Loin pain hematuria syndrome: pain relief with intrathecal morphine

Treatment and Management of Loin Pain Hematuria Syndrome

PURPOSE OF REVIEW

Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available.

RECENT FINDINGS

LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Renal impairment and analgesia: From effectiveness to adverse effects

Kidney pain is one of the clinically significant features of renal dysfunction. Mild to severe pain is seen in the lower back area. Painkillers are mostly recommended in these cases to relieve the symptom. Yet, several analgesics are associated with side effects that can worsen the state of the disease. This review is based on the studies conducted in these aspects analgesics used to treat kidney pain and their effectiveness, renal consequences of postoperative analgesia, and pharmacogenetics of these palliatives are briefly summarized in this paper.

Clinical and safety outcomes of laparoscopic nephrectomy with renal autotransplantation for the loin pain-hematuria syndrome: a 14-year longitudinal cohort study

OBJECTIVE

The objective of this study is to assess clinical and safety outcomes after laparoscopic nephrectomy with autotransplantation for loin pain-hematuria syndrome (LPHS).

METHODS

We conducted telephone interviews using structured questionnaires and retrospectively reviewed data on all patients who underwent laparoscopic nephrectomy with autotransplantation for LPHS between January 2000 and May 2014.

RESULTS

A total of 24 laparoscopic nephrectomies with renal autotransplantation of 21 patients with LPHS were reviewed. Eighty-three per cent were female with a mean age of 31 years. Postoperatively, graft loss resulting in subsequent nephrectomy occurred in two patients; However, no patients died (median follow-up = 22 months, range 5 to 78 months) or required dialysis (median follow-up = 10 months, range 0.2 to 178 months). There was no significant difference in estimated glomerular filtration rate (eGFR) before and after surgery (100 ± 22 vs. 97 ± 23 mL/min/1.73 m² ; P = 0.37). Among 14 patients (16 autotransplantation) with telephone follow-up, 14 (88%) resulted in pain relief and no operation resulted in worsening pain. All procedures resulted in immediate pain relief; pain recurrence was reported after two procedures. However, those patients had pain-free period up to 36 months. The quality of life was better after 15 (94%) autotransplantation with higher employment rate (44% vs. 69%; P = 0.04). Two patients with graft loss reported better pain control and quality of life.

CONCLUSIONS

Renal autotransplantation is a possible treatment option for LPHS refractory to conservative medical treatment. It can offer pain relief and better quality of life. Despite postoperative risk, it seems to be safe for survival and renal outcomes.

The outcome of renal denervation for managing loin pain haematuria syndrome

OBJECTIVE

To evaluate the outcome of renal denervation for the treatment of loin pain-haematuria syndrome (LPHS), a rare syndrome of unknown cause associated with debilitating and intractable loin pain.

PATIENTS AND METHODS

The case notes of 32 patients having 41 renal denervations were reviewed. Data collected included patient demographics, possible causes, cure or not after renal denervation, time to recurrence of pain after denervation and further operative intervention for managing LPHS.

RESULTS

Full data were available for 24 patients (13 women; median age 43 years, range 28-74) having 33 denervations (eight bilateral and one repeat) with a median follow-up of 39.5 months. Most patients had no identifiable underlying cause although many had initially been diagnosed as having stone disease (42%) or pyelonephritis (25%), but with no corroborative evidence. All patients had been extensively investigated and had normal urine samples and cytology, and no abnormality on intravenous urography, renal tract ultrasonography and isotopic renography. Twenty-four renal denervations (73%) were followed by recurrent ipsilateral pain at a median (range) of 11 (0-120) months after surgery. Nine denervations (25%) in six men and two women were curative (median follow-up 16.5 months). Of those with recurrent pain, nine (38%) proceeded to nephrectomy, of whom three then developed loin pain on the contralateral side and two developed disabling wound pain. The analgesic requirement was less after eight non-curative denervations. There were no significant postoperative complications.

CONCLUSIONS

Renal denervation has only a 25% success rate for managing pain associated with LPHS and should be used cautiously for this indication. Men had more benefit from the treatment; a third of patients had less requirement for analgesic after non-curative denervation.

Implantable devices for pain control: spinal cord stimulation and intrathecal therapies

Untreated chronic pain is costly to society and to the individual suffering from it. The treatment of chronic pain, a multidimensional disease, should rely on the expertise of varying health care providers and should focus not only on the neurobiological mechanisms of the process but also on the psychosocial aspects of the disease. Implantable devices are costly and invasive, and such efficacious therapies should be used only when more conservative and less costly therapies have failed to provide relief of pain and suffering. Spinal cord stimulation provides neuromodulation of neuropathic, but not nociceptive, pain signals and when used for appropriate indications in the right individuals provides approximately 60-80% long-term pain relief in 60-80% of patients trialled for efficacy. Intrathecal therapies with opioids such as morphine, fentanyl, sufentanil or meperidine--or non-opioids such as clonidine or bupivacaine--provide analgesia in patients with nociceptive or neuropathic pain syndromes. Baclofen, intrathecally, provides profound relief of muscle spasticity due to multiple sclerosis, spinal cord injuries, brain injuries or cerebral palsy.

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.

Labour pain management in a parturient with an implanted intrathecal pump

PURPOSE

We report the peripartum anaesthetic management for vaginal delivery of a chronic pain patient with an implanted intrathecal pump. This is the first report describing labour analgesia in a patient with such a device. As intrathecal systems become more popular for the management of nonmalignant pain, this situation is likely to be encountered with increasing frequency in the future.

CLINICAL FEATURES

The patient was a nulliparous 23-yr-old with a history of chronic hereditary pancreatitis whose intractable pain had been managed with intrathecal morphine 3 mg.day-1 via an implantable pump for four years. Inadequate time between presentation and onset of labour prevented us from using this system. Intravenous patient controlled analgesia with fentanyl using a bolus of 25 micrograms and a lockout of five minutes was ineffective and epidural analgesia using bupivacaine was initiated and resulted in satisfactory analgesia.

CONCLUSION

The presence of an existing intrathecal delivery system does not preclude the use of supplemental epidural analgesia during labour.

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.

Comparative antidepressant effects of intravenous and intrathecal thyrotropin-releasing hormone: confounding effects of tolerance and implications for therapeutics

A significant amount of preclinical and human data indicate that thyrotropin-releasing hormone (TRH) has antidepressant effects. Although early studies showing these effects using intravenous TRH were not consistently replicated, it has been suggested that this could be explained by its poor blood-brain barrier penetration. For this reason we compared the antidepressant effect of intrathecal and intravenous TRH administered in a double-blind design to 2 treatment-refractory patients with bipolar II disorder. Each experienced a robust antidepressant response by both routes; subsequent open trials of intravenous TRH also were effective until apparent tolerance developed. Intrathecal TRH was readministered and both subjects again experienced robust antidepressant responses. These preliminary data suggest a differential mechanism of tolerance to the two routes of administration and raise the possibility that a subgroup of patients may be responsive to the antidepressant effects of TRH independent of its route of administration.

Intraspinal opioid therapy for chronic nonmalignant pain: current practice and clinical guidelines

The multidimensional nature of chronic nonmalignant pain lends itself to numerous treatment options, which vary in cost and invasiveness. Based on the principle that less invasive and less costly interventions for pain treatment should be attempted first, a continuum of interventions for chronic pain states is presented. Although intraspinal opioid therapy is a relatively invasive and costly modality for pain treatment, it has a rational place in the treatment continuum for some chronic nonmalignant pain patients. A thorough review of the literature, supplemented by clinical experience, provides a foundation for the development of management guidelines.

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.