydration, congenital heart disease and premature birth ( 1 ). Renal vein thrombosis is characterized by a triad of microscopic or macroscopic hematuria, kidney enlargement, and low platelet levels. However, this triad is not always present in all cases. Most patients exhibit at least one of these signs, with 56% presenting with macroscopic hematuria, 45% having a palpable flank mass, and 48% developing thrombocytopenia ( 2 ). Renal vein thrombosis can lead to both acute and chronic complications. The acute complications are particularly dangerous when there is a delay in diagnosis, especially in cases of bilateral RVT with involvement of the inferior vena cava (IVC). These complications include acute kidney failure, hypertension, electrolyte imbalances, metabolic acidosis and hyperbilirubinemia caused by hemolysis. Approximately 58% to 100% of renal vein thrombosis cases result in renal scarring or atrophy. Additionally, around 30% of patients develop long-term complications, such as chronic kidney failure and hypertension ( 3 ) Case presentation This case concerns a 15-day-old male neonate was referred from another hospital due to 10 days of gross hematuria, which was constant and painless. The condition was not associated with fever, vomiting, or poor feeding. Additionally, the baby had noticeable bleeding at blood sugar testing and cannulation sites, which was difficult to stop. The baby was born via spontaneous normal vaginal delivery (SNVD) to a mother with no history of diabetes, gestational diabetes, abortion, or hypertension. He cried immediately after birth, but the Apgar score was not documented. Notably, the baby was admitted to the NICU for the first 8 hours due to hypoxia and hypoglycemia, then discharged home in stable condition. On the fifth day of life, the baby developed hyperbilirubinemia and was treated with phototherapy for 2 days. During this time, he was exclusively breastfed every 3 hours and did not receive intravenous fluids or antibiotics. On examination generally the patient looks ill and mildly distressed, with pale and edematous features. Also, the infant's blood pressure was high, ranging from the 95th to the 99th percentile. The fontanelle was flat and not bulging, and mild icterus was noted in the eyes. Chest examination revealed clear lung fields with normal vesicular breath sounds and no murmurs. The abdominal assessment revealed firm and immobile bilateral flank masses, alongside a distended but soft abdomen. Other systemic assessments revealed no significant or notable findings. At admission, laboratory investigations revealed severe anemia with a hemoglobin level of 6.5 g/dL, mild leukocytosis, and thrombocytopenia (82,000/mm³). Renal function tests showed elevated creatinine at 3.7 mg/dL and urea at 115 mg/dL. Liver function tests indicated total bilirubin of 7 mg/dL with a direct bilirubin level of 1 mg/dL. C-reactive protein (CRP) was elevated at 44 mg/L. Urinalysis showed a high pH, 3 + blood, 3 + leukocytes, negative nitrate, and 1 + protein. The baby also underwent a thrombophilia assessment, including basic coagulation studies, which showed an elevated activated partial thromboplastin time (aPTT) of 210 seconds, a prothrombin time (PT) of 45 seconds, and an international normalized ratio (INR) of 5. Additionally, protein C was low at 28 units (reference range: 85–150 units), antithrombin was also low at 18.6% (reference range: 44–79.6%), and fibrinogen levels were extremely low (reference range: 1.8–3.7 g/l). Sonographic evaluation demonstrated an echogenic intraluminal thrombus with absent venous flow in the inferior vena cava (IVC) (Fig. 1 ). Similar thrombus formation in the right hepatic veins (Fig. 2 ). Bilateral renal vein thrombosis near the hilum, with associated renal parenchymal enlargement and hypoechoic cortex indicative of edema (Figs. 3 & 4 ). Mildly heterogeneous echogenicity within the liver parenchyma. Following the diagnosis of bilateral renal vein thrombosis extended to the IVC. the patient exhibited a bleeding tendency during the first two days, along with an elevated APTT exceeding 210. Therefore, we did not initiate anticoagulation or thrombolysis. Instead, we administered fresh frozen plasma and erythrocytes to manage anemia, along with other supportive treatments for renal failure and hypertension. Two days later, when coagulation parameters approached normal levels, we initiated unfractionated heparin. Unfortunately, the baby's condition continued to deteriorate, leading to anuria and edema. As a result of renal failure and fluid retention, the baby developed heart failure and pulmonary edema. To manage this, we implemented fluid restriction by calculating insensible losses and adding the actual output. However, peritoneal dialysis was not available at the time due to our low-resource setting. Since admission, the baby had been hypertensive and was started on hydralazine, Lasix, and ACE inhibitors. As we were monitoring for signs of clot resolution, we observed further thrombosis in the right hepatic and femoral veins. Meanwhile, liver function tests showed a significant increase, with AST and ALT levels rising to 765 U/L and 565 U/L, respectively. Additionally, total bilirubin reached 25 mg/dL, and direct bilirubin increased to 20 mg/dL. Discussion Bilateral renal vein thrombosis (RVT) involving the inferior vena cava (IVC) is an uncommon yet critical condition, accounting for a small proportion of thrombotic events. In neonates, RVT is the most prevalent non-catheter-related thromboembolism, constituting 16–20% of all thromboembolic incidents in this group, with a male predominance of 67.2%. Approximately 70% of RVT cases are unilateral, with the left side being affected in 63.6% of these instances. Bilateral RVT represents about 30% of cases, and notably, in 43.7% of neonates, the thrombus extends into the IVC( 4 ). The diagnosis of neonatal renal vein thrombosis can be confirmed through imaging, either a CT scan with contrast or ultrasound. However, despite being the gold standard, CT with contrast has limitations due to radiation exposure and contrast use, especially in critically ill neonates. As a result, ultrasound is more commonly used in most centers. Ultrasound findings indicative of renal vein thrombosis (RVT) includes an enlarged kidney with reduced corticomedullary differentiation and increased cortical echogenicity. The detection of a thrombus outside the kidney is highly suggestive of inferior vena cava (IVC) thrombosis. Furthermore, Doppler ultrasound may reveal diminished or absent blood flow in the renal vein branches ( 5 , 6 ). Moreover, it is crucial to perform key laboratory tests such as platelet count, coagulation studies, and an assessment for thrombophilia. Managing bilateral neonatal renal vein thrombosis (NRVT) is particularly challenging due to its complex clinical nature and the limited literature available. Current guidelines suggest that unilateral NRVT without renal failure or inferior vena cava (IVC) involvement can be managed with supportive care and radiological monitoring for thrombus extension, or anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For unilateral renal vein thrombosis (RVT) extending into the IVC, anticoagulation with UFH or LMWH is recommended for 6 weeks to 3 months. In cases of bilateral RVT with renal impairment, initial thrombolytic therapy with tissue plasminogen activator (tPA) followed by anticoagulation with UFH or LMWH is suggested ( 7 , 8 ). Although other sources indicating, there is no consensus on the indications for thrombolysis versus other anticoagulation methods in patients with bilateral NRVT. Existing recommendations are primarily based on observational studies and case series, lacking robust evidence from randomized controlled trials. However, specific guidelines for bilateral NRVT are not well-established, underscoring the need for individualized clinical judgment in managing these patients ( 9 ). Our case involves a 15-day-old infant diagnosed with bilateral renal vein thrombosis extending into the inferior vena cava, resulting in a fatal outcome. The patient was managed with supportive care and unfractionated heparin (UFH). Subsequently, the infant developed severe acute renal failure, leading to anuria, pulmonary edema and heart failure. In this critical condition, neonatal dialysis was required; however, due to the unavailability of such facilities in our low-resource setting, managing the patient became significantly challenging. Additionally, the absence of thrombolytic therapy in this case may have been a gap in management, potentially contributing to the fatal outcome. Conclusion Bilateral neonatal renal vein thrombosis is a rare condition that significantly impacts both mortality and morbidity. Our case highlights the challenges in managing critically ill patients and reveals gaps in critical care approaches. Our case also highlights the potential impact of not using thrombolysis, a treatment that remains controversial for severe bilateral cases. While other factors contributed to the fatal outcome, the absence of thrombolysis also represents a gap in management and raises the question of its significance in such critical cases. Further studies are needed to establish optimal management strategies and improve outcomes in resource-constrained settings, such as Somalia. Declarations Funding No funding was received for the preparation of this manuscript. Conflicts of Interest/Competing Interests The authors declare that they have no conflicts of interest and no competing interests related to this article. Ethics Approval In accordance with the guidelines of the Mogadishu Somali Turkey Training and Research Hospital Ethics Review Board, case reports are exempt from formal institutional review board approval. Consent to Participate Not applicable. Written Consent for Publication Written informed consent for publication, including accompanying images, was obtained from the patient’s mother. As the patient is a neonate, consent was appropriately provided by the mother on behalf of the child. A copy of the written consent is available for review by the Editor-in-Chief upon request. Availability of Data and Material Not applicable. Code Availability Not applicable. Authors’ Contributions All authors contributed significantly to the work: Yasir Khalif Ali : Primary author, data collection, and manuscript drafting. Abdullahi Ahmed Ahmed : Study concept, supervision, data interpretation, and critical revision of the manuscript. Mohamed Nur Ali : Literature review, data validation, and final approval of the manuscript. References Brandão LR, Simpson EA, Lau KK. Neonatal renal vein thrombosis. Vol. 16, Seminars in Fetal and Neonatal Medicine. 2011. p. 323–8. Kayemba-Kay’s S, Kayemba-Kay’ S. Spontaneous Neonatal Renal Vein Thrombosis, a known Pathology without Clear Management guidelines. An overview. ACCEPTED MANUSCRIPT. Bökenkamp A, von Kries R, Nowak-Göttl U, Göbel U, Hoyer PF. Neonatal renal venous thrombosis in Germany between 1992 and 1994: epidemiology, treatment and outcome. Eur J Pediatr. 2000;159(1–2):44–8. Lau KK, Stoffman JM, Williams S, McCusker P, Brandao L, Patel S, et al. Neonatal renal vein thrombosis: review of the English-language literature between 1992 and 2006. Pediatrics. 2007 Nov;120(5):e1278-84. Resontoc LPR, Yap HK. Renal vascular thrombosis in the newborn. Vol. 31, Pediatric Nephrology. Springer Verlag; 2015. p. 907–15. Jorge AFF, Riesenberger PRR, Soares MET. Perinatal Renal Vein Thrombosis: Role of Imaging in the Initial Diagnosis. J Belg Soc Radiol. 2023;107(1). Motta M. Neonatal renal venous and arterial thrombosis. Ital J Pediatr. 2015 Dec;41(S1). Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e737S-e801S. Bidadi B, Nageswara Rao AA, Kaur D, Khan SP, Rodriguez V. Neonatal renal vein thrombosis: Role of anticoagulation and thrombolysis - An institutional review. Pediatr Hematol Oncol. 2016 Jan 2;33(1):59–66. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":109957,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eGray scale examination of the IVC shows complete occlusion of IVC by thrombus.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7819752/v1/1d90079e707247abbecd7dc4.png"},{"id":95510191,"identity":"a3df3ee0-1145-418a-b883-f2ebc1ea7dad","added_by":"auto","created_at":"2025-11-10 07:09:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116017,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRight Hepatic Vein Thrombus.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7819752/v1/d229429545ee0ac9483a1d8b.png"},{"id":95529868,"identity":"246a8b9a-dd03-4c8a-acb0-1bd1bec4c87d","added_by":"auto","created_at":"2025-11-10 10:17:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":150828,"visible":true,"origin":"","legend":"\u003cp\u003eRight Renal Vein Thrombus.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7819752/v1/292c4d802a076b48b78553f0.png"},{"id":95510188,"identity":"21f8637a-a4da-417b-9730-4acbbdc0073e","added_by":"auto","created_at":"2025-11-10 07:09:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":202526,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThrombus in the distal part of the Left Renal Vein.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7819752/v1/3ba25d0257e3a2ca032552c0.png"},{"id":95531783,"identity":"ae2a1cdc-11c5-406f-9e1c-4ec0164edaca","added_by":"auto","created_at":"2025-11-10 10:24:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1015671,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7819752/v1/167d48ae-15f7-4b66-a071-35eea9ca10ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fatal Neonatal Bilateral Renal Vein Thrombosis with Inferior Vena Cava Extension: A Rare Cause of Acute Renal Failure","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeonatal renal vein thrombosis (RVT) is an uncommon yet critical condition in newborns where blood clots develop in the veins responsible for draining the kidneys. RVT stands as the leading non-catheter-associated thromboembolism in newborns, representing 16\u0026ndash;20% of all thromboembolic cases in this group. Unlike older children, neonates are more prone to experiencing thrombosis. In cases where a central venous catheter is not inserted, prior research has shown that up to 80% of neonates diagnosed with RVT exhibited other associated risk factors. The identified risk factors include infections, perinatal asphyxia, maternal diabetes, polycythemia, dehydration, congenital heart disease and premature birth (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRenal vein thrombosis is characterized by a triad of microscopic or macroscopic hematuria, kidney enlargement, and low platelet levels. However, this triad is not always present in all cases. Most patients exhibit at least one of these signs, with 56% presenting with macroscopic hematuria, 45% having a palpable flank mass, and 48% developing thrombocytopenia (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRenal vein thrombosis can lead to both acute and chronic complications. The acute complications are particularly dangerous when there is a delay in diagnosis, especially in cases of bilateral RVT with involvement of the inferior vena cava (IVC). These complications include acute kidney failure, hypertension, electrolyte imbalances, metabolic acidosis and hyperbilirubinemia caused by hemolysis. Approximately 58% to 100% of renal vein thrombosis cases result in renal scarring or atrophy. Additionally, around 30% of patients develop long-term complications, such as chronic kidney failure and hypertension (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThis case concerns a 15-day-old male neonate was referred from another hospital due to 10 days of gross hematuria, which was constant and painless. The condition was not associated with fever, vomiting, or poor feeding. Additionally, the baby had noticeable bleeding at blood sugar testing and cannulation sites, which was difficult to stop. The baby was born via spontaneous normal vaginal delivery (SNVD) to a mother with no history of diabetes, gestational diabetes, abortion, or hypertension. He cried immediately after birth, but the Apgar score was not documented. Notably, the baby was admitted to the NICU for the first 8 hours due to hypoxia and hypoglycemia, then discharged home in stable condition. On the fifth day of life, the baby developed hyperbilirubinemia and was treated with phototherapy for 2 days. During this time, he was exclusively breastfed every 3 hours and did not receive intravenous fluids or antibiotics. On examination generally the patient looks ill and mildly distressed, with pale and edematous features. Also, the infant's blood pressure was high, ranging from the 95th to the 99th percentile. The fontanelle was flat and not bulging, and mild icterus was noted in the eyes. Chest examination revealed clear lung fields with normal vesicular breath sounds and no murmurs. The abdominal assessment revealed firm and immobile bilateral flank masses, alongside a distended but soft abdomen. Other systemic assessments revealed no significant or notable findings. At admission, laboratory investigations revealed severe anemia with a hemoglobin level of 6.5 g/dL, mild leukocytosis, and thrombocytopenia (82,000/mm\u0026sup3;). Renal function tests showed elevated creatinine at 3.7 mg/dL and urea at 115 mg/dL. Liver function tests indicated total bilirubin of 7 mg/dL with a direct bilirubin level of 1 mg/dL. C-reactive protein (CRP) was elevated at 44 mg/L. Urinalysis showed a high pH, 3\u0026thinsp;+\u0026thinsp;blood, 3\u0026thinsp;+\u0026thinsp;leukocytes, negative nitrate, and 1\u0026thinsp;+\u0026thinsp;protein. The baby also underwent a thrombophilia assessment, including basic coagulation studies, which showed an elevated activated partial thromboplastin time (aPTT) of 210 seconds, a prothrombin time (PT) of 45 seconds, and an international normalized ratio (INR) of 5. Additionally, protein C was low at 28 units (reference range: 85\u0026ndash;150 units), antithrombin was also low at 18.6% (reference range: 44\u0026ndash;79.6%), and fibrinogen levels were extremely low (reference range: 1.8\u0026ndash;3.7 g/l). Sonographic evaluation demonstrated an echogenic intraluminal thrombus with absent venous flow in the inferior vena cava (IVC) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similar thrombus formation in the right hepatic veins (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Bilateral renal vein thrombosis near the hilum, with associated renal parenchymal enlargement and hypoechoic cortex indicative of edema (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Mildly heterogeneous echogenicity within the liver parenchyma. Following the diagnosis of bilateral renal vein thrombosis extended to the IVC. the patient exhibited a bleeding tendency during the first two days, along with an elevated APTT exceeding 210. Therefore, we did not initiate anticoagulation or thrombolysis. Instead, we administered fresh frozen plasma and erythrocytes to manage anemia, along with other supportive treatments for renal failure and hypertension. Two days later, when coagulation parameters approached normal levels, we initiated unfractionated heparin. Unfortunately, the baby's condition continued to deteriorate, leading to anuria and edema. As a result of renal failure and fluid retention, the baby developed heart failure and pulmonary edema. To manage this, we implemented fluid restriction by calculating insensible losses and adding the actual output. However, peritoneal dialysis was not available at the time due to our low-resource setting. Since admission, the baby had been hypertensive and was started on hydralazine, Lasix, and ACE inhibitors. As we were monitoring for signs of clot resolution, we observed further thrombosis in the right hepatic and femoral veins. Meanwhile, liver function tests showed a significant increase, with AST and ALT levels rising to 765 U/L and 565 U/L, respectively. Additionally, total bilirubin reached 25 mg/dL, and direct bilirubin increased to 20 mg/dL.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBilateral renal vein thrombosis (RVT) involving the inferior vena cava (IVC) is an uncommon yet critical condition, accounting for a small proportion of thrombotic events. In neonates, RVT is the most prevalent non-catheter-related thromboembolism, constituting 16\u0026ndash;20% of all thromboembolic incidents in this group, with a male predominance of 67.2%. Approximately 70% of RVT cases are unilateral, with the left side being affected in 63.6% of these instances. Bilateral RVT represents about 30% of cases, and notably, in 43.7% of neonates, the thrombus extends into the IVC(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe diagnosis of neonatal renal vein thrombosis can be confirmed through imaging, either a CT scan with contrast or ultrasound. However, despite being the gold standard, CT with contrast has limitations due to radiation exposure and contrast use, especially in critically ill neonates. As a result, ultrasound is more commonly used in most centers. Ultrasound findings indicative of renal vein thrombosis (RVT) includes an enlarged kidney with reduced corticomedullary differentiation and increased cortical echogenicity. The detection of a thrombus outside the kidney is highly suggestive of inferior vena cava (IVC) thrombosis. Furthermore, Doppler ultrasound may reveal diminished or absent blood flow in the renal vein branches (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Moreover, it is crucial to perform key laboratory tests such as platelet count, coagulation studies, and an assessment for thrombophilia.\u003c/p\u003e\u003cp\u003eManaging bilateral neonatal renal vein thrombosis (NRVT) is particularly challenging due to its complex clinical nature and the limited literature available. Current guidelines suggest that unilateral NRVT without renal failure or inferior vena cava (IVC) involvement can be managed with supportive care and radiological monitoring for thrombus extension, or anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For unilateral renal vein thrombosis (RVT) extending into the IVC, anticoagulation with UFH or LMWH is recommended for 6 weeks to 3 months. In cases of bilateral RVT with renal impairment, initial thrombolytic therapy with tissue plasminogen activator (tPA) followed by anticoagulation with UFH or LMWH is suggested (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Although other sources indicating, there is no consensus on the indications for thrombolysis versus other anticoagulation methods in patients with bilateral NRVT. Existing recommendations are primarily based on observational studies and case series, lacking robust evidence from randomized controlled trials. However, specific guidelines for bilateral NRVT are not well-established, underscoring the need for individualized clinical judgment in managing these patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur case involves a 15-day-old infant diagnosed with bilateral renal vein thrombosis extending into the inferior vena cava, resulting in a fatal outcome. The patient was managed with supportive care and unfractionated heparin (UFH). Subsequently, the infant developed severe acute renal failure, leading to anuria, pulmonary edema and heart failure. In this critical condition, neonatal dialysis was required; however, due to the unavailability of such facilities in our low-resource setting, managing the patient became significantly challenging. Additionally, the absence of thrombolytic therapy in this case may have been a gap in management, potentially contributing to the fatal outcome.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBilateral neonatal renal vein thrombosis is a rare condition that significantly impacts both mortality and morbidity. Our case highlights the challenges in managing critically ill patients and reveals gaps in critical care approaches. Our case also highlights the potential impact of not using thrombolysis, a treatment that remains controversial for severe bilateral cases. While other factors contributed to the fatal outcome, the absence of thrombolysis also represents a gap in management and raises the question of its significance in such critical cases. Further studies are needed to establish optimal management strategies and improve outcomes in resource-constrained settings, such as Somalia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No funding was received for the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest/Competing Interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no conflicts of interest and no competing interests related to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003cbr\u003eIn accordance with the guidelines of the Mogadishu Somali Turkey Training and Research Hospital Ethics Review Board, case reports are exempt from formal institutional review board approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten Consent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent for publication, including accompanying images, was obtained from the patient\u0026rsquo;s mother. As the patient is a neonate, consent was appropriately provided by the mother on behalf of the child. A copy of the written consent is available for review by the Editor-in-Chief upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors contributed significantly to the work:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eYasir Khalif Ali\u003c/strong\u003e: Primary author, data collection, and manuscript drafting.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAbdullahi Ahmed Ahmed\u003c/strong\u003e: Study concept, supervision, data interpretation, and critical revision of the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMohamed Nur Ali\u003c/strong\u003e: Literature review, data validation, and final approval of the manuscript.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrand\u0026atilde;o LR, Simpson EA, Lau KK. Neonatal renal vein thrombosis. Vol. 16, Seminars in Fetal and Neonatal Medicine. 2011. p. 323\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eKayemba-Kay\u0026rsquo;s S, Kayemba-Kay\u0026rsquo; S. Spontaneous Neonatal Renal Vein Thrombosis, a known Pathology without Clear Management guidelines. An overview. ACCEPTED MANUSCRIPT. \u003c/li\u003e\n\u003cli\u003eB\u0026ouml;kenkamp A, von Kries R, Nowak-G\u0026ouml;ttl U, G\u0026ouml;bel U, Hoyer PF. Neonatal renal venous thrombosis in Germany between 1992 and 1994: epidemiology, treatment and outcome. Eur J Pediatr. 2000;159(1\u0026ndash;2):44\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eLau KK, Stoffman JM, Williams S, McCusker P, Brandao L, Patel S, et al. Neonatal renal vein thrombosis: review of the English-language literature between 1992 and 2006. Pediatrics. 2007 Nov;120(5):e1278-84. \u003c/li\u003e\n\u003cli\u003eResontoc LPR, Yap HK. Renal vascular thrombosis in the newborn. Vol. 31, Pediatric Nephrology. Springer Verlag; 2015. p. 907\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eJorge AFF, Riesenberger PRR, Soares MET. Perinatal Renal Vein Thrombosis: Role of Imaging in the Initial Diagnosis. J Belg Soc Radiol. 2023;107(1). \u003c/li\u003e\n\u003cli\u003eMotta M. Neonatal renal venous and arterial thrombosis. Ital J Pediatr. 2015 Dec;41(S1). \u003c/li\u003e\n\u003cli\u003eMonagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-G\u0026ouml;ttl U, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e737S-e801S. \u003c/li\u003e\n\u003cli\u003eBidadi B, Nageswara Rao AA, Kaur D, Khan SP, Rodriguez V. Neonatal renal vein thrombosis: Role of anticoagulation and thrombolysis - An institutional review. Pediatr Hematol Oncol. 2016 Jan 2;33(1):59\u0026ndash;66. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Neonatal renal vein thrombosis, renal failure, anticoagulant, thrombolysis","lastPublishedDoi":"10.21203/rs.3.rs-7819752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7819752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Neonatal renal vein thrombosis is an uncommon condition that can result in acute renal failure and long-term complications, particularly in cases of bilateral involvement extending to the inferior vena cava (IVC). This case report underscores the challenges of managing neonatal bilateral renal vein thrombosis in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eWe report a 15-day-old neonate who presented with a 10-day history of gross hematuria and acute renal failure. Ultrasound confirmed the presence of bilateral renal vein thrombosis extending to the inferior vena cava and the right hepatic artery. The infant was managed with supportive care and unfractionated heparin. However, due to the challenges in critical care management, the condition deteriorated, resulting in a fatal outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Bilateral neonatal renal vein thrombosis is a rare, life-threatening condition with high morbidity and mortality. Although other factors may have contributed to the poor outcome, this case also may suggest that the absence of thrombolysis in severe bilateral cases played a role. Further research is needed to guide effective management and improve outcomes in low-resource settings like Somalia.\u003c/p\u003e","manuscriptTitle":"Fatal Neonatal Bilateral Renal Vein Thrombosis with Inferior Vena Cava Extension: A Rare Cause of Acute Renal Failure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 07:09:52","doi":"10.21203/rs.3.rs-7819752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-21T08:51:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T17:43:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-10T15:36:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-07T17:05:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T15:42:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T05:58:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296671204452057258006561342536515916491","date":"2025-11-01T05:21:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T13:03:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327801553508681323719707424914082844308","date":"2025-10-31T12:23:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146552037456612294138885859371415958484","date":"2025-10-31T09:59:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33355577740145318739317904380888355558","date":"2025-10-31T08:17:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44186436614399300864159532806825673643","date":"2025-10-31T08:10:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T02:57:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306027000145275443546602131389380222256","date":"2025-10-31T02:37:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186553218940702215165852365078650992736","date":"2025-10-29T13:36:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29371143330171923441604397372672020340","date":"2025-10-29T10:16:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327884720291098703237967907462990292824","date":"2025-10-29T09:03:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270614792151254275951434133849526352692","date":"2025-10-29T08:06:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-29T08:02:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-29T02:32:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-28T23:53:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-10-09T16:28:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b1258b22-c0ba-484a-b556-e27e7bf296ba","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-21T12:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 07:09:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7819752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7819752","identity":"rs-7819752","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}