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Dr. Campsen: I'm Dr. Jeffrey Campsen, surgical director of kidney transplant and pancreas transplant at the University of Utah. What're your options when you've been diagnosed with kidney failure? That's next on The Scope.

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Dr. Campsen: If you've been diagnosed with kidney failure, there are three options we're going to talk about today. I'm Dr. Jeffrey Campsen and we're with Dr. Martin Gregory, nephrologist at the University of Utah, who is going to tell us more about those options today.
So, a patient comes in they've been diagnosed with kidney failure. What are their options?

Dr. Gregory: Basically there are three main options: kidney transplantation, dialysis, or conservative treatment.

Dr. Campsen: Okay, I do kidney transplants and I'm a big advocate of that, but there's an organ shortage so the other two obviously are the first-line therapies.

Dr. Gregory: Indeed, the majority of people will be treated by dialysis, either hemodialysis or peritoneal dialysis. And it's important we discuss both of those options because they are very different in terms of the impact of the patient and the family, in terms of where the treatment is carried out, how it's carried out, who does it, and what repercussions that has for the patient's lifestyle.

Dr. Campsen: So hemodialysis, "hem" means blood, so that's when they actually filter blood, where peritoneal dialysis, there's a catheter in the abdomen that the abdomen then acts as the body's filter, the kidney.

Dr. Gregory: That's exactly right. Most patients with kidney failure in the United States will have hemodialysis. But, peritoneal dialysis is an equally effective form of treatment and indeed offers many advantages for the patient in terms of convenience and particularly for patients who like to take command of their own treatment and be in control with what's happening, do the treatment themselves, or do it at home. Peritoneal dialysis is a pretty satisfactory form of treatment.

Dr. Campsen: And I think the other thing I'd like to point out is I think each of these therapies have a timeline on them. At some point, patients can get infected with their peritoneal dialysis catheter or it may not work anymore. The same way with hemodialysis where you have to have fistulas created so you have access to the blood and sometimes those burn out also. The same with a kidney transplant, where the kidney transplant may only last so long and there is only so many organs. And so, ultimately it seems like a combination of these therapies are what people with kidney failure need.

Dr. Gregory: You're absolutely right. Many patients will have experience all three of these types we are currently talking about: transplantation, hemodialysis, and peritoneal dialysis. And it's extremely important that patients learn about these at the outset so that they can make appropriate choices and express their preferences for which would work best for each individual.

Dr. Campsen: And so that's interesting, so there's three options. One is conservative management, one is dialysis, and one is transplantation. And what you're saying is some people will try to stay off of dialysis as long as possible, almost to their detriment, until they absolutely need it. And then other patients will really prefer dialysis and then other patients want to receive a transplant before they ever get on dialysis.

Dr. Gregory: All of those are true. Conservative management has a very valuable role particularly in elderly patients or those with multiple other illnesses, comorbidities we call them. These patients may have their life extended by dialysis, but perhaps only by a small amount at the expense of having to go through an awful lot of medical treatment, surgical operations, and time receiving the treatment.
Those patients may well elect not ever to get anywhere near transplantation or dialysis. The situation that you spoke about where people defer getting any treatment until its absolutely necessary is one that frequently leads to a lot of misery down the line. It does lead to bad outcomes and complications. And those are often the patients we see who have a miserable experience with their kidney failure and with dialysis.

Dr. Campsen: Well, I think what's interesting that I'm realizing in speaking to you is that, if you come in with kidney failure, you need very good education on these three options. But once, as a patient, you get educated, really the ball is your court to be proactive and decide what's right for you. No matter what you choose, there is still a lot of work to be done on the patients' part to make sure that the therapies are available and work for them.

Dr. Gregory: Yes, it's always a team approach. The most important part of the team in all circumstances is the patient and things work, as I've just heard you say, very very much better if the patient is pro-active, takes an active part in not only deciding about therapy but then making sure that the therapy is done in a first class way to get first class results.

Dr. Campsen: Kidney failure, it's a lot of work. Getting a fistula created for dialysis and then showing up for dialysis on a consistent basis every week that you need it or three times a week. Or a kidney transplant where you have to have a large surgery and then you have to get your immuno-suppressions and get your labs checked. Any of those things, it's a much bigger responsibility to keep yourself healthy than some other very common morbidities.

Dr. Gregory: It's a huge responsibility for the patient and it's a responsibility that may change and evolve as time goes by. Many patients would dearly like to get a transplant without the need for dialysis, but the majority of those in fact, because of the shortage of donor kidneys, are going to have to have dialysis for some period of time, maybe for many years. This makes it very important that the right form of dialysis is chosen, something that the patient can live with, can stick with, and can work with the remainder of the team to maintain good health until the time of transplantation.
Hemodialysis, for example, is most commonly done in a dialysis center. The patient comes three times a week, but it doesn't have to be that way. Patients can do hemodialysis at home and many patients who do dialysis at home find that's an excellent means. They can do it more frequently, which more naturally mimics what a patient's own kidneys would do, and gives better results. And, the time they spend at home is not nearly as much lost time, as time would be going to a dialysis center.

Dr. Campsen: But as a sidebar, in full disclosure, one of the nice reasons to have Dr. Gregory here is his area of interest in research at the University of Utah is dialysis and hemodialysis.

Dr. Gregory: Yes, we've been trying to arrange a method of hemodialysis, particularly for use in the third world, that would permit us to do hemodialysis without the need for electricity or any external form of energy. Been working on that for a number of years. Potentially it can work, but the devil is the details - actually getting it to be really practicable.

Dr. Campsen: The point is that medicine is evolving and so is treatment for kidney disease and that's why you need to come to an educated physicians, a nephrologist, who can really tailor your treatment specifically to the patient - one of the three options that we talked about, conservative management, dialysis, and transplant.

Dr. Gregory: Knowledge is power. The more you know about your options the more you decide how they would fit with your lifestyle, the better. Working with the team, making sure that what will work for you is part of their plan, is going to be crucial to the success of your therapy.

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Interviewer: You have a patient with kidney failure, but you can't treat the kidney failure because the individual also has Hepatitis C. What do you do? You're going to find out how a creative group of doctors solved that problem next on "The Scope."

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Interviewer: It was a little bit of a puzzle, wasn't it? How to treat a patient that has Hepatitis C that also has kidney failure because you cannot use the new drugs for Hepatitis C on somebody that has kidney failure. We're with Dr. Jeffery Campsen. He's a transplant surgeon here at the University of Utah. Tell me about this cool new procedure that could really change the way we think about patients with kidney failure and Hepatitis C.

Dr. Jeffery Campsen: So it's very cool and it's a plan that we developed with our transplant group, and we're just now seeing the fruits come out of it. Basically we have patients that have kidney failure, but they also have an infection with Hepatitis C. There are deceased donors that die and are also infected with Hepatitis C. And those organs can't be used into people that have never been infected with Hepatitis C, but if you are already infected with Hepatitis C, you can accept an organ, a kidney from a donor that has Hepatitis C. And that's what we did.

We looked at our patients that had both, kidney failure and infection with Hepatitis C, and asked them if they would be willing to accept an organ from a Hepatitis C donor.

Interviewer: There's a brand new treatment for patients suffering from chronic or acute liver failure. We'll talk about that next on The Scope.

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Interviewer: There's a brand new treatment that are suffering from alcoholic liver related failure. We're talking with Dr. Juan Gallegos. He's a liver expert here at the University of Utah Hospital. You're really about this new possibility of this treatment which is in clinical trial right now. Tell me a little bit about what's going on.

Dr. Juan Gallegos: Thank you very much Scott. Yes we are very excited to participate in this clinical trial of this new therapy for patients with severe alcoholic liver disease. We're interested in it because alcoholic liver disease is very, very frequent in the United States. It's estimated that about two-thirds to three-quarters of adults in the United States drink some alcohol, most of them do so very mildly and moderately, but a subset of patients drink heavily and these patients are at increased risk of developing liver disease. And most patients have heard about alcoholic Cirrhosis and probably that's one of the top three causes of liver failure in the United States leading to liver transplantation.
But there is another entity called acute alcoholic hepatitis, or excessive alcohol drinking leads to significant inflammation and liver damage which could cause the liver to fail, and those are the patients that we're interested in studying and treating in this trial because up to until now the mortality for these patients, meaning the number of patients that die from this disease is about 70% six months after the initial episode. So there's a very dramatic impact of this condition.

Interviewer: And up until this point really no way to treat it, is that correct?

Dr. Juan Gallegos: Well there are some ways to treat it and mainly trying to get these patients abstinent from alcohol and that's the mainstay of treatment. Also adequate nutritional support is very important, and there's a couple of medical therapies that we can use that is medical medications that can be used to treat these patients, but even with that the mortality is still around 30 to 40% at 3 to 6 months after this episode of alcoholic hepatitis.

Interviewer: Okay so this is a dialysis machine, just briefly explain what this machine does then and why you're so excited about it?

Dr. Juan Gallegos: We're very excited about it because this is a machine that yes in a way is a dialysis machine; basically it is able to replace at least for a few days the major function of the liver. So basically what this company has made is a special machine where we have cartridges that are full of human liver cells that are alive and then can actually maintain the liver function for these several days, and these liver cells are grown here in the United States, and they're put in the special cartridges that go into this dialysis machine for the liver. The amount of cells there in these cartridges is equivalent to about 500 grams of liver tissue. Which is about a third of a normal liver.

Interviewer: Does it act as a filter, all those liver cells?

Dr. Juan Gallegos: They not only act as a filter they actually make proteins that are important for the normal physiologic function of the body so they make proteins that help with the clotting factors, they detoxify certain chemicals that are only detoxified by liver cells that in a patient that has acute liver failure are not working.

Interviewer: Is it like a respirator is doing the lungs job eventually this machine would be able to do the livers job?

Dr. Juan Gallegos: So what it can actually do the livers job for a few days but not more than that. Other machines that don't use liver cells really they only act like you mention as filters.

Interviewer: So traditional dialysis would be one of those machines?

Dr. Juan Gallegos: Traditional dialysis in a sense is such a machine is just that traditional dialysis can be used for long periods of time, and substitute the kidney function. The liver function is a bit more difficult to replace, and that's why this is so exciting. So what we are trying to see if it's this machine can help these patients over the hump of the severe or acute liver failure so that they can actually survive this episode and go on to either recover from the alcoholic liver disease, or if they don't necessarily recover but maintain their sobriety for a few months they can then go on to be considered for liver transplantation which we would be the definitive treatment for this alcoholic liver disease.

Interviewer: Yeah so the ultimate goal is the liver transplantation. This machine is by no means something you would stay on for the rest of your life.

Dr. Juan Gallegos: Correct that is not the case it's only basically to treat the acute episode and get you over this acute problem so that over time either you recover because sobriety is very important in some of these patients actually recover and if they maintain sobriety their liver can get back to almost normal.

Interviewer: Really it will heal almost to precondition?

Dr. Juan Gallegos: It might, it depends on how advanced the condition is to begin with. So in those patients that already have severe liver disease, and on top of this have an acute insult they're less likely to recover, but there are patients that don't have a severe liver disease to begin with and if they can get over this acute insult they're livers will recover to a point where they might not require a liver transplant in the future. As long as they maintain their sobriety.

Interviewer: And this is cutting edge technology obviously because it's in trial, the FDA hasn't approved it yet.

Dr. Juan Gallegos: Correct.

Interviewer: The whole process you're going through is hoping to prove...

Dr. Juan Gallegos: Yes we're hoping to prove that this will increase the chances of patients surviving to the point that it will be better than what our current medical therapies are, and the FDA is very interested in this so they have allowed us to participate in this trial. It's a multi-centric trial in the United States, and there are other centers in Europe and other places of the world.

Interviewer: So if somebody was interested in this trial what would they have to do?

Dr. Juan Gallegos: Well generally it will be a physician, or somebody taking care of these patients, they would just need to contact us at the University of Utah. I am the principal investigator so I'm readily available as well as our research coordinators.

Interviewer: Any final thoughts on this topic?

Dr. Juan Gallegos: Well I think that it's important to recognize that alcoholic liver disease is a significant problem in the United States, and that episodes of acute alcoholic hepatitis can be deadly, and we're trying to improve that with this machine, and hopefully people out there will be interested in and contact us.

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Scot: You may have read a couple stories in the news recently about something called Live Donor Kidney Chains. What exactly is that? It's where your kidney could help start a chain that would help a lot of other people is what it is. Dr. Jeffrey Campsen is a transplant surgeon at the University of Utah and you're getting pretty good at this here at the University Utah, these transplant chains. Tell me about what they are.

Dr. Jeffrey Campsen: So it's interesting. The Live Donor Kidney Transplant Program at the University of Utah has been going on for quite a few years. Quite often if someone's in renal failure and they have someone who would like to donate a kidney to them, sometimes that's incompatible. So while they have somebody who would want to donate a kidney, it can't be done.

Scot: Kind of like a friend or family member maybe really wants to help.

Dr. Jeffrey Campsen: That's exactly right.

Scot: Yeah.

Dr. Jeffrey Campsen: And so what we've seen is we'll talk to the donor and say, "Would you be okay donating your kidney to somebody else if they also have somebody that would then donate a kidney to your recipient? And it starts to form a chain. And it's very complicated in how these chains work out but recently over the past six months we've been able to do three chains that were three pairs deep. So you actually do six surgeries and three people get transplanted. All three kidney recipients had donors that weren't perfect for them and we were able to match them up and create a chain which then at the end of the day now all those people are off of dialysis, all the donors have gotten their recipients transplanted, but it wasn't to the person they originally wanted to but we still were successful at the end.

Scot: But it was even better because if, for example, you needed a kidney, I agreed to transplant it that's only one person that's helped. These chains have helped up to three people each time.

Dr. Jeffrey Campsen: Oh yeah. It's fascinating. And so you start out by wanting to help somebody and then at the end of the day, you're right, you've transplanted three patients. And what's interesting is we do this over the course of say 48 hours so we do all six surgeries in one to two, to three days. Then all six patients are actually in the hospital on the same floor and what we've found is they're all out walking, getting better and they meet each other and they're like, "You donated a kidney?" "No, I got a kidney." "Oh, you donated his kidney." And now we're finding they're going down and having lunch together in the hospital, they're getting together. Then their family members are meeting and we've seen this now where there are the six people that have had the transplants plus their family members and we're having groups of people in the hallways of like 20 and everybody's happy and it's amazing.

Scot: It must... Does that help their healing process? Because you hear so much about, you know, the mind is so important and your spirits.

Dr. Jeffrey Campsen: Obviously it helps. I think if you're that positive and you see the joy and the success of this, people are just going to do better. And it's really a community coming together to help one another. And then when everybody leaves the hospital they go back to their lives and they're healthy and it's very successful.

Scot: So if I wanted to donate a kidney to somebody how do I become part of this chain?

Dr. Jeffrey Campsen: Well, so there are a couple things that you can do. One is if you know somebody in renal failure and kidney failure and you want to be their donor then you talk to them and you come to the transplant center. But what you're also talking about is also altruistic donors, non-directed donors, someone who's just interested in starting a chain. And we've had quite a few of those lately.
There was a story recently in the paper where one of our dialysis nurses was doing dialysis for our children and he just felt like he wanted to do more so he wanted to offer up his kidney to start a chain. He was able to start a chain that transplanted three people. Two of them were actually children and one was an adult. And we pair with Primary Children's Medical Center on these chains to get them done.
So he started a chain as an altruistic donor but the chains can also just start because you also know somebody in renal failure. But you can come to our transplant center, call our transplant line. We have two transplant coordinators, Sarah and Bruce, that will immediately take your call, talk to you about the donation. There's a website that we have that's coming up right now that explains all of live donation. It'll have videos on it and it'll go through the process. You'll get to know the people that are involved, the nephrologists, the transplant surgeons, the social workers, the coordinators, even our financial people that will help guide you through the insurance.

Scot: And this chain can go nationwide?

Dr. Jeffrey Campsen: It can be. So there are a couple things that we've done. There are local chains which will just stay within our program or Primary Children's locally in the Salt Lake City area or if we can't find a chain to do it here we're actually part of a national organization, two national organizations actually: one through UNOS and one through NKR, the National Kidney Registry, that allows us to do large chains. And I think one of the chains we did this past year went to be about 20, 21 transplants.

Scot: Twenty-one. Are you kidding?

Dr. Jeffrey Campsen: That's absolutely true. I think our goal is to basically get our local patients transplanted and if we're able to help people nationally that's wonderful too especially because the organs come back to us nationally.

Scot: Any final thoughts?

Dr. Jeffrey Campsen: If you're interested in live kidney donation, think about your kidney going to other people besides your recipient and then knowing that your recipient will get transplanted but if you're able to help multiple people and do that kind of good, then consider doing that. We'll never force anybody not to donate to the person they want to but not always is that choice and if you're available to help more than one person that's pretty neat.

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Scot: You may have heard in the news about a live donor kidney chain, that was started a few months ago, by a donor named Ted Bartling. Meaning, he came in, said I want to donate my kidney to somebody and, in doing that, many other people volunteered to donate their kidney and lives were improved and saved. We're talking with Dr. Jeffrey Campsen, surgical director of Live Donor Kidney Transplants. Let's talk about kidney donation. Let's talk about how you could do it, how safe is it, and how does it really improve somebody's life.

Dr. Jeffrey Campsen: So, Ted Bartling is a good example. This is an individual that felt like he really wanted to do something for his community. He's very productive in the world, has a great job, but he felt something was missing; He wanted to do something more. So, he comes to us and says I'd like to donate my kidney. Well, we have a bunch of patients that actually have donors, but they're not compatible. We were able to create a chain of three kidney transplants from him.

Scot: How does somebody come to want to donate a kidney? How does that decision come to be?

Dr. Jeffrey Campsen: So I think there are a couple reasons and there are a couple types of individuals. There's people that are within the family of someone who has kidney disease and they cannot stand to see their family member dying and, basically, they're the hero that goes in and can, literally, save this person's life. The second type of person is someone who feels like they want to do something for their community. So they come in and they, basically, say look, I want to donate my kidney to somebody and, a lot of times, it's to one person that they don't know, and, other times, they start a chain. We've done that here in Utah recently, where they can start a chain of three, four, five kidney transplants in a row. So, their ability to donate one kidney, ultimately, can help anywhere between one patient to five patients.

Scot: I love that. I might donate a kidney if I knew that, maybe, it would get a chain going.

Dr. Jeffrey Campsen: So if someone comes in, wanting to donate a kidney, even if they have a recipient, we ask them if they'd be willing to donate to someone other than their own recipient. We look at other patients, that have donors that are incompatible, and we see if we can pair them up.

Scot: It's like solving a puzzle. You've got all the pieces, you just have to figure out how they best go together.

Dr. Jeffrey Campsen: That's exactly right and the University of Utah has a transplant team who specializes in solving kidney transplant puzzles.

Scot: Do you find that donors tend to fall in some sort of a demographic group? Is it people later in life? Is it richer people, poorer people?

Dr. Jeffrey Campsen: No, it's all people. We had some very young donors come by lately. Meaning 18 and 19 years old.

Scot: Eighteen and nineteen? Really? And, did you ask them why?

Dr. Jeffrey Campsen: Well, one girl, who actually ended up donating, wants to go to medical school. She actually wants to be a transplant surgeon and she felt that there would be no better way to understand her patients than if she actually donated her kidney.

Scot: Wow. That's dedication, on a couple of levels.

Dr. Jeffrey Campsen: It is, but on the same hand, we just transplanted a pair, where the husband's kidney failed, and he's in his 60's, and his wife is 60, and she donated her kidney to him. Now, they come in together as a couple and their going to live their lives a lot longer because now, he's not on dialysis, and it's going to extend his life. So it's the spectrum, both sides, and, then, there's a bunch of people in the middle.

Scot: If I give up one of my kidneys, I have two of them, and even that one is more than I need, are there concerns that I would have? Like, I might want both, just in case one of them fails.

Dr. Jeffrey Campsen: Our priority, in this entire conversation, is the safety of the donor. So, we have a live donor kidney transplant team, here at the University of Utah, that specializes in making sure that the donors will be safe after transplant.

Scot: How many people actually donate kidneys?

Dr. Jeffrey Campsen: There are thousands of people, each year, that donate kidneys. Interestingly, kidney donation in the United States peaked around 2004, with about 7000 people that year donating. Since then, it's actually trickled off. I think, the last year, in 2012, only about 4 or 5 thousand people were donating. So, for some reason, it's gone down and one of the things that we wanted to do today was, basically, raise awareness that this is very safe for the donor and that's our priority, but, also, it is the best way to do a kidney transplant. The results are better than any other way to do a kidney transplant.

Scot: So a live kidney is much better than a kidney from somebody that passed away and was an organ donor.

Dr. Jeffrey Campsen: That's exactly right. For lack of a better word, we only cherry-pick the very best kidneys for live donation, again, for the safety of the donor. Where as a cadaveric donor, while those kidneys are very good, that patient has died and, from that death, the kidneys have sustained some trauma and, so, there's a difference in the quality of the kidney, but if that's all that's available, that's what we're going to use because that kidney transplant is still vastly superior to dialysis.

Scot: Tell me about the lifestyle impacts of the recipient of a kidney donation. How does it change their life, in your experience?

Dr. Jeffrey Campsen: Well, one, they no longer have kidney failure. It sounds simple, but that's true. Kidney failure is life ending. Then, two, the way that they've survived at this point is probably they're on dialysis. So it stops dialysis. Dialysis is three times a week, four hours at each run, and you don't feel great afterwards. So, all of a sudden, they have all this free time, they feel better, and, again, a machine can't replace a human organ. So, the quality of filtration that the kidney transplant is doing is better than any other method and they just feel better.

Scot: And what are your final thoughts?

Dr. Jeffrey Campsen: I think that if you're able to donate your kidney, that's wonderful. What you can do is you can, basically, help somebody, you can be a hero to your community and that person, and, then, the ripple effect that happens from that is then that person goes back into the community and helps the community as a functioning person.

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Interviewer: The kidney 101, what is it? What can go wrong, and what can you do about it? We're going to find out next on "The Scope"

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You are listening to "The Scope".

Interviewer: Time for kidney 101, kind of the basics on the kidney, talking with Dr. Jeffery Campsen from the University of Utah. Let's start with, what exactly is the kidney and what does it do?

Dr. Jeffery Campsen: You've got two of them and they sit basically in the lower part of your back. And they are the organs in the body that filter the blood. And the filtration that they do then produces the pee, the urine that you make. So they're the body's filter.

Interviewer: All right. So let's talk about what's in the blood that's getting filtered out by the kidneys. I find that interesting.

Dr. Jeffery Campsen: So there are two things. One is as you continually go through life you're breaking down parts of your body and that's getting into your blood and it needs to be filtered. The second thing is as you eat the nutrients are being digested, getting into the blood, being delivered to the different organs that need them, and then it's the byproducts of those organs. Just as with anything in life you make waste and you need to filter that out so you can basically stay healthy. And then the kidneys filter out anything that they can and then produce urine, and that's how you get rid of it.

Interviewer: Are there different levels of kidney failure?

Dr. Jeffery Campsen: There are. So the neat thing about the kidney is you're actually built with too much kidney. Right.

Interviewer: That's good.

Dr. Jeffery Campsen: It is. So you probably have four times as much kidney as you need, so you can take away one of your kidneys and still have twice as much, but doctors will monitor that. So if you have 100% at one point, they monitor it until you get down to about 25%. At that point, they're going to say, "Well, you're starting to have kidney failure. You may need dialysis or you may even need a kidney transplant at that point."

Interviewer: And dialysis is simply the external filtering of that blood.

Dr. Jeffery Campsen: That's exactly right. So medically we've been able to build a machine that removes blood from your body, filters it in the machine, and it puts the blood back. Again, it's not perfect. It's not as perfect as a human organ, but it does keep patients alive and allowed to stay alive for a long time.

Interviewer: How often do I have to go in for dialysis?

Dr. Jeffery Campsen: Many patients it's three times a week for about four hours a time. So it's an intense amount of time. I don't think people feel very good on dialysis, but they feel better than if they don't have dialysis. If you don't have dialysis, you'll die from your kidney disease.

Interviewer: And what are some of the reasons that a kidney might fail? Let's get back to both lifestyle and naturally occurring.

Dr. Jeffery Campsen: I think some people are born with innate diseases that can ultimately cause the kidney to fail. Some people are only born with one kidney. Some people are born with small kidneys. Some people are born with a defect that ultimately causes their kidneys to fail.

Then on the flip side you could have perfect kidneys, but your lifestyle treats the kidneys poorly. Meaning that for whatever reason you're overweight, you have high blood pressure, high blood pressure being the main thing that hurts the kidneys. So if you control your blood pressure, you're going to protect your kidneys. Diabetes is another one where the diabetes, the disregulation of your sugar or your glucose will then cause your kidneys to be damaged also.