Arch Dis Child: first published as 10.1136/adc.20.103.129 on 1 September 1945. Downloaded from RENAL VENOUS THROMBOSIS AND INFARCTION IN THE NEWBORN BY J. EDGAR MORISON, M.D., B.Sc. From the Department of Pathology, Queen's University, Belfast, and the Belfast City Hospital, Northern Ireland Haemorrhagic infarction of the kidney is usually (3) Infarction secondary to renal inflammation considered to be secondary to venous thrombosis with or without venous thrombosis. and to be a rare lesion both in the newborn and in older children. Thrombosis of radicles of renal veins Without infarction. In five cases there were Most recent reports have described one (Heller, thrombi in radicles of the renal veins without 1923; Aschner, 1927; Nordwall, 1933; Hepler, haemorrhage or damage to renal parenchyma. 1934; Marshall and Whapham, 1936; Behr, 1938); two (Petramand, 1923) or three (Oppenheim, 1920) Case 1. A male infant weighing 7 lb. 9 oz. (3,430 cases occurring in the first year of life, and eight of gm.) at birth lost 11 oz. (312 gm.) in the first three these occurred in the neonatal period. A few of days of life and a further 12 oz. (340 gm.) by the the older European workers found the condition seventh day. Icterus was then in excess of the more frequently and this was discussed by Oppen- normal, and diarrhoea and vomiting commenced heim and by Faerber and Bussel (1930). The con- and continued for four days. Blood-tinged fluid dition is, indeed, not rare and Cruickshank (1930) was obtained on lumbar puncture on the eleventh found fifteen examples among thirty cases of visceral day. Diarrhoea and vomiting began again on the thrombosis encountered in 800 neonatal deaths. fifteenth day and continued until death on the Barenberg, Greenstein, Levy and Rosenbluth (1941) nineteenth day when the weight was 5 lb. 7 oz. (2,466 had five cases in the newborn in twenty-five autopsies gm.). in epidemics of diarrhoea complicated by secondary Anatomical summary. Unhealed umbilical site: infections. Campbell (1937) noted eighteen cases slight arteritis: scars in intima of umbilical vein. under six months in the records of one hospital. Thrombi in intrarenal veins with organization: old http://adc.bmj.com/ Later he reported (Campbell and Matthews, 1942) and recent emboli in small pulmonary arteries: two unilateral cases treated by nephrectomy. He terminal lung infarcts. oeso- did not distinguish cases with and without pyelone- Thrush stomatitis and phritis. Pyelonephritis was responsible for the four cases reported by Schr6der (1926). No detailed description of the lesions was given by Cruickshank or by Campbell. Oppenheim and Schroder have both discussed the pathology of special varieties of the condition in infancy and Behr has studied renal on September 26, 2021 by guest. Protected copyright. venous thrombosis at all ages, but no representative series of cases in the newborn has been studied. It may be useful to describe eighteen cases without pyelonephritis. All but one of these occurred in the neonatal period. Four cases of pyelonephritis with vascular lesions, two of them in the neonatal period, will also be discussed. In all of these cases a detailed histological examination was made of nearly every organ of the body. All cases of renal venous thrombosis are not associated with infarction and in some cases of haemorrhagic necrosis there is no venous thrombosis. It is proposed to distinguish three main groups. (1) Thrombosis of radicles of renal veins. (i) without infarction; (ii) with infarction. FIG. 1.-Organization of a thrombus at the commence- (2) Haemorrhagic infarction without primary ment of an interlobar vein. Case 1. van Gieson. renal venous thrombosis. x 125. K 129 Arch Dis Child: first published as 10.1136/adc.20.103.129 on 1 September 1945. Downloaded from 130 ARCHIVES OF DISEASE IN CHILDHOOD phagitis. Bilateral purulent otitis media. Terminal lesions were found in these infants, but their pro- pneumonia. Minimal subarachnoid haemorrhage. gress had never been satisfactory and they probably In the intrarenal veins the thrombi were of different suffered from a septicaemia. ages and some channels were not involved. The oldest thrombi were in dilated arcuate vessels and In the first three cases there was a clinical history at the beginning of the interlobar veins, and here of episodes of dehydration and septic lesions were they were hyalinized and projected into the lumen, present somewhere in the body. In cases 4 and 5 but were covered by endothelium and partly or- lesions were found and severe dehydration ganized by fibrous tissue (fig. 1). The large and ill- no septic supported veins at the hilum were also dilated and was a terminal event. Thrombi were seen at post- columns and laminae ofplatelet thrombus supported mortem in cases 1, 2 and 4, focal congestion of a fibrin mesh with entangled red blood cells. Here kidney tissue was noted in cases 1 and 4, and, except there was no growth of endothelium over the throm- in case 2, the lesions were bilateral. Cases 1, 2 and bus or proliferation of fibrous tissue from the vein 3 provided evidence that the oldest thrombi, those wall. In the small pulmonary arteries there were showing most organization or endothelial over- numerous hyalinized thrombi and sometimes endo- growth, were to be found in the arcuate veins. In thelium had grown over these from the vessel wall no case was there infiltration of the peri-vascular, (fig. 2). Groups of alveoli with indistinct walls interstitial or peri-pelvic tissues or invasion of the lumen of the tubules by inflammatory cells. Other cases have been seen with thrombi in the intrarenal veins, but without cellular reaction or distinctive arrangement of platelets and fibrin. Thrombosis was probably agonal, but there was sometimes localized congestion of the kidney. With infarction. In five cases red blood cells had escaped between the tubules of a few renal papillae and here epithelial cells were degenerating. In two cases extensive haemorrhage had enlarged the kid- neys to twice their normal size and converted por- tions of them into little more than blood filled cysts, and in two others there were pale grayish-pink infarcts as well as haemorrhagic areas. Case 6. A male infant was very asphyxiated after a difficult forceps delivery. He was fretful for three days and slightly jaundiced. On the fourth day the temperature was 1000 F., vomiting became severe, both ear drums were injected, and the weight had fallen from 6 lb. 13 oz. (3,090 gm.) to 5 lb. 12 oz. http://adc.bmj.com/ (2,610 gm.). On the fifth day the respirations were were over the chest. FIG. 2.-An embolic thrombus in a small pulmonary rapid and there crepitations artery with endothelium growing over it. Case 1. He died on the seventh day. H. E. x 275. Anatomical summary. Excessive deposits of debris of liquor amnii in alveoli: diffuse atelectasis: were packed with red blood cells with no excess of bilateral broncho-pneumonia: gross congestion all polymorphonuclear leucocytes. organs. Endothelialized thrombi in arcuate and interlobar veins of both kidneys and slight haemorr- on September 26, 2021 by guest. Protected copyright. Case 2. A male child died suddenly on the hage into medulla of left. Right catarrhal otitis seventeenth day. He had had an oral thrush in- media. fection from the twelfth day and was dehydrated. Urine was obtained at autopsy and contained only Extensive thrombi in the arcuate and small inter- a few red blood cells. lobar veins of the left kidney sometimes showed an Cases 7, 8, 9 and 10. These full term infants, two endothelial covering and there were fragments of male and two female, died on the eighth, ninth, ninth embolic thrombus in the pulmonary arteries. and twenty-fourth days of life. Case 7 had a thrush infection and a terminal aspiration pneumonia. The Case 3. A male child died on the twenty-first of case 8 had a toxaemia and day from broncho-pneumonia. There was a history mother pre-eclamptic of diarrhoea and vomiting he developed a temperature of 102° F. on the of skin sepsis, episodes seventh day, but no cause for this was found. Case and a loss of weight from 9 lb. (4,080 gm.) to umbilicus and liver lesions and oz. In both kidneys about a 9 had an unhealthy 6 lb. 4 (2,835 gm.). was described as case 6 in a paper on acute inter- quarter of the arcuate veins contained organizing stitial hepatitis (Morison, 1944). Case 10 had had thrombus, but the only reaction was a few mono- All evidence of some haemosiderin, skin sepsis for five days. presented nuclear cells, of which contained dehydration for at least two days before death. near the vessels. Only a little haemorrhage disrupted the pattern of Cases 4 and 5. In two male infants aged twelve the tubules towards the tip of a few pyramids, but and fourteen days well formed thrombi were present the kidneys were enlarged and congested and their without cellular reaction in the arcuate and inter- pelves were also congested. Poorly formed thrombi lobar veins of grossly congested kidneys. No other in the larger veins at the hilum showed no cellular Arch Dis Child: first published as 10.1136/adc.20.103.129 on 1 September 1945. Downloaded from RENAL VENOUS THROMBOSIS AND) INFARCTION IN THE NEWBORN 131 reaction, but thrombi in the smaller intrarenal vessels were becoming covered with endothelium in cases 8 and 10 and organized in case 9. Emboli were found in some pulmonary arteries in cases 9 and 10 and small pulmonary infarcts had developed in cases 7 and 8. Case 11. A male infant was admitted on the seventh day with a history of persistent crying.