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Dr. Campsen: If you are being evaluated for an organ transplant, you're going to come in to the University of Utah for a full day workup, and one of the people that you'll meet is our social worker. Today, we're going to talk about that part of the organ transplant visit.

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Dr. Campsen: My name is Jeff Campsen. I'm a transplant surgeon at the University of Utah and I'll be talking with Melissa Morales, one of our social workers at the University of Utah Transplant Clinic.

So we have people that come in who are in organ failure and need an organ transplant and we try to have them come in during a full day visit to meet a medical doctor, to meet our financial advisors, but also to meet you as the social worker. And I'd like to talk to you a little bit about what that visit's like and what is your role in that visit?

Melissa: Anytime I've kind of explained to patients what I do, I sort of start with, "I'm here to make sure that they are a good candidate and I want them to not be at risk." I take a detailed social history and some of the things that we talk about is their mental health history. We talk about having adequate support, this is family support, emotional support, making sure that they have sufficient resources. A lot of our patients are from out of state and so they have to stay here for up to four weeks.

And overall, it's about compliance. It's about making sure that they are going to be a good candidate, they're going to follow the medical team's recommendations so they have excellent results after transplant.

Dr. Campsen: So that's what they can expect from your visit. Is there anything else that they should be prepared for when they come in?

Melissa: I think it's important for them to know that the reason why we're here is because we want successful results. This isn't necessarily to rule someone out or to find out anything negative about them but it's really to see who they are and what resources they already have in place and what's available to them, how we can further help them if they need to be.

Dr. Campsen: So once you see them, you're going to give them recommendation to the Transplant Selection Committee on whether or not they should receive an organ transplant. And based on what you're saying, have you ever actually said no to somebody? And if you have, are there avenues for them to change and then proceed with their organ transplant?

Melissa: So I actually haven't ever said no. I would say that most of the patients are doing well. Again, they have this support, these resources in place. There are times where patients come in with unmanaged mental illness and they need additional support from either an individual therapist or a psychiatrist, and we help make those referrals to community services and get the help that they need.

Dr. Campsen: So as part of the transplant team then, how does your interview really affect the transplant process?

Melissa: So I sort of serve a dual role. I am there to evaluate and to assess how I think that they would do post-transplant. But I also am there to advocate, to link them to these community resources, to refer them out if they need to be. You know, we see these patients about once a year, and so there are times where I have to follow up with them more than that if there are any concerns on my end. So we get to build a connection, a relationship throughout their listing, and it's great.

Dr. Campsen: But this dual role is interesting because not only are you an advocate for the transplant program and helping the transplant program select the right people to give organs to, you're also a member of the team of the patient. And how do you navigate that dual role?

Melissa: You know, my goal, my purpose is to make sure that patients are successfully transplanted in a safe way and that they have the resources and support that they need, making sure that they're linked to exactly what they need that will help them have successful results.

Dr. Campsen: Well, I know what advice you've given me. What advice would you actually give a patient that was coming in to clinic to see you?

Melissa: I think something really important that I like patients to know is that their mental health really affects their physical health. If they are depressed or have anxiety, all those things are going to exacerbate especially after transplant, and I want them to know that we have these resources, we have ourselves, and we're available to help them through any sort of difficulties that they might have from an emotional, psychosocial side. You know, I really like making these connections with patients. Sometimes I do wish that I had more interaction with them than just once a year. But just seeing how successful they are, see how different their lives can be, a lot of them go back to work after several months and, you know, they talk about how grateful they are for our team and really for this process and having gone through that.

Dr. Campsen: I know that I always like to say that basically, once a patient gets listed and they get an organ, they're always a member of our team and they always have medical resources. But they also have social resources, correct?

Melissa: Right. Yeah, so we're available to them post-transplant. You know, we usually say for about a year after but we're happy to meet with patients any point whether it's been years out or, you know, within a few months.

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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.

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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: Coming up next on The Scope, if you are a brittle diabetic, a possible treatment option.

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Interviewer: If you suffer from a kind of diabetes called brittle diabetes, you might want to consider a different type of treatment you might not have heard of before. We're with Dr. Jeffrey Campsen from the University of Utah Health Care. He's a transplant surgeon here. The process is called pancreas alone surgery. What exactly is that?

Dr. Campsen: What we're talking about today are patients with type I diabetes that have very unstable diabetes, meaning they've tried their best to control it but they're still very brittle. What that means is they have swings in their sugar levels, their glucose levels, whether they go too high but more importantly they go too low. If you have too low sugars, it's known as hypoglycemia and that can be deadly. If you have the inability to control this with standard therapies, which is insulin and insulin pumps, one therapy we may offer you is a pancreas transplant.

Interviewer: All right. So if some of these other things haven't been working for whatever reason, a pancreas transplant might be the key. How would somebody know if this is something that would be right for them?

Dr. Campsen: Well I think first of all, there's two types of diabetes. There's type I diabetes, which means that your pancreas doesn't actually make the hormones that you need, insulin and glucagon and other things. Then there's type II diabetes, which means that you're resistant to the insulin. So a pancreas transplant doesn't work very well if I'm giving you a pancreas and you're already resistant to insulin, so we're just talking about the type I diabetics.
Once you know that you're a type I diabetic, and most people do know that, it's are you able to comfortably treat this safely. Many people use insulin, they have insulin pumps and monitors, but the problem is not only do they not produce insulin, but they don't produce a hormone called glucagon, which then keeps them from going too low. If they continue to have these episodes where they get too low sugars, then it risks their life. So if this is happening they're referred to as a brittle diabetic.
The final thing is that if they're brittle and the insulin levels are swinging back and forth and the glucose levels are swinging back and forth, they may have other complications. Whether or not they're going blind because of the diabetes, they have nerve damage, they have other issues, chronic infections. These may be reasons that we'll then offer you a pancreas transplant that you would then benefit from.

Interviewer: The name pancreas alone sounds interesting to me. Why is it called that?

Dr. Campsen: Historically the diabetes will attack the patient's kidneys over time. As their kidneys go into failure, we can give them a kidney transplant. But a kidney transplant in a type I diabetic doesn't work as long as it does in non-diabetics because the diabetes comes back and attacks the graft, the kidney transplant, and shortens the life of the kidney transplant. So historically we would give both a pancreas and a kidney to those patients that would need it to protect the kidney. The other school of thought is, why wait until your kidneys have already failed? Why not give you a transplant sooner, a pancreas transplant alone, that then protects your kidneys so you never need a kidney transplant?

Interviewer: So kind of the old school way of thinking was, when it gets to the really dangerous situation, that's when you do the transplant. This is a little bit more proactive.

Dr. Campsen: That's right. And you have to understand that there's a balance, because transplant surgery is a big deal. The surgery itself is a large vascular surgery, and on top of that you have to take immunosuppressive medications for the life of the transplant. So you're kind of trading diabetes for the disease of transplant. However the disease of transplant is much smaller and safer than this brittle diabetes that people talk about or kidney failure.

Interviewer: So if catching the patient before things get terrible is the key, how soon could somebody get one of these transplants?

Dr. Campsen: Many type I diabetics are diagnosed when they're children. That's probably too young because you have to have someone who's very responsible who can take care of the transplant. So we like to see the patients get at least towards their late teens if not into their 20s. They have to really show that they've really tried to manage their diabetes aggressively and very good compliance with their insulin and they've still failed.

Interviewer: All right. What should a patient know at this point? This isn't something that necessarily a lot of physicians would refer.

Dr. Campsen: Right. I think the interesting thing about type I diabetics is the only way that they survive is by really managing their disease. Obviously physicians, endocrinologists, medical doctors have to help them and support them to do this. But they're living every second of their day and their lives with this, and if they're able to control it, then they know a lot about diabetes. They know whether or not they're brittle. They know whether or not their other organs are starting to fail because of the diabetes. Then I think a patient who has this needs to realize that we now offer this as a therapy to help cure the diabetes.

Interviewer: What would be your one takeaway for somebody listening to this?

Dr. Campsen: I think if you're a brittle diabetic, and you know who you are, then pancreas transplant may be an option for you and you should come talk to us. You'll meet our transplant team, the professionals that manage different types of transplants at the University of Utah, and we'll sit down and see if you qualify for this and more importantly will you benefit from an organ transplant?

Interviewer: What are some of the benefits of getting the transplant versus not?

Dr. Campsen: Well I think that basically there's nothing better than a human organ. Everything that we do outside of transplant is approaching the quality that a human organ can give you, but there's nothing better than that. So if you're having trouble with your diabetes and you're noticing it's still damaging you, whether it's giving you heart disease, eye disease, nerve disease, all the kind of things that really happen because of type I diabetes, the fact that you're married to your insulin pump, then a pancreas transplant is an option that then will cure your diabetes. The moment that you have the transplant you're off insulin.

Interviewer: It sounds like the sooner that you contact somebody and talk about this, the better because I would imagine there is a wait time for pancreas transplants.

Dr. Campsen: There is a wait time. First of all you have to go through the workup, and then once you're listed the available organ has to be offered to you. It can be a year or two.

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

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

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

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

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Dr. Campsen: Today we're here talking about the transplant process. Dr. Jeffrey Campsen, one of the abdominal transplant surgeons at the University of Utah, and I'm here with two of our transplant coordinators, Heidi and Hillary, who are going to answer questions about the transplant process. The purpose of this today is to describe the process and help people understand what they go through as they're being listed and going to transplant.
This can be a very difficult time in your life, and we're hoping this information can help you understand the process and help it be easier. Patients come in to the University of Utah, and they have some sort of organ failure disease. What's the first step as far as being referred to the transplant center?

Heidi: First, I want to explain that everyone gets assigned a transplant coordinator. The transplant coordinator sees them through the whole process of the transplant. From the time they're referred, while they're on the waiting list, and during their post-transplant phase, they have someone that they can contact at any time and be able to see them through to anything that they need to do.
We see you in clinic. We schedule any appointments that you need that are related to your transplant. We retrieve and review your medical records. We present you to the committee. We have a committee of people that are there to also walk you through the process as well. We actually get you listed on the transplant waiting list, and then we monitor you while you're on that list.

Dr. Campsen: So, an outside physician may have a patient that has some sort of organ disease, whether it's kidney failure, liver failure, or type 1 diabetes. Then, they're referred to our transplant clinic?

Heidi: Yes, the patient can be referred by a physician or they can self-refer. Once we get their information, then we send them out a packet. They fill out the information, giving us their medical records and sign a release so we can retrieve those records and review them with the physicians.

Dr. Campsen: Once they come to clinic, what happens there? Hillary, you're one of our pre-coordinators on liver. What happens after that?

Hillary: Once they come to clinic with us, we typically have them see our social worker. They see our transplant coordinator, they see the financial coordinator, they see dietary, and they also see one of the transplant pharmacists. So they get a pretty good understanding of who we all are as a multidisciplinary team. We each get a chance to meet with them, review what our piece of the education is with them, and just help them feel more at ease with what's happening through the process to get a better understanding of the testing that's going to happen.
Typically, we schedule our diagnostic testing for the following day where they go through a battery of lab tests, medical imaging, echo, and all those kinds of things. Once they go through that process, then we take all those things together and make a summary sheet out of that, which we do present to our selection committee, which is basically all of those same multidisciplinary people who review all the information that we gather and determine whether or not they are an appropriate candidate for transplant.

Dr. Campsen: That sounds a little overwhelming. How long does that take, and can it be overwhelming?

Hillary: It's very overwhelming, especially if you have not been seen by such a team in the past. Typically, you've seen probably your primary care doctor, or your hepatologist, or your GI doctor, kidney doctor, or whoever it may be, and then they refer you and then all of the sudden you're bombarded with a bunch of the team.
Basically, the first person you typically meet with would be the transplant coordinator who tries to explain to you everything that's going to happen over the next little bit that day as well as the following day. We also send out a packet ahead of time informing you so that you have the opportunity to call and ask questions prior to that actual meeting.

Dr. Campsen: Once all of this transplant day goes by, then what happens? We go to selection committee?

Hillary: We go to selection committee. Once we've determined that you're an appropriate candidate, then it goes on to our financial coordinator who submits everything, all the medical information, to the insurance company, and the insurance company from that point makes a decision, which typically can take anywhere from a few days to several weeks. Once we have that approval, then we would ask you to get labs drawn again, at least from the liver side, to get a MELD score. Once you have that MELD score, we can list you.

Dr. Campsen: Heidi, the transplant selection committee. Can you tell us a little bit about that?

Heidi: The selection committee is made up of physicians that specialize in kidney disease, the surgeons, it's also made up of social workers, pharmacists, and the dietician attends that meeting as well. There are several nurses that are involved in that.

Dr. Campsen: So it's made up of a fairly large group of highly trained professionals, and then the patient's presented?

Heidi: Yes, we present the patient at those meetings. The goal is to see if they're ready for transplant. Once they're ready for transplant, then we can list them on the deceased donor wait list. The difference with kidney verses any other organ failure is that we have dialysis that bides us time, so the workup for kidney is not as quick. As Hillary was saying, when they bring someone in the very next day they do testing, with kidney transplant we don't do that. We send them back home and they do testing that's in their local area, but you do have someone that walks you through the entire process.

Dr. Campsen: The timeline of how quickly the workup can happen is really based on the severity of illness?

Heidi: Yes, absolutely. It depends on their age, it depends on their comorbidity and it depends on their diagnosis.

Dr. Campsen: Once the patient is presented at the selection committee and they get placed on the list, then they're available to be called in for a transplant?

Heidi: Yes.

Dr. Campsen: They can be called in at any time. How does that process work?

Heidi: We ask them to be available 24 hours a day, seven days a week. That includes nights, weekends, and holidays. They could get a call any time. With kidney transplant, they do not need to live locally but we do ask them that they're available any time over the phone so that we can start the process of bringing them in.

Dr. Campsen: They can come in from almost anywhere. You and I were just on call the other night, and you had to bring in a patient from far away, is that correct?

Heidi: Yes, I was very surprised when I spoke to her and she told me she was in Hawaii.

Dr. Campsen: She was able to get a medical flight and come in, and she received a successful transplant.

Heidi: Yes. She was here within 10 hours and did receive her transplant.

Dr. Campsen: Really, depending on the circumstances, we really try to bend over backwards to bring our patients in and make sure that they can be available for transplant.

Heidi: Absolutely. Our goal is to have you have a successful transplant.

Dr. Campsen: Hillary, once a patient gets called in, what should they expect from the time of being called to basically going into the operating room?

Hillary: We request that they be there about a certain time, and request that they wait in the waiting room until the admission people are able to get them a room if they aren't able to get one prior to them leaving their home. They are taken to their room with a packet of information that goes to the operating room with them. They may spend a short amount of time in that room. They may spend hours or days, even, in that room as well, because we don't know for sure how long it's going to take for things to progress with the donor.

Dr. Campsen: That's a good point to where our transplant program will never transplant an organ we don't think is going to work. At any given time, what could be called a dry run can happen. Can you describe that a little bit?

Hillary: We've had patients who can be considered back up, or they may be considered primary, which is the patient who is expected to get that organ, but they may come in and something can occur. As a transplant coordinator, I typically make sure that I let them know that this is a potential organ transplant, that this is not a definite thing, so that they aren't surprised or disappointed, as much as we can make them not disappointed. Things may not happen. There may be an issue with the donor. There may be an issue with them. We don't know for sure that they're well enough to be transplanted at that point in time.

Dr. Campsen: We really try to err on the side of making it so that they can get an organ. If for some reason they come in once or twice and the organs don't work out, we explain to them that's okay because the organ has to be right for them.

Hillary: Right. I explain that to them a lot throughout the pre-process as well just so that we let them know ahead of time that this could potentially happen and we don't want you to be surprised when something happens and it's not unusual for that to happen.

Dr. Campsen: If everything works out, they go to the operating room and they receive their organ. What we're talking about is either a liver transplant, a kidney transplant, a pancreas transplant, or actually what we call multivisceral where they could receive a combination of a couple transplants. The transplants can take anywhere from four to 12 hours, depending on how that goes. Once they come out of the operating room, they're in our intensive care unit. What should the patients expect over the next couple of days, do you think?

Hillary: I try to also inform the family and the patient ahead of time as well to let them know that the patient's going to come out typically intubated with a breathing tube in so they are not surprised when they come out and see them with a lot of hardware, with lots of tubes and pumps and things attached to them, because that's typical of what happens post transplant. When they see them we just want them to not be scared and think that's abnormal. That's a normal part of the process.
Then they usually will spend, depending on the organ, with livers, sometimes in the ICU six to eight hours. Sometimes they're there for days. It just kind of depends on how sick the patient was going into transplant. Our typical stay in the hospital, we like to keep it around a week if we can, but some of the patients are very, very ill going into transplant and that just is not a possibility.

Dr. Campsen: Heidi, during their stay and before they leave, the families and the patients get teaching so they don't just leave the hospital with a new organ?

Heidi: Yes. They get one-on-one education with their discharge coordinator. They get a new, what we call, owner's manual to their new organ where they will be able to have all of the instructions they need as far as when to call us, what they need to look for, signs and symptoms, and so forth.
They also are discharged with their medications. We don't want to take a risk that their pharmacy will be closed or what have you, so we want to make sure that they their medications with them when they leave the hospital and they understand everything. We have color-coded charts for them, and everybody knows what's going on before they leave the hospital, including all of their follow-up visits.

Dr. Campsen: That packet is basically called an owner's manual, right?

Heidi: Yeah.

Dr. Campsen: We give out what each organ gets an owner's manual, and they get a pillow that looks like their organ. The bottom line though is that we don't want our patients to leave with any questions at all. They need to be very well informed. However, if they do leave, there is a coordinator on call 24 hours a day that they can speak to. Is that true?

Heidi: Yes. Twenty-four hours a day, there's someone available, a registered nurse, to talk to them and work out any situation that they may have.

Dr. Campsen: It's different for each of the organs, but basically there's an intensive amount of follow up, especially in the first month. Is that correct?

Hillary: There is a lot of follow up. With liver specifically, we have them have labs drawn three times a week, we have them follow up in clinic at least once a week, just depending on how well they're doing. We ask patients who live not locally that they need to be aware that they need to have some place to stay within our area for approximately four to six weeks just so that they are available should something happen. We want to make sure they're stable enough before we actually send them out to be home far away.

Heidi: For kidney, they only are required to stay for about two weeks with the promise that they'll come back for their frequent follow-ups. Then they also have a little bit less stringent lab follow up, but we do want to see them back weekly for about a month.

Dr. Campsen: I know the head liver doctor that we have here, Dr. Box, talks about the first 100 days. The first 100 days after transplant is very important because it's a little bit of a roller coaster ride. Managing immunosuppression, following up with your labs, and any sort of issues normally happen during that time, and it's different for each organ. Would you agree that once they get about 100 days out, it's less intense after that?

Hillary: Yeah, the first 100 days can be a rollercoaster. Rejection typically happens earlier on if they're going to have some kind of rejection.

Dr. Campsen: What I like to tell patients is after the transplant's done, that they're part of the club. We monitor them for basically the life of the organ, which is basically their entire life. Is that true?

Hillary: That's true. We follow our patients basically from the time that they first get referred to us until forever. I let them know that, "You're with me until you're listed, and then you move on to somebody else and they keep you forever."

Dr. Campsen: Heidi, based on this discussion of how transplant evolves, what is the take-home message that you would give somebody listening to this?

Heidi: I think it's important for everyone to know, whether they're a patient or a family member, that you have a team of professionals that are here for you before, after, and during the transplant process.

Dr. Campsen: Hillary, if anybody has any further questions, how would they get in touch with us?

Hillary: We have a University of Utah transplant website that I believe will lead you to whichever organ transplant you're having. If you're a liver transplant patient, it will show you what the liver program referral process is, what you need to do. It gives you all the phone numbers if you have any specific questions. I would highly recommend you checking out the University of Healthcare website.

Dr. Campsen: Those pages have been updated recently with patient stories, the coordinators, and the physicians and the team members, too.

Hillary: That's correct.

Dr. Campsen: I think, if you wanted to do a little research, that's a good place to start. Thank you two very much for coming and helping educate the community. I really appreciate your time today.

Heidi: Thank you for having us.

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

Dr. Campsen: There's a new treatment available for hepatitis C without the horrible side effects, and we are preventing the recurrence of hepatitis C and the need for retransplantation of the liver due to reinfection. I'm Dr. Jeffrey Campsen. I'm a liver transplant surgeon at the University of Utah, and that's 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. Campsen: I'm here with . . .

Dr. Gallegos-Orozco: Dr. Juan Gallegos-Orozco. I'm an Assistant Professor of Medicine at the University of Utah School of Medicine, and I'm part of the liver transplant team.

Dr. Campsen: Juan, thanks for joining us today. The study that we're talking about today is a study that we're involved with for our patients that are receiving liver transplant for hepatitis C. What's exciting about it was that it's never been available, especially in the state of Utah, and its available now to our patients as a trial. The way that the trial is set up is that these patients are listed for liver transplant because of their cirrhosis, but they also have a Hepatitis C infection. They also probably have had a cellular cancer on top of it. They are then treated with the antivirals that you described, and hopefully the hepatitis C virus is cleared down to an undetectable level. At time of transplant, they receive their liver transplant and are given an immunoglobulin called Civacir that then continues after transplant. Hopefully, in combination of the antivirals before transplant, the liver transplant, and then the immunoglobulin after transplant will keep them from ever having hepatitis C again.

Dr. Gallegos-Orozco: Yes. This strategy is very exciting because following the footsteps of the hepatitis B immunoglobulin, which are antibodies against hepatitis B and was a big step forward in transplanting patients with hepatitis B, which is another kind of viral infection that can also cause chronic hepatitis, cirrhosis, and liver cancer. In hepatitis C, we're following this strategy, and our goal is to prevent the reinfection of the new or healthy liver that's being transplanted. The way we achieve that, like you mentioned, is not only with treatment before the transplant, but also with this immunoglobulin or antibodies against hepatitis C in an effort to neutralize any residual virus and, hence, preventing the reinfection of the transplanted liver. We hope that this strategy, in combination with the antiviral therapies, will ultimately lead us to prevent infection of hepatitis C, which, as you know, is a big problem in transplantation.

Dr. Campsen: It's a huge problem. So if you get a liver transplant and then the Hepatitis C comes back, it's basically a brand new infection in the liver transplant. It can really blossom to the point to where those patients won't survive the year after the liver transplant because the virus is so aggressive in how it comes back, which is demoralizing and tragic to everybody involved.

Dr. Gallegos-Orozco: I agree.

Dr. Campsen: Let's talk about this study. We started this study this past year, and we enrolled our first patient in the study. Can you tell us a little bit about him?

Dr. Gallegos-Orozco: Yes. This gentleman that we enrolled was a patient with chronic hepatitis C. He had developed cirrhosis and complications of his cirrhosis, and one of those complications was liver cancer. The patient was listed for liver transplant, and we followed him very closely during his course. We treated his liver cancer successfully, but he still required a liver transplantation. We knew that he had hepatitis C. He had the genotype one, which is one of the most difficult genotypes of hepatitis C to treat, and we were fortunate enough that we were able to get him through treatment with these new antivirals that did not require any interference. Just the combination of two pills that he took everyday for several weeks were good enough to decrease the amount of virus in his blood to basically undetectable levels.
At that time, a liver became available, and he was transplanted successfully with this healthy liver. Because of his participation in the trial, he also received this hepatitis C immunoglobulin or antibodies against hepatitis C, and he's completed the first six weeks of this treatment after transplant. So far, there's been no evidence of recurrence of hepatitis C in his blood, and his liver graft is doing very well.

Dr. Campsen: How exciting is that? Basically, what we did was we cured the hepatitis C if you can use that word. It's a strong word, but that's what I believe. We also cured him of his liver cancer, which is something that you probably couldn't have done a year ago.

Dr. Gallegos-Orozco: Correct. I agree, and I think that's a very exciting time, not only in the treatment of the hepatitis C overall, but certainly in the treatment of hepatitis C in our liver transplant patients.

Dr. Campsen: As with any medical procedure, there are concerns as to the safety of the procedure. Liver transplant in and of itself is a high-risk procedure. At the University of Utah, we have excellent outcomes, and our patients have done very well. However, when you add other new medications on top, there's a concern. Specifically for the Civacir trial, the hepatitis C immunoglobulin trial that we're speaking about today, I feel that it is a very low-risk procedure. How do you feel about it?

Dr. Gallegos-Orozco: I agree. So far, the evidence of the side effects from this clinical trial that we're participating in have shown that this procedure is safe and very well tolerated. It basically requires the patients that are participating to receive this immunoglobulin after an IV infusion, and they do that for several times during their first few weeks after liver transplant. So far, they've tolerated the procedure well. It hasn't been associated with any significant adverse events, and we feel that it's similar to the hepatitis B immunoglobulin and other types of antibodies that are used in medicine that overall it's a safe procedure. Of course, in the setting of the clinical trial, we're very vigilant about side effects, and we monitor our patients very, very closely.

Dr. Campsen: We're one of the centers that are involved in this trial. I think there's about 20 centers across the United States that are involved in the trial, and they're seeing very similar results to ours. Which are one, the safety profile of the drugs seems to be excellent, and then, two, the efficacy, meaning does it actually work, also seems to be very good. There are different arms of the study, but the study arms where the patients are actually getting the drug that we're talking about, no one's had a recurrence of the virus, which, I think, is an excellent result.

Dr. Gallegos-Orozco: I agree, and definitely, that's what we're wishing for with this, hepatitis C antibodies to prevent reinfection of the liver. So far, that's what the trial has shown.

Dr. Campsen: But with any study, it's the long-term follow-up that really makes the difference. So today we're talking about the early success of this, how excited we are to do something that we've never been able to do before, but, again, we're going to monitor it at a university setting along with our other universities that are involved and see if it truly is a therapy that will be used long-term.

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

Interviewer: You just had a surgery. You might be wondering when can you get back to your life, the things you enjoy doing, your activities? We're going to find out next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: How long after surgery until you can kind of get back to your life the way it was before surgery? That's a question a lot of people have. We're with Dr. Jeff Campsen. He's a surgeon at the University of Utah Hospital. So, when can you get back to your life after surgery?

Dr. Jeff Campsen: Well, it depends on the type of surgery you have. Anytime you have some sort of incision that goes intra-abdominal, you have to heal that incision. Depending on your state of health, it can be shorter or longer. An average time length that a lot of people say with an abdominal incision is about one to two months or even just six weeks to where you really want to let it heal and you try not to put too much pressure on your abdomen during that time.

Interviewer: Is it the skin that's the issue, that that's going to break apart, or is there muscular things underneath that need to heal as well?

Dr. Jeff Campsen: That's exactly right. It's the deeper tissues, what's called the fascia. The fascia needs to heal, and that's what you would get a hernia through. The skin heals fairly quickly, but the deeper tissues take a little bit longer to heal. That's what takes one or two months. Those tissues are basically what make up your abdominal wall. They're sewn back together, but then the stitches that we use, the deep sutures, will only hold up so long. Most of the time over time they get absorbed, so it's really your body reforming that abdominal wall.

Interviewer: Oh, so after surgery there's multiple stitches. There's the stitches inside of me, and then the stitches I see on my skin.

Dr. Jeff Campsen: That's right. You can have internal sutures or external sutures on the skin, but it's the deep sutures that are really what's prohibitive to getting back to your normal daily activities. Basically, lifting anything greater than 10 pounds, putting any kind of stress on you abdomen.

Interviewer: Wow. That's not a lot of weight. I mean, you can't go grocery shopping without lifting something that's 10 pounds.

Dr. Jeff Campsen: You can't. Most children are greater than 10 pounds, which really puts a damper on a lot of people and just daily activities puts you in that position. But it's worthwhile waiting for it and letting yourself heal because then the end result is that you tear through those sutures or don't heal, and eventually you get an abdominal wall hernia, which then can be life-threatening and will need to be fixed at some point, adding another surgery onto what you've already had.

Interviewer: Wow. So it's very serious stuff.

Dr. Jeffrey Campsen: It can be.

Interviewer: Yeah.

Dr. Jeffrey Campsen: It can be extremely serious, and this is the one thing where it's a good idea to pay attention to your doctor.

Interviewer: All right. So what types of activities are OK and not OK?

Dr. Jeffrey Campsen: I think as you get further and further out, the activities open up more. In the first two weeks you have to be very conservative. You want to walk, because getting out of bed opens up your lungs and pumps blood back from your legs to your heart, so it keeps you from getting a pneumonia or blood clots. So you definitely want to get up, walk, and do activities around the house. You can still do desk work and different things like that. You need to be active to allow healing.

After about two weeks, at two to four weeks you can start doing a little bit more physical activities. What I tell my patients is there's a little voice in your head that's probably saying, "Eh, that's not a good idea," and if that pops up, you should back away from it. Then after a month, you should start to push it a little bit. If it feels bad, don't do it. Wait a couple days. Try it again. If it feels good, move forward, because I'm not there with you, and you're going to be, basically, living this every second and you need to sort of use a lot of common sense on what to do and not to do, and basically really listen to yourself. The mantra is, "If it doesn't feel right, maybe give it a few more days."

Interviewer: Got you. When you say feel bad, you're talking about pain? Is that what you mean by feel bad?

Dr. Jeffrey Campsen: Pain, pressure. You know, you don't want to hear somebody call in and say, "I lifted something and I didn't listen to you, and I heard a pop."

Interviewer: Oh.

Dr. Jeffrey Campsen: What you want to do is not get to that point, and so you're basically. . . If you're pushing yourself a little bit, you're starting to lift something heavy, you're starting to do some exercise, all the good things that we actually do want you to do, and you start to feel pressure on your belly, maybe back away and give it a little bit of a rest.

Interviewer: So, it sounds like if you just kind of pay attention to your body, you're going to have a fairly good idea of what is appropriate or not. Or should you do far less than what you feel is appropriate?

Dr. Jeffrey Campsen: No, I think if you pay attention to your body, you can pretty much do what's appropriate. It's just you really have to use some good common sense and listen to yourself and not push it too far.

Interviewer: Anything else that we should talk about? Anything that might surprise somebody about this topic? Anything that you feel like we forgot, or feel compelled to say?

Dr. Jeffrey Campsen: I think one whole different aspect is this also comes into the realm of when can I drive after surgery? I think driving comes back into your abdominal wall healing. It's not so much your ability to turn the steering wheel and press the gas pedal. It really comes down to: Is your abdominal wall healed enough to where you can stomp on the brake? You obviously need to be off your pain medications, because you can't drive on pain medications, but if you can stand straight up after surgery, whatever many days later, and take your brake foot and stomp on the ground really hard and it doesn't hurt your belly so bad that you are writhing in pain, then you can proceed to drive.

The reason that is, is that most people can drive around. They can push on the gas pedal. They can work the clutch, all that kind of stuff, but if they get into a situation where they've got to stomp on the brake to stop their car rapidly, and they can't because it's painful to them, then they're going to get into a wreck.

This kind of goes into when is your abdominal wall healed enough that you can handle that? Everybody heals a little bit differently, and so it kind of comes into common sense. So, if you can do that test before you ever get into the car, and you're successful, chances are you're going to be fine.

Interviewer: Should you avoid twisting, turning motions?

Dr. Jeffrey Campsen: This gets into. . . You know, it's springtime in Utah, and a lot of people are golfers. What we basically say to that is very similar to lifting and all the other things. You can turn and twist, but if it starts to put too much pressure on your belly, you need to wait. As you get two, four, six week out, you can do more and more.

The analogy with a golf club is maybe in the first two weeks just sort of use your putter, and in the two to four weeks, you can sort of use an iron and just do a half of a backswing. Then, maybe after six weeks to eight weeks, you can really do that full golf swing that you want to do. I think that sort of relates to, basically, what do you do with your abdominal wall, and any of that twisting and turning you can do more and more as you get further out from the sugary, but also the rule, again, is if I feel like it's painful, if it's putting too much stress on my abdominal wall, back off. Give it a couple days to rest, and then try it again in three or four days.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

updated: June 29, 2018
originally published: June 25, 2014

Interviewer: You've had a surgery now what do you eat afterwards? Does it matter? We're going to find out next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: After you've had a surgery does your diet influence how well you'll heal? We're with Dr. Jeffrey Camden. He's a surgeon at the University of Utah Hospital. Does your diet matter after surgery?

Dr. Jeff Campsen: I think so. Let's start from the beginning, so you have some sort of inter-abdominal surgery, and you come out of the surgery, and at some point you're going to want to eat again. Some people take a couple days to feel hungry, some people want to eat right away, and it depends on what's going on. So we sit down as the managing team and really try to make sure that your intestines for lack of a better word wake back up and can accept food and basically allow you not to get sick after surgery. So the things that we look for are basically everybody hears their stomach rumble, we want to hear those sounds. So after surgery sometimes your intestines can shut down. It's called an ileus and it basically means that the intestines aren't actively moving food forward, and so if that's happening then you can't eat yet.

Interviewer: And that rumbling is that what's happening?

Dr. Jeff Campsen: That's your intestines basically waking back up. Basically being comfortable that no one's going to go in and touch them again and operate on them again.

It's interesting there's actually two things that help your intestines wake up and they've been proven. One is getting up out of bed and walking because that normalcy and the pumping of blood from the walking through the body helps, and then there is a good study out of the Mayo Clinic that said chewing bubble gum actually helps intestines come back quicker, and it's probably because you're not really creating any food but you're giving that sort of reflex of tasting something in your mouth and stimulating your stomach and your lower intestines to think that they need to be working, and so chewing gum and walking those two things are probably the best advice that you can get to moving along.

Interviewer: Got you, alright so what types of foods do you want to start eating at that point?

Dr. Jeff Campsen: So at that point when we start hearing bowel sounds, and we actually ask our patients, you know, "Are you passing gas?" This is a difficult question for some people because no one wants to admit that, but in this particular case that's a good thing and we want to hear that. What we don't want to hear from you is that you're burping. Burping's bad, that means that stuff's not going through and it's backing up in your stomach's getting distended. The reason that that's concerning is if your stomach gets too distended it can cause you to vomit, and if you vomit too much and you've just had surgery, and you're mildly sedated you can actually breathe that vomit in which is called aspiration, and it can give you a very bad pneumonia.

Interviewer: Does that have any chance at that point of rupturing those internal sutures?

Dr. Jeff Campsen: I think that it can. Your abdominal wall is going to spasm to do those violent vomiting episodes, and you probably can damage the repairs that we've made on you, and so we'd prefer that not to happen.

Interviewer: So at this point are you still under the care of a physician and a team?

Dr. Jeff Campsen: Yes.

Interviewer: Up until this point.

Dr. Jeff Campsen: Right, so you've come out of the operating room, we're in the first sort of 24 hours, 24, 72 hours, are you starting...Are you not burping, is your intestines making the rumbling sounds, and plus or minus are you passing some gas? At that point what we would start you on is basically some clear liquids. If you can see through it it's not thick, not milk which is very thick, we start you on that. If you can tolerate clear liquids then we, what we call it is advanced diet is tolerated, then you may go onto something soft, it's called a soft mechanical diet, that's not very spicy, not hot, not all these kind of things that may upset your stomach, that's very bland. Bread and sort of soup those kind of things and if you handle that then you can move along to what you would want to eat.

Interviewer: Alright and when you get discharged and you go home what should you be thinking about in your diet at that point?

Dr. Jeff Campsen: Well I think at that point you can basically go back and eat whatever you would normally want to eat. I do think it's an opportunity to really reevaluate what you are eating and basically try to eat healthy because if you've had inter-abdominal surgery you need the building blocks for healing, protein, sugars, different things that go into along your abdominal wall to heal, and if you're eating unhealthy during that time you're not going to give your body the kind of tools and building blocks that it's going to need to heal properly. So you want to look at your diet and try to eat as healthy as possible during that time. Now if you can parlay that into lifelong better dietary habits then that's great. You might as well; you've gone through the surgery you might as well benefit from it on that angle too.

Interviewer: Got you, so it sounds like if you ate healthy beforehand just continue your normal diet afterwards. If perhaps you didn't have the best diet beforehand that be a good time to reevaluate and maybe make some lifestyle changes.

Dr. Jeff Campsen: I think so; I think it's extremely important during the first month to eat healthy because again you have to have the right components in your diet to allow your body to then create a new abdominal wall, for lack of a better word. To heal that area that was, where the incision was made, and if you don't give your body that then you're not going to heal well, and then if you get an infection, a complication, a hernia it could be a result of that.

Interviewer: And what does it mean to eat well? I mean do you have to go all superstar diet, super clean foods, or...?

Dr. Jeff Campsen: No I don't think so. I think it comes down to you want to have a moderate amount of calories. So you want to look and see how tall you are and based on that how many calories you should have a day and try to stick within that, and then on top on that it needs to be balanced. You need to have the building blocks of protein and carbohydrates, but all sugars and no protein, and I think based on that and who you are going into the surgery your dietary requirements fluctuate a little bit, but again it's the basic food groups that go into it, and then moderation.

Interviewer: The stuff we've learned as kids.

Dr. Jeff Campsen: That's exactly right.

Interviewer: The stuff we all know but ignore when we go to the, you know, the fast food restaurants.

Dr. Jeff Campsen: Right. No I think the biggest thing is that everybody's intestines wake up at their own speed. It's whoever your body actually is at the time coupled with the type of surgery you have, and everybody's intestines will wake up, but if you move too quickly you can hurt yourself.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: September 25, 2018
originally published: June 12, 2014

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.

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Interviewer: Organ donors save lives, but for some reason it can be kind of scary checking the "Yes" box that you want to be an organ donor when you get your drivers license or ID. You might have some questions. Well, hopefully we'll answer some of those coming up next on The Scope.

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Interviewer: I think most people know that being an organ donor is a good thing, but for some reason there might be some questions or some concerns that you have that keep you from saying, "Yes. I want to be an organ donor," when you get your drivers license. We're going to talk about some of those right now with Dr. Jeffrey Campsen, transplant surgeon at the University of Utah Hospital. First of all, if something was to happen to me and I was an organ donor, what organs would be used to help other people?

Dr. Jeff Campsen: From a solid organ transplant, which is what I do, the heart is usable. Both lungs are usable. They can go to actually individual people. The liver is usable. The liver can actually be split and go to two individuals. Both kidneys are usual. The pancreas is usable. The intestines are usable. And then expanding out from there, corneas, tissues, bone are all on the table for donation and other parts of the body, if they're not available for transplant, can actually be used for research.

Interviewer: That sounds pretty awesome. All these different organs can go help 10 or 15 people potentially, it sounds like. Why aren't more people checking "Yes" do you think?

Dr. Jeff Campsen: I think there's a couple reasons. I think that there's always a fear of death, and who wants to think about their death? Some people do, but most people don't. So avoidance of that conversation is very easy. Once you start talking about it in a time that's not emotionally charged, rationally, it sounds very good in the sense that if you do die, you can help people. I think it also provides a lot of closure for your family members and your loved ones to know that even though there was this tragedy, something really great came out of it. It's almost, like, you've become a hero in your death. I think another reason that people are scared sometimes is misinformation that people are going to try to take their organs early. The Institute of Medicine, which is a formal body governed in the United States has made very strict rules about organ donation, it's highly regulated, and about brain death. No one can donate their organs unless they are brain-dead. There's tests that have to be confirmed then reviewed. I think when people realize that it's not waiting around to try to take organs, but it's the process of dying that then you can get something out of after you're death. Again, in a non-emotional setting you understand that it's very helpful. I think the final thing is that people have a lot of deep, personal beliefs in their faith and religion. The good news is that over many years, many of the different religions have come to think about this and embrace it and realize that it's something that's acceptable. I think you just check and talk to the people in your faith and see what they think.

Interviewer: If I choose to be an organ donor, can I have an open casket funeral?

Dr. Jeff Campsen: Absolutely. Absolutely. The incisions where the donations are made are hidden, and the organ procurement organizations which are called the OPOs actually work with the medical examiner's office as well as the funeral home directors about exactly how the family and the person themselves want themselves to be presented at time of funeral, and we respect those.

Interviewer: What is the process of organ donation?

Dr. Jeff Campsen: When someone comes to the hospital and they've had an injury that results in brain death, there's an organization called an organ procurement organization, the OPO, and each region has one. Utah has one, California has one, so forth and so on. These individuals are highly trained specifically to approach families about organ donations. They're not involved with the University of Utah. They're not involved with the transplant surgeons. They're a separate organization. They approach the families and say, "The physicians that are taking care of your loved one has an unsurvivable injury and is brain-dead. Would you like to proceed with donation?" If you say, "We'd like to talk about that," they come in and they talk to you about it, and then you talk about how you would like to proceed with the donation. The drivers license allows them to come and talk to you, but also if they have not done that and you say "Yes" to it, then you have a conversation. Just because you're talking to them doesn't mean you're going to proceed, and just because you're proceeding with that doesn't mean that they take over. We work with the families on a minute-by-minute basis to make sure that donation benefits both the families as well as the patients receiving the organs.

Interviewer: As an organ transplant surgeon, it must frustrate you when people say that they're not going to donate their organ.

Dr. Jeff Campsen: It does frustrate me. I'm an organ donor. The people in my family are organ donors. It's something that I support probably because I see the good that comes out of it. Literally, these are not only life-extending procedures improvement in quality of life but life-saving procedures where many of the patients, especially those receiving heart, lungs, and livers, are literally going to die in the next month are so, and then they go onto live decades. We cure diabetes with the pancreas transplant. We take people off of dialysis with kidney transplants. It changes people's lives. It saves them. So when I'm dipped in that and I see that on a day-to-day basis, it is frustrating to know that people don't want to be involved in that. However, that's their choice, and that's okay, but this is why we're trying to educate people on this, and then they can make a rational decision at a non-emotional time if they do want to proceed and help people.

Interviewer: Any final thoughts? Any take-aways?

Dr. Jeff Campsen: These tragedies are going to happen. They happen every day, and that's unfortunate. There's nothing that we can do about that, but if donation is able to help with closure of the tragedy, help do good from that, I think it's very important, and I think people realize that after donation that even though they've lost somebody, they've helped other people, and it helps people move on.

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Interviewer: A lot of people with Type 1 diabetes believe that the insulin shots and a pump is enough, but there might actually be a better option, a pancreas transplant. We're with Dr. Paul Campsen, Surgical Director of Pancreas Transplant Surgery with the University of Utah. That option is pancreatic surgery.

Dr. Paul Campsen: That's correct. Right now we do pancreas transplants for Type 1 diabetics. Type 1 diabetics can't survive without insulin, so they give themselves shots and they can administer this sometimes through am insulin pump which is a very good way to keep them alive. The control that they get from that is not a replacement for the human organ, the pancreas. That's where the pancreas transplant comes into play in the sense that you can help yourself stay alive just like dialysis helps with kidney transplant, or with failure. A pancreas transplant gives you back the human organ that you actually need.

Interviewer: Plus, also a better quality of life.

Dr. Paul Campsen: A much better quality of life. Over the long term the pancreas transplant itself is completely correcting the diabetes, so any of the sequelae of diabetes, whether it be peripheral vascular disease, damage to your eyes, damage to your nerves, damage to your coronary arteries, all of that stuff is stopped with a pancreas transplant.

Interviewer: Not with the insulin shots or the pump?

Dr. Paul Campsen: No, I think that the insulin helps a lot. It slows down the damage. Obviously it literally saves their lives by giving them insulin, but it doesn't stop the diabetes because you're still a diabetic. The pancreas produces a variety of different enzymes and secretes many things that actually help the body including insulin, also glucagon, which keeps the sugars from going too low which can be life threatening, and any of the pancreatic enzymes that help with digestion. None of that' s given with the insulin pump. When you replace the pump with a human pancreas you get all of those benefits.

Interviewer: It sounds like a great solution. Why aren't more people doing it? Is it a dangerous surgery or is it fairly safe?

Dr. Paul Campsen: The diabetics who come to us hate their diabetes so much and they're so scared by it, and their so scared by brittleness of their, meaning they go too high with their sugar or too low, that they would do almost anything not to have to use insulin anymore, but they're scared because surgery is a big deal. The vast majority do very well with this surgery. It's very safe. They stay in the hospital for about a week afterwards, but the moment that they leave surgery they're not a diabetic anymore.

Interviewer: That's pretty amazing, isn't it?

Dr. Paul Campsen: It is pretty amazing. Many of the patients that come to us, their diabetes has also ruined their kidneys, so they're on dialysis at the same time. We'll do a simultaneous pancreas and kidney transplant. The moment that they leave the surgery the next morning they're cured of their diabetes and they're cured of the their renal failure and they're not on dialysis. The other thing that's very interesting in these patients is if you just give them a kidney transplant their Type 1 diabetes will still attack the kidney transplant.

Interviewer: It just kills that organ.

Dr. Paul Campsen: That's exactly right. The pancreas transplant added on top, because it cures the diabetes, actually protects the kidney transplant. Then both organs survive much longer.

Interviewer: Who would be a good candidate for this type of surgery?

Dr. Paul Campsen: I think anybody who has Type 1 diabetes. We're talking about unfortunate people who were diagnosed with diabetes probably before they were 20. We'd like to see these patients well before they get into their 30's. The earlier we see them the better.

Interviewer: OK. What are your final thoughts for somebody that has Type 1 diabetes and is a little on the fence?

Dr. Paul Campsen: I think basically this is a safe surgery. Coming and seeing us doesn't mean we're going to trap you and give you the surgery, but it's something where we can talk about it and see if this is the right surgery for you. If it is, we can cure your diabetes. If you have kidney problems we'll take care of those too.

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