Autotransplantation to Alleviate Pain, Save KidneysJun 2, 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.
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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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