Treatment of loin pain hematuria syndrome by renal autotransplantation

Loin Pain Haematuria Syndrome - A Narrative Review of Pain Management Strategies

Loin pain haematuria syndrome (LPHS) is an uncommon clinical entity that has divided renal physicians, pain practitioners, and even psychiatrists since its initial description. A relative paucity of data exists regarding the condition, with best practice guidelines lacking amid the existing threads of anecdotal experiences and variable follow-up observations. The aim of this article was to review the cumulative published experience of pain relief strategies for LPHS.

Loin pain hematuria syndrome: a psychiatric and surgical conundrum

PURPOSE OF REVIEW

The loin pain hematuria syndrome presents a dilemma with regards to the etiology, as well as the treatment of this rarely seen entity. In view of the increasing frequency of diagnosis, and the question of whether this disorder constitutes a somatoform disorder or a physical disorder remedied through renal autotransplantation we should familiarize ourselves with this condition, so as to clarify its nature.

RECENT FINDINGS

There may be a subset of loin pain hematuria syndrome patients that have a somatoform disorder. Patients appear to have better outcomes with autotransplantation, than with intraureteric capsaicin treatment or renal denervation.

SUMMARY

This paper attempts to provide an overview of the topic and propose further investigation to better determine whether a subset of these patients have a somatoform disorder.

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.

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: how effective 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 technically successful 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 18 months 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.

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.