Loin Pain Hematuria Syndrome Research Articles

LAPAROSCOPIC RETROPERITONEAL LIVE DONOR RIGHT NEPHRECTOMY FOR PURPOSES OF ALLOTRANSPLANTATION AND AUTOTRANSPLANTATION

We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation. A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation. All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks. In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.

Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome

Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome

Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome.

To evaluate early results of the intra-ureteric instillation of capsaicin for the treatment of loin pain haematuria syndrome (LPHS). Ten patients with LPHS were treated using intra-ureteric capsaicin instillation. A solution of capsaicin was infused into the affected ureter through an embolectomy catheter, under anaesthesia. The success of the treatment was assessed using patient questionnaires and the quantitative reduction in the patients' analgesic requirements measured. During a mean follow-up of 6 months, six of the 10 patients had short- to medium-term symptomatic relief after one or more treatments; four had no relief from their symptoms. One patient had a mucosal ulceration in the bladder after extravasation of the capsaicin solution. Two patients subsequently underwent simple nephrectomy for symptomatic nonfunctioning kidneys. These results are consistent with other preliminary reports of the efficacy of capsaicin treatment in LPHS and such treatment therefore has a definite therapeutic role in this difficult condition. We are uncertain if the treatment contributed to the deterioration of the excised kidneys. This early experience suggests a need for careful consideration when contemplating this treatment, with attention directed to both the initial diagnosis and possibly the technique of capsaicin/instillation. We include a protocol to follow when preparing patients for capsaicin treatment.

RENAL AUTOTRANSPLANTATION FOR THE LOIN PAIN-HEMATURIA SYNDROME: LONG-TERM FOLLOWUP OF 26 CASES

Purpose We review the long-term results of renal autotransplantation as a form of nephron sparing renal denervation for patients with the loin pain-hematuria syndrome. Materials and Methods From 1985 to 1997, after exclusion of other urological, nephrological and psychiatric causes for severe intractable flank pain and recurrent hematuria, 22 patients with severe debility and heavy narcotic dependency underwent 26 renal autotransplantations for pain control. Postoperative pain relief, narcotic use, level of function in daily activities and status of the autograft were assessed. Results Median and mean followup was 78.5 and 84.7 months (range 30 to 138), respectively. There were 2 technical failures. Pain recurred within 2 years after 6 procedures, of which 3 resulted in transplant nephrectomy and 3 were managed with a reduced analgesic requirement. Of the 16 patients with minimum 5 years of followup 12 (75%) were pain-free after surgery with 3 additional patients pain-free after transplant nephrectomy. Overall, 18 of the 26 autotransplant procedures (69.2%) resulted in pain relief, in some cases beyond 10 years, with patients returning to normal daily activities. Conclusions Renal autotransplantation results in durable narcotic-free favorable results in the majority of meticulously screened loin pain-hematuria syndrome patients. Although some failures, which usually occur within 2 years after surgery, can be expected, autotransplantation is justified as a nephron sparing denervation therapy for select loin pain-hematuria syndrome patients.

Loin pain haematuria syndrome: distress resolved by pain relief

Loin pain haematuria syndrome (LPHS) is a syndrome of severe chronic pain of unknown aetiology. This study assessed pain, mood variables and psychiatric status in patients ( n=26) with LPHS. Patients were assessed before and after treatment with capsaicin. Assessment inventories used were the McGill Pain Questionnaire, the Pain Discomfort Scale, the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Pain relief was achieved in 65% of patients. In this group pain ( P<0.001) and psychiatric ( P<0.01) scores were significantly reduced. By comparison, in those patients who did not gain pain relief, scores remained steady ( P>0.05). In addition, most pain-free patients completely stopped their opiate analgesia without addictive symptoms. These results suggest an organic pathology to LPHS and militate against suggestions of primary psychological cause or drug addiction. The results also show that the psychiatric disturbances associated with this chronic pain disappear if the pain disappears.

The use of surgical sympathectomy in the treatment of chronic renal pain.

To assess the efficacy of renal sympathetic denervation in the treatment of chronic renal pain. In a 10-year period, 21 patients suffering from chronic renal pain underwent 27 renal denervation operations, six of which were bilateral. The cause of pain was the loin pain haematuria syndrome in 18 patients. Four operations resulted in complete pain relief to date (median follow-up 53.5 months). Pain relief after the other 23 operations in 18 patients lasted a median of 6 months. Assuming that recurrent pain was due to neuronal regeneration, nine of the 18 patients with recurrent pain underwent a total of 10 re-explorations of the renal pedicle, stripping it of all nerve fibres and areolar tissue. Three of these re-explorations produced complete pain relief to date (median follow-up 40 months). The median pain-free interval of the other seven re-explorations in six patients was 19 months. Renal denervation cures severe intractable pain in about 25% of patients. Recurrence of pain could be prevented in more patients if there was a way of preventing re-innervation.

Autotransplantation as an Effective Therapy for the Loin Pain-Hematuria Syndrome

Autotransplantation as an Effective Therapy for the Loin Pain-Hematuria Syndrome

Recurrent graft pain following renal autotransplantation for loin pain haematuria syndrome.

To review retrospectively the Perth experience of autotransplantation for loin pain haematuria syndrome and identify possible factors associated with its failure. The medical records of 11 women patients (median age 42 years, range 29-48) who had 12 autotransplantations were reviewed. All patients were then interviewed and asked whether they considered the operation a success. All patients initially had complete relief of symptoms. Three patients who had four transplants are still symptom-free with a follow-up of 24-46 months. Five patients have had partial relief with marked variability in their patterns of recurrent pain. Three patient have symptoms as severe as those before operation. One kidney was lost because of acute thrombosis and another developed a urinoma. No patient had deterioration in renal function. Renal autotransplantation is a treatment option of last resort, with acceptable morbidity in patients with intractable, functionally disabling renal pain, but three-quarters of these patients may develop recurrent pain in the transplant site. A current or past history of depression or absence of haematuria may represent risk factors for a poor post-operative prognosis. Treatment failure is predictable by a poor response to sympathetic neurolytic block.

Loin pain haematuria syndrome.

Loin pain haematuria syndrome is a descriptive diagnosis of recurrent episodes of loin pain accompanied by haematuria, in which investigations do not reveal adequate pathology to account for the symptoms. The majority of patients present between 20 and 40 years, but onset may occur in older children. A significant number of patients show psychological and psychopathological features. Renal histology may show minor abnormalities, including mesangial proliferation, arteriolar and arterial hyalinosis and C3 in arterioles. Renal angiography is often normal but changes in intrarenal arterioles and cortical infarcts may be seen. Haematological abnormalities include decreased heparin-thrombin clotting time and elevated free plasma serotonin concentration. It is important that the assessment include a detailed psychiatric history, the patient's perception of pain, and the psychosocial environment. The pain may be very severe, leading to the requirement for addictive analgesics: management often becomes very difficult and frustrating to medical practitioners. Surgical intervention with capsulotomy, denervation and autotransplantation should only be considered as a last resort, as there is frequent recurrence of pain on the same or contralateral side.

Loin pain-hematuria syndrome associated with thin glomerular basement membrane disease and hemorrhage into renal tubules

Loin pain-hematuria (LPH) syndrome is a poorly understood disorder in which the patients, mainly young women, experience unexplained severe chronic unilateral or bilateral flank pain associated with gross and/or microscopic hematuria. By contrast, thin glomerular basement membrane (GBM) disease is generally thought to be a benign disorder, affecting males and females equally, in which the major manifestation is asymptomatic microscopic hematuria. Herein we describe seven patients (6 females, 1 male) in whom thin GBM appeared to be the cause of the LPH syndrome. The gross hematuria in these patients could be attributed to thin GBM disease because the renal biopsy demonstrated red cells in renal tubules (indicating glomerular hematuria) and the only glomerular abnormality present with thin GBM. In addition, the other causes of gross hematuria were excluded by appropriate testing. The flank pain in these patients might also have been the result of their thin GBM disease. This is suggested by renal biopsy findings of multiple renal tubules filled with red cells, apparently occluding the tubules. We suggest that occlusion of a relatively small fraction of renal tubules could cause renal pain if back-leak of glomerular filtrate occurred that was of sufficient magnitude to expand renal parenchymal volume and stretch the renal capsule. Preliminary observations suggest that treatment with the angiotensin converting enzyme (ACE) inhibitor enalapril importantly reduces the frequency and severity of the episodes of gross hematuria and flank pain in most patients. ACE inhibition might decrease glomerular hemorrhage in patients with think GBM by decreasing glomerular hydrostatic pressure. We conclude that (1) Thin GBM disease can be the cause of gross hematuria, apparently as a result of rupture of thin GBM. (2) Rupture of thin GBM resulting in hemorrhage into renal tubules may be the cause of the flank pain and gross hematuria in some patients with the LPH syndrome.

Loin pain hematuria syndrome: Pain relief with intrathecal morphine

Loin pain hematuria syndrome (LPHS) is characterized by hematuria and incapacitating loin pain. The pain experienced with LPHS is, in general, extremely difficult to treat. Many surgical and pharmacologic therapies have been directed at LPHS pain without success. This report documents successful pain control in a patient with LPHS using long-term intrathecal morphine delivered via an implantable pump. Intrathecal narcotic therapy may provide pain relief for the chronic pain of LPHS.

Loin pain-hematuria syndrome: Howeffective is renal autotransplantation in its treatment?

Objectives. To evaluate our experience with renal autotransplantation in the management of loin pain-hematuria (LPH) syndrome after relatively long follow-up (30 to 35 months). Methods. Four patients with LPH syndrome of 3 to 18 years' duration underwent technicallysuccessful autotransplantation. All patients preoperatively had normal radiologic investigations, including renal arteriography and biopsy. All required narcotic analgesia for pain control. Patients were followed for 30 to 35 months. Results. All 4 patients were pain and narcotic free for 6 months postoperatively. At 18months after surgery, 3 of the 4 had recurrence of the pain and at 30 months, 2 required nephrectomy. Only 1 patient of 4 had sustained pain relief at 35 months. Conclusions. Renal autotransplantation certainly offers temporary relief from LPH syndrome,but in our experience this was not durable in the majority of our patients.

Bilateral nephrectomy and haemodialysis for the treatment of severe loin pain haematuria syndrome

Bilateral nephrectomy and haemodialysis for the treatment of severe loin pain haematuria syndrome

IgA nephropathy and loin pain haematuria syndrome associated with acute renal failure

IgA nephropathy and loin pain haematuria syndrome associated with acute renal failure

Renal Autotransplantation in the Loin Pain-Hematuria Syndrome: A Cautionary Note

The current literature suggests that renal autotransplantation is nearly uniformly effective in controlling the severe and debilitating pain of the loin pain-hematuria syndrome (LPHS). However, we report two patients thought to have this syndrome in whom renal autotransplantation did not result in long-term control of pain. In case 1, autotransplantation resulted in immediate cessation of pain; however, the flank pain recurred 7 1/2 months later. The recurrent pain was also severe and debilitating, requiring narcotic medications for control. In case 2, autotransplantation of the left kidney resulted in chronic pain in the left pelvic area, the site of the autotransplanted kidney. In addition, the patient continued to experience chronic discomfort in the left flank and along the flank incision. One year after autotransplantation, the patient still requires multiple daily doses of narcotic medications for pain control. Our two patients represent the 13th and 14th reported patients subjected to renal autotransplantation for management of LPHS. They represent only the third and fourth reported patients with recurrence of pain after renal autotransplantation. Because studies with negative results are less likely to be reported in the literature than studies with positive results, it is possible that the literature overestimates the effectiveness of renal autotransplantation in the LPHS. To assess the true effectiveness of renal autotransplantation in LPHS, a survey of patients with LPHS who have undergone renal autotransplantation needs to be performed.

Loin Pain-Hematuria Syndrome: Role for Renal Autotransplantation

The loin pain-hematuria syndrome is a poorly understood constellation of symptoms consisting of persistent hematuria and intractable loin pain with negative comprehensive urological evaluation. The patients are severely debilitated by the pain and are usually dependent on narcotics. Various medical and surgical treatments have been tried unsuccessfully, ultimately leading to nephrectomy in many instances. The symptoms may subsequently occur contralaterally. Renal autotransplantation as a form of nephron-sparing denervation therapy for relief of pain was performed on 12 kidneys in 10 patients (2 bilaterally). Excluding 3 patients with followup of less than 1 year (all 3 are pain-free), 8 of the 9 autotransplantations have resulted in dramatic relief of pain, curtailment of narcotic use and return of the patient to normal daily function. Median followup was 43 months (range 15 to 53 months). The remaining patient had pain in the graft area necessitating transplant nephrectomy 4 months later. For patients severely affected by pain and narcotic dependence with this syndrome, renal autotransplantation may provide a nephron-sparing surgical solution.

31. Are there abnormalities of ureteric peristalsis in loin pain haematuria syndrome?

31. Are there abnormalities of ureteric peristalsis in loin pain haematuria syndrome?

Heterogeneity of Glutathione S-Transferase Isoenzyme Expression in Renal Disease

Recent work has suggested that glutathione S-transferase (GST) enzymuria may be used to assess renal injury in transplant kidneys. There is little work investigating the possibility of using glutathione S-transferase enzymuria to assess other renal diseases and this study was undertaken to evaluate the localisation of GST isoenzymes in various glomerular and tubular pathologies so that the specificity of these enzymes as markers of tubular injury could be defined. Immunostaining was carried out to establish the location of alpha and pi class GST in renal biopsies from patients with a wide variety of renal diseases including membranous glomerulonephritis, minimal-lesion glomerulonephritis, mesangial proliferative glomerulonephritis, loin pain haematuria syndrome, and renal allograft rejection. In the cases of glomerulonephritis studied, alpha class GST was detected in proximal tubules and pi class GST in distal convoluted tubules, podocytes, and Bowman's capsule. The majority of cases of glomerulonephritis showed a heterogeneous pattern of expression of both isoenzymes: that is, there was variation in intensity of staining both in single tubules and also between tubules as opposed to the uniform staining pattern observed in normal kidneys. The location of enzymes in the cases of glomerulonephritis was the same as that in normal kidneys and we were unable to demonstrate any de novo expression of GST isoenzymes. However, seven out of ten renal allograft biopsies showed expression of pi class GST in proximal tubules which were atrophic. Provided there is no significant tubular atrophy, urinary release of these enzymes may be used to localise renal tubular injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of loin pain hematuria syndrome by renal autotransplantation

Loin pain hematuria (LPH) syndrome is a poorly understood and relatively rare symptom complex, but one that increasingly deserves recognition as a clinical entity. The syndrome lacks specific diagnostic criteria, but patients with this condition, most frequently female, present with microscopic hematuria and incapacitating loin pain, usually leading to narcotic addiction. The appellation LPH syndrome was first applied by Little and associates [ 11, who described the original cases in England. Since then, no more than 130 cases have been described around the world. Various pathogenetic mechanisms have been postulated and a multitude of therapies attempted, but the entity remains a diagnostic enigma and a therapeutic dilemma for patient and physician alike. The patient described herein is presented to heighten the awareness of American physicians concerning this obscure syndrome and to suggest renal autotransplantation, to date employed mainly by the Australians, as a therapeutic option. The case report is accompanied by a chronologic review of the existing literature concerning this entity.

Treatment of loin pain hematuria syndrome by renal autotransplantation

Treatment of loin pain hematuria syndrome by renal autotransplantation