Search for tag: "kidney"

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Scot: They say kidney stones are more painful than childbirth, if you can believe that. I suppose people who have had kidney stones would think that. This is "Who Cares About Men's Health," a Men's Health Essentials. We're talking about kidney stones today. Is there anything you can do to prevent them?

And we've got the cast and crew here today. My name is Scot Singpiel. I bring the BS. We've got Dr. Troy Madsen. He is the MD to my BS.

Troy: Hey, Scot. I've never given birth to a child, but I imagine it's painful and I imagine kidney stones are much more painful.

Scot: Producer Mitch is also on the show.

Mitch: Hey. So I'm looking at this pain scale, not to derail too far, but out of 50, a kidney stone says it's 42, and childbirth is a 32, and a really bad tooth break is a 19.

Scot: Oh, wow.

Mitch: I'm excited to hear more.

Scot: Dr. John Smith is a urologist. He's going to help sort us through the kidney stones. How are you doing today?

Dr. Smith: Oh, living the dream, gentlemen. Thanks for having me.

Scot: You ever have kidney stones?

Dr. Smith: I have not, but I've seen enough patients that have that I drink four liters of water a day to make sure I don't have one.

Scot: It's one of those things where when you see somebody that has it, you start doing the things that are going to prevent you from getting them. Is that actually one of the good things to do? Is it caused by not drinking enough water, or can you prevent them by drinking more water?

Dr. Smith: Absolutely. So the old Chinese proverb of the solution to pollution is dilution is correct.

Mitch: I love that.

Scot: Is that a Chinese proverb?

Dr. Smith: I don't know. It was told to me when I was training by one of my mentors and he said it was a Chinese proverb, but it doesn't sound like one to me. It just sounds like good advice.

Scot: Yeah, sure.

Troy: That's funny. So you've heard that in your urologic training, and then I hear it all the time with toxicology, with overdoses. "The secret to pollution is dilution." So, anyway, it crosses multiple specialties

Dr. Smith: And the orthopedic colleagues will say, when they're rinsing out a joint that's infected, that that's the solution.

Troy: Yeah. There you go.

Scot: So, with kidney stones, what's causing those things? Is it because of something I've eaten or something I'm doing, or are they more hereditary? What's the story on that?

Dr. Smith: Yes.

Mitch: Well, no. That's a really good question. I've got a buddy, he's a listener, and I don't want to go too far into it, but I've seen him go through kidney stones. It seems like he gets them every single year. And I know he does a lot to drink all his water, he's done some things to change his diet, but he still gets them. So what could be causing them other than lifestyle, I guess?

Dr. Smith: So I don't know. Troy, do you want to jump in here? I'm happy to go over my spiel that I give my patients who are the chronic kidney stone guys and even the ones who are first-timers.

Scot: I think we want to hear that, don't we, Troy? I mean, I could listen to Troy anytime. I don't always get to listen to Dr. Smith.

Troy: Scot gets tired of listening to me, so please go on.

Dr. Smith: Man, that was some shade, Scot. Wow.

So when I have folks that come in and we talk about kidney stones, there are a couple of different reasons that people get them. And usually, for folks that are first-timers who've never had a kidney stone before, they meet . . .

The other day I had a patient in his mid-40s who came in, never had a kidney stone, and we started discussing stones. Most commonly for folks who aren't predisposed genetically or have some kind of a metabolic issue, it's usually a hydration issue. And so dehydration will put you at risk for stones.

I usually use the analogy of if you ever made those salt crystals or sugar crystal things as a kid where you had that pot of tons of salt or sugar and you dipped a string in and you made those crystal things. You guys ever do that?

Mitch: Yeah.

Scot: Yeah.

Troy: Yep.

Scot: That's what's going on?

Dr. Smith: It's similar to that, because the more concentrated your urine is, the more stuff that's in there that could form a stone. And all a stone is, is a crystal that forms and it's made of different material. The most common ones are calcium-based. A dilute urine will not form a stone the way that a concentrated urine would. So that's the first thing I tell people to do. To drink plenty of fluids is going to keep them from having a concentrated urine. That's number one.

And I usually say there are four things that you can do to prevent a kidney stone regardless of the kind of stone you make, regardless of why you get them.

Number one is hydration. And I usually tell people you want to make at least two to two and a half liters of urine per day. Now, that's a hard one to do because nobody just measures their urine every day. And so that generally means . . .

Scot: Let alone in liters. I mean, what are we doing with the metric system here? We're in America. Come on.

Dr. Smith: Well, but in medicine we use the metric system, unfortunately. But I usually tell folks if you go get those big packs of water at Costco or the supermarket, those are a half a liter each. Those 16.9-ounce bottles are a half a liter each. So you should be drinking four to six of those a day.

Scot: Yeah, or one of those big sodas. Those are two-liter bottles of soda. Now you're talking.

Dr. Smith: Sure. See, now we're talking things. So if you drink at least 6 of those a day, your body uses between 500 and 750 milliliters of fluid a day for metabolic purposes, and so you're not making urine out of that. That's just what you need to be alive. And so anything above and beyond that gets turned into urine. That's why I say you need to drink two to three liters of water per day. To make two liters of urine, you've got to drink around three liters.

Troy: Now, Scot just mentioned he's going to go start drinking those two-liter bottles to measure it. What about drinking soda? Is that going to increase your risk?

Dr. Smith: So it can, depending on the type of stones you make. Obviously, the more stuff you have in your body that your body has to metabolize and break down and put into the urine, the more stuff is in your urine, the more likely you are to make a stone.

And so, for some folks, they're really predisposed to that, so it can make a difference for them. And for other people, it may not make a huge difference. That's something where when we get to the diet-related stuff I usually mention, but the first thing is just drinking plenty of fluids.

The second thing that anybody can do would be to decrease the amount of salt in your diet. And so that means soda. Oftentimes diet soda in particular has a ton of salt in it, as well as other processed foods. Pre-made stuff that you buy at the supermarket has a ton of salt in it.

Your body gets rid of excess salt in the urine and oftentimes the other solutes, the things that are going to help make stones, will follow that salt out into the kidneys and make urine. So that's another thing that you can avoid.

The third thing you can do is avoid animal protein. Now, that doesn't mean beef. It means any kind of animal protein -- fish, pork, chicken. Those create a high acid load in your system and decrease the pH of your urine. And when your urine pH is decreased, that increases your risk of stones. Stone formation increases when you have a low pH in your urine.

And that leads into the fourth thing that I usually tell people. Alkalinizing your urine in some way with lemon, lime, fresh fruit, berries, things that have citrate in them will cause a base to form in the urine and increase the pH.

So those are the four things you can do. Without knowing what kind of kidney stone you have if you've never had it analyzed and you have chronic stones, those are the four things you can do to decrease your risk of stones.

Scot: So coming back to our core four, kidney stones are caused by the types of foods that we're eating and drinking. It's totally diet based, right?

Dr. Smith: So not necessarily. Obviously, the dehydration thing is huge, but someone who has . . . So Mitch's buddy probably has a metabolic issue where his urine makeup predisposes him to having stones.

And so oftentimes, for folks in that situation, we'll do a 24-hour urine test and look at what's in the urine and what's spilling into the urine to see what's high level. If there are high levels of calcium or high levels of certain chemicals, high levels of nitrogen from animal protein, high levels of just salt, and different things that can predispose you to having stones, we definitely look at those.

Scot: How much does genetics play into whether somebody develops kidney stones or not? I would imagine that there are plenty of people that aren't drinking water and eating high salty foods and never get stones, or is that not true?

Dr. Smith: No, I think there is definitely a genetic component. How strong it is, is very difficult to kind of put your finger on. The literature shows that there can be some predisposition for folks who have family history.

And I've seen that anecdotally in my practice. Folks who come in at a younger age with stones oftentimes have family members who have chronic kidney stones. So I definitely think there's a correlation for those folks. Absolutely.

Scot: And you talked about the different kinds of stones. What's that about?

Dr. Smith: Well, there are a few different kinds of stone. The most common are calcium-based. There are calcium stones, multiple different kinds of calcium stones, but the important part is they're made with calcium.

Now, that doesn't mean don't drink milk, don't eat calcium. You actually want to have a normal amount of calcium, but not overdo it and not underdo it, which has been a misnomer for people. They're like, "Oh, I'll just stop drinking milk, I'll stop eating calcium, and it'll fix my stone problems." And it actually has been shown to make it worse in some of the literature. So you don't want to cut that out completely, but you also want to make sure that you're not eating other foods that may be problematic.

So calcium oxalate is the most common types of stones. And when you have a high oxalate diet . . . So coffee has oxalate, tea, spinach. Dark green, leafy vegetables have oxalate in them. There are other foods that have oxalate. Some people will say, "Oh, you've got to go on an oxalate-free diet," when in reality if you have calcium and oxalate in your gut, your gut can bind those things and it actually gets put out in the stool instead of going into the system. That's why you don't want to cut out calcium completely.

I mean, there are a lot of dynamics to kidney stones that kind of make it difficult, and knowing what type of stone you have can be helpful. So the calcium stones, we can kind of base things on diet.

The other type of stone that we see in folks is uric acid. Those are probably the second most common that I see. Those ones can actually be "melted" with medication and alkalinizing the urine, making the pH of the urine go up. So that's one where if we know that someone makes those and we keep their urine pH up, we can decrease the size and the amount of the stones that they make with the pH of the urine.

Scot: Which stones are the prettiest stones?

Troy: Calcium, of course.

Dr. Smith: They're all beautiful. They're all terrible.

Troy: Well, the calciums are kind of nice and shiny and it almost looks like a pearl.

Scot: Are you serious, Troy? Do they really?

Troy: I don't know.

Scot: I thought maybe you knew.

Troy: I just know they show up really well on an X-ray.

Dr. Smith: They do. That's the calcium.

Troy: Yeah. I don't know how they look when they come out exactly. But I can say hearing this, though, it sounds like the key is, like you said, John, drink lots of water, try to avoid eating too much meat, avoid salt, fruits and vegetables. Those are the keys. I mean, that just kind of gets back to a lot of what we talk about. Just healthy diet in general.

But hearing this, we talked just a little bit about the pain with kidney stones, but I can tell you when I see someone in the ER with a kidney stone, I don't know that I ever see anyone on a regular basis in the ER who has more pain than a person who's there with a kidney stone. You can tell. You walk in the room, they're writhing. They're pacing around the room, kind of holding their side. It's just incredible pain.

Every time I see them, I kind of have the same feeling you do. It's just like, "Hey, I want to do everything I can to avoid this." And if it means drinking tons of water and just watching my diet, it's well worth it just because that looks absolutely miserable.

Mitch: So what are some of the symptoms, I guess? I mean, we're talking about the pain itself and how to prevent them, but what are the actual symptoms? Is it just, "I've got pain in my stomach"? Or where do we feel it and things?

Dr. Smith: Well, I think Troy could probably answer that because he has them come in, but usually it's a pain in the flank, which is kind of the upper outer portion of your back on either side. And as the stone kind of travels down the ureter, that pain can migrate to the low back, even into the groin.

And I usually tell folks when stones are sitting in the kidney, they don't usually cause pain because they're not obstructing. They're not bothering you. But when they start blocking the flow of urine and they get into the ureter, the small tube, your body tries to get rid of that by peristalsing, just the way it does when it moves food through your intestines.

And so at that time, the stone, once it gets into the tube is where you start to have the pain and it usually starts in the flank and then moves down.

Troy: Yeah, and that's exactly what I see. People are kind of holding their sides. So if you were to kind of reach around, hold your sides of your abdomen, that's typically where they're feeling the pain. I push on their stomach, their belly doesn't hurt, they're not really tender, but it's just a deep, severe pain. And they'll tell me it comes and goes, it's sharp, sometimes it's better, sometimes it's worse. John, it's exactly like you mentioned, that spasm where that ureter is spasming. That's when they really seem to have severe pain.

Scot: And then is the treatment painful too? I mean, is this the double whammy of not only does the thing hurt, but the treatment is going to hurt bad as well?

Dr. Smith: Well, what Troy does for people doesn't hurt. They really love Troy. They don't like it when they come and see me after they've seen Troy.

Scot: Okay. Because Troy gives them . . .

Troy: I just give them pain meds.

Scot: And then you send them to John.

Troy: Exactly. But it's great, though, because there is a non-narcotic and non-steroidal anti-inflammatory medication that we give intravenously. And it just works beautifully for kidney stones. So it's not like we're just knocking people out with narcotics. Some people need narcotics, but so many people, I give that medication and they're just like, "Wow. I feel better."

Scot: What's the treatment then, Dr. Smith?

Dr. Smith: So there are a couple of different treatments depending on where the stone is at and different things. I mean, there's a little bit more to it here, some nuance. But if it's moving down and it's relatively small, oftentimes we'll offer people to pass it on their own. We call it medical expulsive therapy. It's not pretty, but it gets rid of the stone.

And so we give them some medication to help the stone pass. And after we do that, we let them kind of do their thing and pass the stone on their own for a couple of weeks. And if it doesn't pass, well, then we bring them back and we offer them surgery. Stones can be . . .

Scot: Ugh.

Dr. Smith: Go ahead.

Scot: No. I just went, "Ugh."

Mitch: Yeah, ugh.

Troy: Two weeks of that. Yeah.

Scot: Yeah. I don't have to say anything other than ugh.

Dr. Smith: I mean, I'll give them a little bit more than two weeks if they're really confident that they're passing it and they're not wanting to do anything surgically.

But the other options that we have are if the stone is visible on an X-ray, just like Troy alluded to earlier, sometimes we can do what's called an extracorporeal shock wave lithotripsy. Some people just refer to it as lithotripsy, where we use an external shock wave beam to break up the stone, and then you still have to pass the fragments. And that's only if we can see it on an X-ray to target and hit it.

Scot: So those are my two options? Either give birth to that stone myself or . . .

Dr. Smith: No, there are other options. I'm just saying those are the two . . .

Scot: Oh, okay.

Dr. Smith: I'm going from least invasive to most invasive here.

Scot: All right. Get them busted into shards or have surgery. Yeah, that's more reasons why to drink more water, I guess.

Dr. Smith: Exactly. So the third option that I offer folks is called a ureteroscopy laser lithotripsy, where we go up with a small, thin, flexible camera and we find the stone and we blast it with a laser.

Scot: Oh, that sounds badass.

Dr. Smith: It's pretty cool.

Mitch: It's all pretty cool, but miserable.

Dr. Smith: Yeah. And usually, with that, they have to put what's called a stent, which is a small, thin, flexible plastic tube from the kidney to the bladder. And they are miserable. I always tell patients, "It's miserable. You keep it in for about a week to let things heal and then you take it out in the office."

Troy: And I think Scot, when he thought that was really cool, I think it's probably worth telling him how you get the laser up to the stone.

Scot: Oh, no.

Mitch: Oh!

Scot: No, I'm good.

Troy: You're good? Okay.

Dr. Smith: Well, there's no cutting, Scot, so you can use your imagination.

Scot: Yeah. Just thread that thing right up there, huh?

Dr. Smith: Yep. Just like throwing darts.

And then the last thing that we do for stones if they've gotten too large to pass and they're in the actual kidney, we can do what's called a percutaneous nephrolithotomy. They use the term PCNL because it's way easier to say. And that's where we make a small incision in the back and we go into the kidney and we actually are able to remove the stone in larger pieces that way.

That's obviously the most invasive way to do it, and we do that for much larger stones. You've got to have a stone that's a centimeter and a half or larger, or at least that much volume of stone in the kidney before we would contemplate doing that.

Scot: Troy, can these stones get so bad that you're going to see somebody in the emergency room that has to have an emergency surgery because they just can't urinate anymore?

Troy: I can't say I see them where they can't urinate, because usually it's just in one of the ureters and so the other kidney is working, although you could have it, I guess. I've rarely seen it where it's so bad that you can really see it's impacted their overall kidney function.

The more concerning thing I see is when you get an infection along with the stone, and those are the cases where they're definitely admitted to the hospital.

But yeah, if it's a really large stone, like John mentioned . . . Usually the cutoff we use is six millimeters, but even there, I think sometimes our urologists will say, "Give it a little time. Let's see what happens." But if they've got a big, centimeter and a half stone just lodged in there, yeah, those are cases where the urologists will admit them and do something sooner rather than later.

Dr. Smith: Good point, Troy. When you have an infection above the stone blockage, those folks can get real sick real quick. And those are the people that emergently get surgery. And oftentimes we don't treat the stone immediately. We treat the infection. We put a stent in and give them antibiotics and come back another day to take the stone out. They're just so fragile as far as their health goes at that point that oftentimes they need antibiotics to clear out that infection before we're able to treat the stone.

But Troy is right. Anything 5 millimeters and under have a 75% to 80% chance of passing on their own. Now, that to be said, I have folks who come in with two-millimeter stones who are unable to pass them and folks with seven-millimeter stones that pass them and they said it wasn't a big deal. So, again, it's all relative to the patient. But once you get these larger stones, definitely surgery is much more frequent for those folks with larger stones.

Scot: Hey, Mitch, we're wrapping this up. Do you have anything you'd like to share?

Mitch: I'm just very uncomfortable and trying to drink my water off camera. That's what I'm doing right here right now.

Scot: You went and got some more water.

Mitch: I did. And I'm saving everyone from the sipping noises, but yeah, a refill was necessary.

Scot: These lifestyle changes that we make, Dr. Smith, is there a percentage of reduction of risk that they will do that we know about?

Dr. Smith: That's a tough one. I don't know that there's an actual percentage of risk. I would say when you do it, if you are a chronic kidney stone patient, we usually follow your 24-hour urines to check your risk assessment. But folks who have a stone and pass a stone and then hydrate themselves can really reduce their risks just by doing those things.

The numbers that I know and usually quote people is if you have a kidney stone that requires surgery, 50% of folks who have that issue will have another episode of a kidney stone within a year. And so that's why I usually tell folks the more you can do to drink and keep them away, the better off you are.

Scot: Well, it was a fun topic. I still don't know which stones are the prettiest stones, which makes me a little bit sad, but that's okay.

Dr. Smith, thank you so much for being on the show, and educating us on kidney stones, and telling us what to do. Would you like to summarize, Mitch? What are you going to do? You're going to drink water. What else?

Mitch: I'm going to just drink all the water and I'm going to make sure that I'm not having too much salt in my diet.

Scot: Watch the processed foods.

Mitch: And watch the processed foods. I need to eat less taquitos.

Scot: And maybe a little lime in your water, it sounds like. Is that right, Dr. Smith?

Dr. Smith: Yeah.

Scot: Get that pH down. Is that what that . . .

Dr. Smith: It won't hurt you.

Scot: No, that's getting that pH up, isn't it?

Dr. Smith: Yeah, pH up. Correct.

Scot: Yeah.

Mitch: Okay. So preventing scurvy and rocks in places I don't want rocks. Got you.

Scot: Dr. Smith, thanks for being on the podcast. Thanks for caring about men's health.

Dr. Smith: Troy, Scot, Mitch, it's always a pleasure. Thanks for having me.

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.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

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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Passing a kidney stone has been called the worst pain in the world. Of course it would be second to active labor and childbirth. Kidney stones are on the rise, and on the rise in women. This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at the University of Utah Health Care and this is the scope of Kidney Stones in women on The Scope.

Kidney stones are small, hard bits of crystals that have grown in the kidney, minerals like calcium that are filtered by the kidney. Kind of like hard water that develops hard bits in your tea kettle. They can be small, much smaller than a pea, but they don't feel small. They're usually without symptoms when they're growing in the kidney but when they pass down the very small tube called the ureter, they can get stuck and cause severe pain called renal colic. Renal colic is an intermittent severe pain in your back or side that might move into your pelvis as the stone is passing down to the bladder. It's often associated with nausea and vomiting and frequent urination. There may be blood in the urine. There's really nothing quite like it except childbirth.

Kidney stones aren't new. Evidence of bladder stones was found in a seven thousand year old Egyptian mummy. Bladder stones were well-known in Hippocrates' time in Ancient Greece. But kidney stones are becoming more common in the United States and more common in women. We used to think that kidney stones were a problem for middle aged men but now, they're becoming more common in middle aged women and can also be a problem in pregnancy.

Once someone's had one kidney stone, they have about a 50/50 chance of getting another. Ow! Kidney stones now affect about one in ten men in their lifetime and one in twelve women. There are different kinds of minerals in kidney stones but the most common are calcium containing stones. There are some diseases that are associated with kidney stones like gout or overactive parathyroid gland and others but the most common stones just happen.

Why is the incidence of kidney stones increasing in women? Well, the risk for stones include obesity, high-salt diet, increased sugar in the diet, and diabetes. All these risks have increased for women over the past 30 years. Some recent studies looked at the risks for kidney stones in women. 82,000 post-menopausal women were followed in the women's health initiative study. Women who didn't get stones had the highest intake of fiber, fruits and vegetables and lower sugar intake.

Unfortunately, women who've already had stones didn't seem to lower their risk of getting them by having a diet high in fiber, fruits and vegetables. So once you're a stone former you're kind of stuck, or the stone is stuck. Another study of many thousands of women showed that a diet high in calcium was a little bit of a risk but taking calcium supplements wasn't.

So you want to avoid being the one in 12 women who will get kidney stones in their lifetime, what should you do?

1. Avoid a high-salt diet, processed foods, canned foods, cheeses, bottled salad dressings, high-salt snack foods and baked goods. Avoiding these are all part of a healthy diet anyway and the rise of these foods in our diet has been associated with the obesity epidemic.

Pizza is the poster food for kidney stones, salty crust, salty pepperoni, salty cheese, salty processed pizza sauce, but you can make your own with limited salt. (Okay, maybe you can have pizza once in a while.)
2. Eat your fiber, eat your fruits and veggies without salt.

3. Make sure you drink enough water. Getting dehydrated or lower fluid intake is a risk for stone formation.

4. The calcium story is mixed. Some studies suggest that increased calcium increases the risk, some show that it doesn't. Don't restrict your calcium but don't get too much because some sources of calcium like cheese are high in sodium.

5. Maintain a healthy weight. Obesity is a risk but maybe it's the foods that are associated with obesity that we already mentioned.

If you've had a stone, talk to your doctor about what kind of stone you made. What minerals were the crystals made of and what should you do to decrease your risk of recurrence. In the interest of full disclosure and as I am disclosing it, isn't a HIPAA violation. I'm a middle-aged, chubby, pizza-loving woman who is one of the one in 12. And having a kidney stone certainly got my attention, I was very impressed.

So if you want to avoid the worst pain ever except child birth—and there you get a baby out of it, which is much better than delivering a little kidney stone—eat your fruits and veggies, keep your gut happy with a high-fiber diet, and stay hydrated. Limit your salt and sugar intake, maybe pizza only twice a month. And stay tuned to Scope Radio.

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.

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.

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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.

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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.

Announcer: We're your daily dose of science. Conversation. Medicine. This is The Scope. University of Utah Health Sciences Radio.

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

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.

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

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.