Nutcracker syndrome: symptoms, causes and treatment

Our body is a highly complex organism, made up of a huge number of systems that operate in unison to allow us to survive. However, sometimes these systems can become damaged, fail, or have their functionality altered or reduced by injury or illness.

Regarding the latter, some are more or less frequent and well-known, while in other cases we find with strange and unusual situations of which there is at least little knowledge due to its little prevalence.

An example of a rare and infrequent disease can be found in the so-called nutcracker syndrome, a kidney and vascular disease which we are going to talk about throughout this article.

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Nutcracker syndrome: what is it?

It receives the name of nutcracker syndrome or nutcracker syndrome to a rare kidney disease that arises due to compression of the left renal vein by blood vessels that surround it and/or other parts of the organism.

Said compression generates entrapment and stenosis of the renal vein, something that greatly increases the pressure in said vein. This in turn facilitates the appearance of internal fistulas and renal bleeding.

Symptoms

This syndrome sometimes appears asymptomatic, but the presence of symptoms at the level of the genitourinary system is often observed. Specifically, it is common for visible hematuria to appear at a macroscopic level, that is, for reddish urine to appear when blood is also expelled in urination. Internal varicose veins and in the legs also tend to appear, as well as pelvic congestion.

It is not uncommon for it to appear unilateral low back pain, a nuisance whose intensity can be highly variable depending on the case. In addition, in the case of women, dysmenorrhea or dysregulation of the menstrual cycle may appear.

Sometimes dysparurenia or pain during intercourse is observed, and it can also cause emotional disturbances. Proteinuria, or the expulsion of protein through the urine, may also be seen, especially in young people.

Even though it's about a disease that tends to be benign and not generate major complications (in fact, the prognosis is almost always very good), the truth is that in Sometimes complications may appear at the renal level that can compromise life or become very serious. invalidating. For example, if recurrent and regular bleeding occurs, it is easy to fall into anemia, kidney disease may appear, and blood and arterial pressure can be dangerously altered.

It is a change that It can appear at any age and regardless of gender, although it is more frequent in women. It is also more frequent in the third and fourth decades of life, and according to the available literature it is more prevalent in the population from the Far East.

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basic types

Nutcracker syndrome can occur in different ways, highlighting the following as the most common (and especially the first).

anterior nutcracker syndrome

The most common form of this syndrome occurs when compression of the left renal vein is caused by the aorta and mesenteric arteries.

Post Nutcracker Syndrome

Unlike the previous case, in the posterior type nutcracker syndrome the renal vein is trapped and compressed between one of the two arteries and the vertebral column. The associated effects and symptoms are generally the same.

Combined Nutcracker Syndrome

On this rare occasion, it is the case that the left renal vein is clamped in its branch anterior through the two arteries while the posterior does the same between the aorta and the spine vertebral.

Causes

As we have seen, the nutcracker syndrome is an alteration that is caused when the aortic and mesenteric arteries superior clamp and compress the left renal vein, just as a nutcracker would with the dried fruit (in fact, hence its name). name).

The symptoms appear when the level of pressure in the renal vein increases, damaging the septa between veins and the renal apparatus and blood entering the urine. In turn, this would give rise to a venous circulation towards territories such as the gonadal (something that would influence the symptoms of a genital and sexual nature) and the urethra.

The reason for this clamping is not clear, but it may be caused by alterations at the embryonic level. Although it is more common in the population of the Far East, a relationship with genetic inheritance has not been proven, being the majority of sporadic cases. In the case of children, it can sometimes occur due to bodily changes (which do not occur proportionally throughout the body) typical of growth.

In adults, some of the possible hypotheses in this regard propose that it could be caused by abnormalities such as duplications of the renal vein, the presence of tumors or inflammations that push the arteries in such a way that they compress the left renal vein, an excessively low body mass (the fat present in this area makes it easier for there to be more space between the two arteries), hyperlordosis or problems related to the position of the kidneys during postural changes.

Treatment

As we have seen previously, the nutcracker syndrome is usually benign in behavior, although Sometimes it can pose a threat to the life of the affected person.

Sometimes this condition may not require treatment beyond monitoring, observation and control of the patient's condition, but in others it will be necessary to carry out some type of intervention, generally of the type surgical.

Among the most frequent and recommended is implantation of an intravascular or extravascular stent, a device that allows the affected vessel to be kept open. In cases of severe renal bleeding (visible in haematuria) transfusions of blood and other interventions that allow to preserve the state of health and the maintenance of the constants. An auto-kidney transplant or a by-pass in the renal vein may be necessary.

Bibliographic references:

• Chen, Y.M., Wang, I.K., Ng, K.K., Huang, C.C. (2002). Nutcracker syndrome: an overlooked cause of hematuria. Chang Gung Med J., 25(10): 700-705.
• Gulleroglu, K., Gulleroglu, B. & Baskin, E. (2014). Nutcracker syndrome. World J Nephrol., 3(4):277-281.
• Hermida Perez, J.A. (2016). Nutcracker syndrome. General and Family Medicine, 5 (1): 21-24.
• Martínez-Salamanca García, J.I., Herranz Amo, F., Gordillo Gutiérrez, I. Díez Cordero, J.M., Subirá Ríos, D., Castaño González, I., Moralejo Gárate, M., Cabello Benavente, R. & Hernandez Fernandez, C. (2004). "Nutcraker" syndrome or nutcracker: demonstration by helical CT with 3D reconstruction (VR). Spanish Urological Acts, 28 (7).
• National Center for Advancing Translational Sciences (s.f.) Renal nutcracker syndrome. Genetic and Rare Diseases Information Center [Online]. Available in: https://rarediseases.info.nih.gov/espanol/13285/sindrome-renal-del-cascanueces.