Autotransplantation for intractable loin pain: report of a case with long-term followup

Loin pain hematuria syndrome

Loin pain hematuria syndrome (LPHS), first described in 1967, is a rare pain syndrome, which is not well understood. The syndrome is characterized by severe intermittent or persistent flank pain, either unilateral or bilateral, associated with gross or microscopic hematuria. LPHS is a diagnosis of exclusion as there still is not a consensus of validated diagnostic criteria, though several criteria have been proposed. The wide differential diagnosis would suggest a meticulous yet specific diagnostic work-up depending on the individual clinical features and natural history. Several mechanisms regarding the pathophysiology of LPHS have been proposed but without pinpointing the actual causative etiology, the treatment remains symptomatic. Treatment modalities for LPHS are diverse including simple analgesia, opioid analgesic and kidney autotransplantation. This review article summarizes the current understanding regarding the pathophysiology of LPHS along with the steps required for proper diagnosis and a discussion of the different therapeutic approaches for LPHS.

Hyperphosphaturia after kidney transplantation in syngeneic rats: effects on nephrocalcinosis and bone metabolism?

BACKGROUND

Studies on kidney transplantation have thus far mainly dealt with surgical techniques, immunology, and transplant tolerance. Disturbed mineral metabolism after renal denervation has not received much attention. Basic physiological research in short-term experiments has shown that experimental renal denervation in rats leads to parathormone (PTH)-independent hyperphosphaturia (HPU). HPU and other metabolic complications also have been described after clinical kidney transplantation. Furthermore, there is an unexpected increase in the risk of bone fracture. However, these studies have examined an organism pre-damaged with regard to the parathyroid and immunosuppression. Experimental investigations in syngeneic rats were performed to see whether HPU also occurs after transplantation and thus after denervation and which target organs are involved.

METHODS

Thirty-six male Lewis rats subjected to laparotomy (n = 12), unilateral nephrectomy (n = 12), or unilateral transplantation and bilateral nephrectomy (n = 12) were observed for 18 weeks.

RESULTS

Animals that underwent transplantation had a significant loss of phosphate in the urine not associated with decreased calcium, phosphate, or magnesium in bone. Stability test showed no deterioration, despite a slight increase in the bone parameters of alkaline phosphatase, cyclic AMP, and hydroxyproline with unchanged calciotropic hormones. Nephrocalcinosis was not observed. Parallel to HPU, there was a compensatory reduction in fecal phosphate excretion.

CONCLUSIONS

The loss of phosphate after clinical kidney transplantation in the predamaged parathyroid hormone control system as well as immunosuppression and a surprising increase in the incidence of bone fractures may be explained by the denervation-related loss of phosphate. The lack of intestinal counter-regulation could be an important pathomechanism.

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.

Hematuria-loin pain syndrome: its existence as a discrete clinicopathological entity cannot be supported

OBJECTIVE

To (a) review existing literature and current concepts on Hematuria-Loin Pain Syndrome (HLPS) and (b) to describe seven cases of this syndrome.

PATIENTS AND SETTING

Seven HLPS patients seen over a period of 8 years by the pain and nephrology services of the Toronto Hospital, Toronto, Ontario, Canada.

METHODS AND RESULTS

Retrospective analysis was performed. All patients were remarkable for the variability of clinical presentation, pain characteristics, and dissociation of pain and hematuria occurrence. Routine renal investigations revealed different benign kidney pathologies in 5 of 7 patients. All patients, however, displayed variable combinations of personality factors, drug seeking behaviour, psychopathology, and presence of significant psychosocial stressors. Four cases were managed conservatively with antidepressants, anxiolytics, and supportive counseling and did very well despite persistent hematuria in two.

CONCLUSIONS

HLPS does not constitute a distinct clinicopathological entity. In a minority of cases only underlying kidney pathology is related to pain, and in many cases psychosocial stressors and underlying psychopathology may play a significant role in the reported disabling pain. A concerted medical/psychological approach is advocated.

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.