What are the effects of ligation of both renal veins (RVs)?

Effects of Bilateral Renal Vein Ligation

Bilateral renal vein ligation causes severe renal dysfunction and is not compatible with kidney survival, requiring immediate surgical intervention to restore venous outflow. 1

Pathophysiological Effects

• Bilateral renal vein ligation leads to acute kidney injury (AKI) due to severe venous congestion, which prevents normal glomerular filtration and causes marked increases in serum creatinine 2, 3
• The condition creates a severe hemodynamic disturbance in the kidneys with venous hypertension, reduced renal perfusion pressure, and compromised glomerular filtration rate 1
• Unlike unilateral renal vein ligation where collateral venous drainage may develop, bilateral ligation eliminates all major venous outflow pathways, resulting in renal failure 4

Clinical Manifestations

• Acute renal failure requiring dialysis is the primary immediate consequence 5
• Significant proteinuria develops due to increased hydrostatic pressure in glomerular capillaries 5
• Hypertension may occur due to activation of the renin-angiotensin-aldosterone system (RAAS) in response to perceived renal hypoperfusion 5
• Radiographic evidence shows marked renal swelling and congestion 5
• In severe cases, hemorrhagic infarction of kidney tissue may occur 2

Management Considerations

• Immediate surgical intervention is required to restore venous outflow to at least one kidney 6
• Temporary hemodialysis may be necessary during the acute phase 3
• If recognized during surgery, immediate venous reconstruction should be performed 6
• In cases of severe renal vein injury without self-limiting bleeding, surgical intervention rather than angioembolization is indicated 1

Differences from Unilateral Renal Vein Ligation

• Unilateral renal vein ligation may be tolerated in patients with two functioning kidneys due to development of collateral venous drainage pathways 4
• Studies show that isolated left renal vein ligation with a functioning right kidney typically results in temporary renal dysfunction that resolves within days to weeks 4
• However, bilateral renal vein ligation eliminates all major venous outflow pathways, making it incompatible with kidney survival 5, 6

Special Considerations

• In cases of bilateral renal artery stenosis or stenosis affecting a solitary kidney, the kidneys are already in a compromised state, making them more vulnerable to additional insults like venous outflow obstruction 1
• Patients with pre-existing chronic kidney disease would experience more rapid and severe deterioration with bilateral renal vein ligation 1
• The right kidney typically has less collateral venous drainage compared to the left kidney, making right renal vein ligation generally less tolerable 2, 4

Warning Signs and Monitoring

• Immediate oliguria or anuria is a warning sign of severe renal compromise 5
• Rapidly rising serum creatinine levels indicate severe kidney injury 2
• Monitoring for signs of fluid overload and electrolyte abnormalities is essential 3
• Kidney ultrasound would show increased kidney size, decreased renal blood flow, and increased resistive index 1

In emergency situations where bilateral renal vein ligation has occurred, immediate vascular surgical consultation and intervention are necessary to prevent permanent kidney failure and the need for long-term dialysis 6.