Search for tag: "kidney"

Interviewer: Your young child has abdominal pain? It could be kidney stones. We'll find out more about that next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Gary Faerber is a urologist at University of Utah Health Care. And if your child has abdominal pain, it could be a lot of different things, but one of the things it could be that is sometimes not diagnosed properly is kidney stones because the incidents of kidney stones in kids in increasing and increasing. That's incredible. First of all, why is that? Why are kids getting kidney stones? That doesn't seem like something that I would expect.

Gary: You're right. Most people wouldn't expect that kids should be getting kidney stones. Most people think of kidney stones as happening in somebody who is in their 40s and 50s, and not . . .

Interviewer: Yeah, guys like us.

Gary: . . . absolutely, guys like us and not young kids. But there's no question that the incidence and prevalence of kidney stones in the pediatric population has gone up, and it's gone up quite dramatically. Probably over the last 15 years, it's gone up almost two-fold. So it's not that really rare thing that happens anymore, it's what I would call commonly uncommon.

Interviewer: So if a child has abdominal pain, it could possibly be kidney stones?

Gary: Yes, absolutely. There's no question about it. It, obviously, probably wouldn't be the first thing on my differential diagnosis list.

Interviewer: Yeah, it would be a little ways down.

Gary: Right, absolutely. But it's something that I think caregivers would and should think of. For example, in the pre-pubescent age group, the most common presenting signs or symptom of a kidney stone in a young child is abdominal pain. And that's seen in up to 75% of those children who present with a kidney stone.

Interviewer: And that's different than how adults present?

Gary: Yes. Adults typically present with a terrible flank pain. Why kids don't get the flank pain is not quite clear and it's clear that they get sort of abdominal pain, which is odd. The one thing that may tip a provider off, in that it might be a kidney stone, is the abdominal pain is often associated with blood in the urine. So if a child has blood in the urine and is having abdominal pain, that certainly would make me concerned that they might be having a symptomatic kidney stone.

Interviewer: Is the increase in children pretty much the same reason for the increase in adults? They're not getting enough water, which, drinking enough water is so important in preventing kidney stones. Their diet, that sort of thing?

Gary: Absolutely. Kids are just like their adult parents, where they don't drink enough fluids. Specifically, they don't drink enough water, and it's important that they do. I would love to have my listeners think that having sugary drinks is probably not a really good thing for kids. Water's a great thing and milk and all the healthy stuff is probably better for them than the sugary drinks, that's for sure.

Interviewer: Yeah. For a whole variety of reasons, not just getting kidney stones. So it's fascinating some parents might be dealing with a child that has a kidney stone. Is the treatment the same as it would be an adult, then?

Gary: Surprisingly, yes. And the good news about most kidney stones that both children and adults present with is that the vast majority of these will pass on their own, and there are medications that we can provide both adults and children that facilitate them passing the stone. In those patients, adults and children who don't pass their stone, there are very effective surgical management strategies that are available that we can treat these stones.

Interviewer: So if you take your child to the doctor and it's abdominal pain and you have to go back a couple of times, then you might want to start considering kidney stones. If you have that conversation, how would they find out for sure whether or not that was what was causing it?

Gary: There are a number of x-ray studies that are available now. I think if a child presents to the emergency room, for example, or to their pediatrician or primary care provider, either an abdominal ultrasound exam or, in some cases, a CT scan can be done. And both of those studies are very good in identifying a kidney stone.

Interviewer: Just something else a parent and a kid has to deal with in today's age, I guess, huh?

Gary: That's exactly right.

Interviewer: Or hopefully not, if you do the right lifestyle things.

Gary: Right.

Interviewer: Yeah. Any final thoughts?

Gary: Make sure that your kids drink plenty of water, especially during these hot summertimes in Utah.

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Interviewer: You had kidney stones once in your life, what you need to know going forward. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: So you already went through the process once, the excruciating pain, then the re-passing of the stone or the operation to remove the kidney stone. Does that change how you need to look at your life from that point on? Well, we're going to find out right now. Doctor Gary Faerber is a urologist at University of Utah Health Care. If somebody has a kidney stone once, are they inclined to have another one?

Dr. Faerber: Yes, they are. If you have a kidney stone and you make no changes in your lifestyle or anything else like that, you have a 50% chance of forming another stone within five years.

Interviewer: So I suppose the general advice would go, regardless of the stone, you need to drink more water, you need to watch your diet, the salts, the sugars, reduce that kind of stuff. Does that apply across the board?

Dr. Faerber: That really applies across the board and of all of the things that you've mentioned there, keeping yourself well hydrated is the most important aspect of prevention of kidney stones. And I think in patients who have risk factors, for example, if they have a family history of stones, if this isn't their first stone and they've had several others, or if they have on their imaging studies more than one stone, those people really need to have an evaluation to figure out why they may be forming stones and what can we do to prevent them.

So in those patients, they'll get some blood test to look at their overall kidney function, we'll get serum calcium levels and if that's elevated we may get a parathyroid hormone level. And then above that, we'll also have them collect urine over a 24-hour period and look at the chemical composition of the 24-hour urine. And that will help us direct what medical therapies and dietary therapies would be appropriate for the folk.

Interviewer: So you might prescribe some sort of medication to help as well?

Dr. Faerber: Yes, absolutely.

Interviewer: Yeah. And would you prescribe a very restrictive diet more so than just eating healthy?

Dr. Faerber: I often will tell patients that a really good, healthy, what they call the DASH diet, which is used for patients who have cardiac disease, the DASH diet is a good diet to prevent kidney stones. It's made up of fruits and vegetables, low sodium, limitations of red meat, mainly poultry and fish, legumes and whole grains. Eating a diet like that, especially if you manage your calories and you're not eating too much compared to your activity levels, that's a great way to start limiting or restricting your incidence of forming stones in the future.

Interviewer: So you do the analysis, the tests, based on that result, you might prescribe a medication. Is there anything else that you would tell somebody that just had a kidney stone going forward?

Dr. Faerber: Well, if they have a family history, where their mom or dad or grandfather or grandmother or a brother and sister have a kidney stone, I often tell them, "Listen, you can't run away from your genes and you're sort of stuck with who you're with." And in that case, I will really push them to make sure that they keep their fluids up. I think the only other thing that is really important is to limit the amount of salt intake that you have, watch the potato chips and move that salt shaker away from the kitchen table.

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Interviewer: Older adults are at a higher risk for death if they have low levels of bicarbonate in their blood. Bicarbonate, it's the main ingredient in baking soda. We'll talk about that next on The Scope.

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Interviewer: I'm talking with Dr. Kalani Raphael, a nephrologist and Associate Professor of Internal Medicine at the University of Utah and at the Salt Lake City VA. Dr. Raphael, tell me about the main finding of your study. It's pretty interesting.

Dr. Raphael: In this study, we were looking at the association between serum bicarbonate levels and mortality in a generally healthy older population. The basic finding from our study was that in people with low bicarbonate levels, they had a higher risk of death and their risk of death was about 24%, 25% higher over a mean follow-up period of about 10 years or so.

Interviewer: So that's pretty significant. What is bicarbonate?

Dr. Raphael: Bicarbonate is very important in the body for maintaining your pH levels in a normal range. In order for our cells and our organs to work normally, the pH needs to be kept at a range of about 7.40.

Interviewer: So people with low bicarbonate would have blood that's more acidic. Why might that be unhealthy?

Dr. Raphael: The bicarbonate levels could be low for two main reasons. One is it could be because the kidneys are holding on to too much acid and your bicarbonate levels fall. That's something we call metabolic acidosis. Or the reason the bicarbonate level could be low is because the lungs are breathing off too much carbon dioxide and your bicarbonate levels fall as a compensatory response is what we call that.

So we're not exactly sure why the bicarbonate levels were low in these people. If I had to guess, I would say that the most likely reason the bicarbonate levels are low is because of an impaired ability of the kidney to get rid of the acid that we need to on a daily basis. The main reason why I say that is because our diets are really high in acid content in these western diets that we have now. We don't consume enough fruits and vegetables in relation to the amount of acid that we intake.

So if I had to guess, I would say that the most likely reason that the bicarbonate levels were low is because of an impaired ability to get rid of acid by the kidneys.

Interviewer: So what caused you to even take a look at that in the first place?

Dr. Raphael: Well, in people with kidney disease, we know that low bicarbonate levels occur quite commonly. It occurs in about 15% of people with kidney disease who aren't yet on dialysis. What we know is that in people with kidney disease who have low bicarbonate levels, they have a higher risk of death and they have a higher risk of progression of their kidney disease to end-stage renal disease or needing dialysis or a transplant in order to survive.

But much less was really known about generally healthy people and so I was interested in whether or not low bicarbonate levels have any association with poor outcomes in people who are otherwise healthy. So that was really the driving force behind this research study.

Interviewer: So do you think measuring bicarbonate levels could be some sort of test or indicator that someone could do to evaluate the healthiness of somebody?

Dr. Raphael: Absolutely. I mean, bicarbonate levels are very commonly measured in clinical practice these days. Bicarbonate levels are measured usually when a physician wants to check on somebody's kidney function. They'll order a chemistry panel or a renal panel. In primary care, I'm not exactly sure how well people look at these levels and I think that one of the things that maybe doesn't attract their attention is they don't really know what it means for that person.

So if you had a healthy person sitting in your clinic who had a bicarbonate value that was low, I think most physicians would say, "Okay. It's low. I'm not sure what to do with that." But I think what this research is showing is that it's probably something we should be paying attention to. But I don't really know quite yet what we should do about that.

Interviewer: Right. Maybe it would be a signal that it's worth taking a second look at this patient to see . . .

Dr. Raphael: Absolutely.

Interviewer: . . . if something else is going on.

Dr. Raphael: Right. So, I think you said it correctly that it's a signal for potentially bad things. That might trigger the physician to look into their kidney function a little bit more or maybe consider underlying lung disease or heart problems in that person.

Interviewer: So do you think more research needs to be done to figure out exactly what this could mean?

Dr. Raphael: Absolutely. The key thing about this research is that these were really healthy people. I mean, they were older folks. They could have had diabetes. They could have had some cardiovascular disease. But they were independently living. They could take care of themselves. They could walk a quarter-mile. They could climb up stairs. These were pretty healthy, older folks.

Interviewer: Right. So not necessarily any other indication that something was wrong, right?

Dr. Raphael: Exactly.

Interviewer: Interesting.

Dr. Raphael: Yep. So I think the next steps are to kind of look into why this cohort had low bicarbonate levels in the first place. Is it an undiagnosed or yet to be determined type of kidney disease or some other underlying lung disease, potentially? Then, I think the next thing also to consider is can we raise the bicarbonate levels in these people with various types of interventions and perhaps improve their outcomes, make them live longer, those sorts of things?

Interviewer: Is there anything else you'd like to add?

Dr. Raphael: The takeaway from this type of research is that we can say that there are associations between bicarbonate levels and outcomes. We can't really say quite yet whether or not people should be changing their diets or taking baking soda. I think that's something that needs to be cautioned against at this point, pending further clinical trials.

But I think if somebody is interested in keeping their bicarbonate levels at a normal range, I think that the safest way to do that is to look at how much fruits and vegetables they eat because fruits and vegetables are a source of bicarbonate, that bicarbonate largely comes from citric acid in fruits and vegetables, which gets converted by the liver into bicarbonate. We all know that fruits and vegetables have great health benefits for lots of other reasons.

One of the cautions about increasing fruits and vegetables in your diet is in people with kidney disease because those have high levels of potassium and that could cause potassium buildup in people with kidney disease. So I think if somebody is thinking about increasing their fruits and vegetables in their diet to keep their bicarbonate levels in a normal range that they should probably check with their doctor to make sure that it's safe.

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Interviewer: Expanding the kidney donor pool with en bloc kidney transplantation. What is it? You'll 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: We're with Dr. Jeffery Campsen, he is a surgical director of kidney transplantation. We're going to talk about something called en bloc kidney transplantation. Is that how you pronounce it? En bloc or is it en bloc?

Dr. Campsen: Either way is fine, potato, potato. It's EN and then bloc. Some people call it lollipop kidneys. Basically what we're talking about is transplanting two kidneys from the same donor at the same time. In the United States, there are thousands of people on the waitlist for kidney transplants and there are not enough organs available. Dialysis keeps people alive, but ultimately they want a kidney transplant.

Interviewer: Nothing replaces a kidney.

Dr. Campsen: Nothing replaces a human filtering kidney. So many medical centers, high-volume transplant centers have started trying to expand the donor pool by using organs that we used to not. And one of the areas is an extremely young donor. Unfortunately, young children die and often their organs are not used because they're deemed too small to be used.

Interviewer: And how young are we talking?

Dr. Campsen: For this discussion we're going to talk about children that are less than a year old.

Interviewer: Okay.

Dr. Campsen: Really less than 15 kilograms or less than 10 kilograms. Very, very small children. And as you can imagine, just one of their kidneys is not enough to filter an adult who a normal adult's greater than 70 kilograms so it's a significant size mismatch.

But what we found is if we keep the kidneys together, meaning that they're en bloc, they're not separated at the time of donation and transplant them together into an adult that actually ends up being enough kidney volume to filter an adult. But then what we found that's really cool about this is that these kidneys grow, and over time over the next year, the kidneys will grow to almost adult size.

So at this point, a person who has kidney failure that gets the small kidneys will ultimately almost get two kidney transplants so they come off of dialysis and they do very well. And these are organs that were being wasted or discarded, not thought to be able to be used in the past.

Interviewer: Yeah, so normally a child can transplant to another child, but if you don't have another child then now they can be used in adults as well.

Dr. Campsen: That's exactly right. So what we talk about with transplantation is you have to have a blood supply and then you have to be able to produce urine for kidneys. And so the arteries and veins are the blood supply. And in the past, surgically, we thought that maybe these arteries and veins are a little small and are high risk to transplant.

But because we keep them together and use the great vessels to sew them in the aorta and vena cava, the vessels aren't as small. And then, what we can do is they stay open. They don't clot and the organs are successful. They are higher risk in the sense that they do have the predisposition to want to clot. So we use anticoagulation in these kidneys.

So the medicine and the surgery behind it is more complicated than a complicated transplant in the first place, but at a center that does these like the University Utah, and has done them successfully, our patients can benefit from these types of donors. We have a good relationship with Primary Children's Hospital and other children's hospitals in the country, which then allows us access to these organs so they're not wasted.

Interviewer: So I think where we are going with this message now at this point is that conversation that we all should have as adults, now we need to include our children as well if something was to happen, realizing that organ donation is a possibility and you could bring some good to a real bad situation.

Dr. Campsen: That's the perfect way of putting it. Unfortunately, people are going to die. And unfortunately, children are going to die. And what transplantation offers is something good coming out of that tragedy.

Interviewer: Is this something that parents that know that they have a child that might be high risk for other reasons that might die soon after birth, would those kidneys be able to be used, or are those still a little too young?

Dr. Campsen: That's a great question too. There are surgeons in the United States now experimenting with those very, very small kidneys. Talking about patients that are just being born or just after birth, that is something I think we're moving towards and those transplants that have been done have worked. And it's a high level of difficulty. You have to have it done at a center that does these and specializes in these types of en bloc pediatric donors. And that's what we're starting to provide here.

Interviewer: A very exciting time for you and for anybody that would need organs, especially in a time of shortage. Any final thoughts?

Dr. Campsen: I think when you come to your transplant center, you basically talk to them about your options. And if your transplant center offers you some unique ways of getting transplanted, whether it's very small donors, these en bloc kidneys or it's a live donor chain or anything else that that they offer you, keep an open mind because ultimately getting our patients off of dialysis is the goal. And it's complicated because there are just too many sick people and not enough organs.

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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."

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 "The Scope."

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.

Dr. Jeff Campsen: You've had kidney pain. You don't know what to do. You're at the end of your rope. There may be a procedure that can help you. We'll talk about that next on The Scope.

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

Dr. Jeff Campsen: I'm Dr. Jeffrey Campsen, and I'm here today with Dr. Blake Hamilton. We're going to talk about kidney disease, kidney pain, and techniques to help kidney pain. It's a specific type of pain that we'll talk about today that may be helped by a procedure called autotransplantation of the kidney. So there's all types of kidney pain. Is there a specific type of pain or a scenario that a patient comes to you and ultimately gets to this point?

Dr. Hamilton: Yeah. Well, first let's make it clear. We're talking about very unusual, extreme pain after other things have failed. We're not talking about your basic first time kidney stone episode. Kidney stone pain is very severe. It's some of the worst pain you can have. Most of the time, this pain goes away. The kidney stone passes. You have surgery. It gets better. But sometimes people who have had previous episodes will end up with this recurrent, chronic, refractory pain that doesn't seem to respond to anything. We can take out all the stones. We can make sure the kidney's not obstructed. Everything looks fine, and the patient still has debilitating pain. And then the question is, "What do you do? How do you help them?"

Many things have been tried. Obviously, one of the things that people do is they simply take the kidney out. Well, that's a problem because you lose a kidney. So this idea of autotransplantation is an extension of kidney transplant, which is what you've built your career on and is an expert at. The typical transplant of a kidney is a kidney that's donated by somebody else and goes into the patient. Autotransplant means it's the patient's own kidney that's taken out and then transplanted into a different part of the body. In this case, it goes down into the pelvis, adjacent to the bladder. The idea of this is that when you take the kidney out, you sever the nerve supply from the kidney, and so you stop that pain. But by transplanting it, you preserve the function of the kidney.

Dr. Jeff Campsen: So from what you've said, I've got a couple of questions. At the beginning, when you're trying to diagnose this, is there a scenario or a type of pain that really moves you in the direction that this may help them?

Dr. Hamilton: The character of the pain may range from dull and aching to severe flank pain. So it's not the quality of the pain as much. The location has to be fairly typical, but it's really the duration, the chronic nature of it, and the fact that we tried everything else to make it go away and cannot. The next step is to say, "Can we predict if an autotransplant will work?" So we've been working with our radiology colleagues, and what we have them do is under radiology guidance, they'll put a needle right by the hilum of the kidney and they'll inject some anesthetic right where those nerves run. If that makes the pain go away, then we can predict that this operation is going to be helpful for them. We're early in our series, but so far, we've got a pretty good track record. We think this is an excellent technique for predicting success.

Dr. Jeff Campsen: Now, this is something that you've developed over your career to try to figure out whether or not this will work. It's not something that's written about a lot, and it's a procedure that you've had success with recently?

Dr. Hamilton: Yeah. Autotransplant has been around for a while. It was originally described for something called Loin Pain Hematuria Syndrome, which in Layman's term means, you've got flank and and you've got blood in your urine, and nobody knows why. This is more focused on the pain aspect of it. They may or may not have blood in the urine. The success rate is somewhere between 60 and 70 percent, but by comparison with other things like chronic pharmacologic management of the pain, which is not very good and leaves people somewhat functionally debilitated because of the medications, this is an excellent opportunity to improve people's quality of life.

Dr. Jeff Campsen: In your understanding of this, why do you think this works?

Dr. Hamilton: The nerves are sending a message to the brain that something's wrong when there is no longer something wrong. So what we're trying to do is interrupt that message by severing the nerves. These are sensory nerves to the kidney, so after you sever the nerves to the kidney, the kidney functions just fine. We know that, again, from the long history of kidney transplant experience. We also know that people with kidney transplants don't really experience pain in their kidney. For example, if they get a kidney stone, they don't get that same kind of pain. That's why we suspected that this would work.

Dr. Jeff Campsen: Importantly, I think, by the time they get to this point to where you're going to offer them this procedure, they're ready to literally get rid of their kidney?

Dr. Hamilton: Most people say, "Do anything you want. Take the kidney out. Stomp on it. Get rid of it. Throw it away." But that's a little short-sighted because we have two kidneys, and there is some reserve for sure. But if you're 30 years old and you've got another 50 or 60 years to live, that second kidney may prove to be very useful down the road. So we do everything we can to save kidneys, and this is yet one more way to do that without sacrificing a good functioning kidney.

Dr. Jeff Campsen: As people are listening to this and they say, "Well, I've got pain that I think is from my kidney," how should they go about seeing a urologist or a primary provider to start thinking about this?

Dr. Hamilton: The first step is to do an evaluation of the kidney. So imaging, like, a CAT scan, looking for stones, looking for common things. Often, there may be some little stones if they have a history of stones. So, we'll usually go in and do an endoscopic surgery where we remove all of the stone pieces, all of the fragments, really clean out the kidney, and then let a little time go by and reevaluate. If the pain goes away, that's great. If there's any blockage, if it's relieved by some kind of a drain, great. But if you do several things and the pain persists, then we start talking about what we might do next. Often, these patients have had all of this done by other physicians and they come to me looking grasping for straws, looking for any hope, any sliver of a chance that they might get better. At that point, they're ready to have their kidney removed. In fact, curiously, they often ask if they can donate their kidney. I have to tell them, "No, I don't think anyone wants your kidney."

Dr. Jeff Campsen: That's a good point. I think the piece to pull away from this is that this is not the first line therapy. This is way down the road after multiple attempts to take care of the pain and the primary disease have not necessarily been completely successful.

Dr. Hamilton: That's right. This is in-stage treatment. I mean, I would guess something, like, 1 out of 10 or 1 out of 20 patients in these extreme conditions actually progress to this point.

Dr. Jeff Campsen: So someone's at the end of their rope. They've had a lot of procedures with their urologist. What do they do?

Dr. Hamilton: Most of the time, these patients are referred by their urologist who send them to me because we're a University center, and I have some experience in this. The urologist often doesn't really know what more to do either. So that's where we get started. This is not the kind of thing that's done around the community. I mean, this is a very specialized procedure. Even among academic medical centers, not everybody is offering this to patients. So, I think it will grow in popularity as we and others demonstrate good success with this.

Dr. Jeff Campsen: I think the University of Utah really provides a multidisciplinary group that can handle the care of this difficult patient.

Dr. Hamilton: Right. This goes beyond my own expertise. I mean, I need people who are good at image-guided needle placement. I need somebody who can do the transplant surgery. We need post-op management. We need pre-op evaluations. So it really is a team approach here.

Dr. Jeff Campsen: So what do you think? Does it work?

Dr. Hamilton: Well, I think our success rate is around 75 percent. It's not perfect, but I think in this patient population where there are not a lot of options, this is a very good approach. I think it's showing great promise.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, the University of Utah Health Sciences Radio.