October 2009


Today’s Los Angeles Times reports that the UCLA Medical Center recently performed kidney transplants in a chain that involved 18 patients, resulting in nine transplants. The chain started with one nondirected donor, followed by eight incompatible donor-recipient pairs, and finally ended with a recipient without a donor.

As outlined in a sidebar story, the surgeries were not simultaneous, which meant some donors underwent their surgeries after their recipient partners had already received kidneys.

UCLA

A mother and son formed an incompatible pair. Photo from LA Times

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This morning, I’m attending a Patient Lifestyle Meeting hosted by the Renal Support Network. These meetings are intended for patients with chronic kidney disease (CKD) and their family members. However, I am attending in order to meet some people who are on dialysis to learn more about their daily activities.

The goal of these meeting is to provide encouragement to patients with kidney disease or a kidney transplant. The Renal Support Network website states:

“Any illness—and particularly CKD—is too demanding when you don’t have hope. If people with CKD do not believe they have a future, then the demands placed upon them by dialysis or by the immunosuppressant regimen will prove overwhelming. The goal of the patient lifestyle meeting series is to let patients know that their kidney problems are just that… problems that can be overcome with hope, an eye toward the future, a working knowledge of their disease, and a touch of common sense.”

The meeting is interesting, but not what I expected. It consists of a series of lectures by medical experts and there isn’t an opportunity for me to talk to people on a one-on-one basis. However, I do learn a lot about the history of dialysis technology. I also learn that for the past 50 years Seattle, and the University of Washington Medical Center in particular, has been at the forefront of research and implementation of dialysis treatment. It is also one of the leading places for organ transplants. That reassures me that my experience with my transplant is likely to be safe and successful.

Among the tidbits I learn is that in 1962 the King County Medical Society (located in Seattle) helped open one of the first facilities that allowed hemodialysis to be handled as an outpatient procedure. Since each dialysis treatment lasts for several hours and occurs several times a week, the savings were substantial, though it was still very expensive. The facility, eventually called Northwest Kidney Center was also the first to promote and facilitate home dialysis, which reduces costs even further, and enhances patient outcomes because it allows daily treatment and overnight treatment.

Even though it was no longer considered experimental, insurance companies would not cover dialysis because of the cost. Donations could not cover the cost for all patients who wanted treatment either, so access had to be severely rationed. Thus, an admissions committee was formed. The committee, sometimes called the life and death committee consisted of two doctors who were not nephrologists and five members who were not in the medical field. They examined case logs and decided who would get dialysis and who would not, and thus would die. The workings of the committee are described in Life magazine in 1962 (and is currently portrayed in a play entitled “Who Lives?”). The resulting outcry from the article eventually led Congress in 1972 to pass an amendment to the Medicare rules to cover dialysis and kidney transplants regardless of patient age. Since then, even as Medicare costs have grown rapidly, the proportion of Medicare’s total budget spent on chronic kidney disease has increased and now consumes 6.4% of the budget even though patients with ESRD make up less than 500,000 of the 44 million Medicare beneficiaries.

The history of chronic kidney disease has much to teach us about the current health care reform debate. A more personal story on the impact of federal insurance on kidney disease survival appears in Salon in September.

by George Taniwaki

After my consultation with the surgeon, I go to the radiology lab to have a computed tomographic scan (CT scan or CAT scan) of my abdomen taken. This scan will produce a 3D image of my kidneys and the arteries and veins that connect to it.

The surgeon and nephrologist will review this image to ensure that I have two functioning kidneys and select which one I can safely donate.

If both kidneys are the same size, they will want to remove the left one, since it is easier to get to. If they are not the same size, they will want to remove the smaller one (and leave me with the bigger one).

Finally, if the arteries and veins don’t branch a lot, they can use a technique called laparoscopic surgery. Unlike traditional open surgery, where the incision must be large enough for the surgeon to insert his/her hand into the body, laparoscopic surgery uses one or more small incisions and the operation is performed using thin robot instruments inserted through the holes, called ports. This reduces the chance of bleeding and infection. When successful, it also leads to shorter recovery time, less scarring, and less postoperative pain.

What is it? CT scan angiogramCreates a 3D image of the arteries and other structures in the abdomen
Why is it needed? Ensures you have two functioning kidneys and that one can be safely removed. Also helps the surgeon plan the operation
How is it done? A contrast agent is added to the blood and a series of x-rays are taken
Preparation None
Test time One hour
Risks Repeated exposure to x-ray energy can increase the chance of cancer. A CT scan is the equivalent of about 40 chest x-rays
Discomfort You have to pull down your pants (you can leave your underwear on). The contrast agent can leave a metallic taste in your mouth and can cause tingling in your abdomen and bladder. The test is not painful

 

How a CT scan image is created

A CT scan is a series of thin sliced cross-section images of an object, in this case my abdomen. The images are created by sending a large number of x-ray beams through the object from various X-Y directions and measuring the energy absorbed from each beam. By using an algorithm, called the inverse Radon transform, the data from all the beams are combined to produce the density value (shades from black to white) for each pixel, or more accurately each voxel, and produces a single X-Y slice. By moving the object (my body) back and forth along the Z-axis, a large number of slices can be created and the entire 3D object can be imaged.

The procedure

The CT scanner at UWMC is a GE model. It consists of a large ring, about five feet in diameter. The x-ray source and the detector are attached to a rotating ring while the patient lies on a non-metallic table that can slide back and forth through the center of the ring.

Conveniently, I don’t have to disrobe and put on a silly hospital gown for this procedure. I just lay on the sliding table. The operator covers me with a sheet and I slide my pants down to my knees (so that the metal zipper doesn’t interfere with the scan). I have to raise my hands above my head so that they don’t interfere with the scan either.

GtaniwakiCTScan

Ready for a CT scan. Photo by UWMC staff

The scan consists of three passes. In the first pass, a low-resolution image is taken to ensure that my abdomen is in the correct position. After this initial pass, the operator returns from behind the lead wall and attaches a small IV drip of iodine solution to my arm for about 1 minute. The iodine will absorb x-ray energy, which will increase the contrast of the image. It will make blood vessels like the renal arteries stand out to produce an image called an angiogram. Iodine is also filtered out of the blood by the kidneys, and the amount of iodine collected by each kidney will indicate how well each kidney is functioning.

Even though the contrast agent is injected into my arm, it causes my mouth to feel dry and my abdomen to feel warm and tingly. The operator tells me that some patients say the feeling is similar to urinating on oneself. Two high-resolution passes are made after the iodine IV. One immediately after the IV that will show the iodine in my arteries and another about 6 minutes later after the kidneys have filtered the iodine from my blood and it collects in my bladder. (I had no idea that the kidneys worked so fast.)

The images

After completing the CT scan, I walk past a sign that says the fee for copying radiological images onto CDs and shipping them to another hospital is $13.50. Being curious, I ask if I can just pay the fee and take the CDs with me. The clerk says sure and so I ask how I can view the images. He says the viewer app is on the CDs. Then he asks me if I know how to interpret the images. I say no, but that’s OK, I’ll figure it out on my own.

When I get home, I load the three CDs containing almost 1,500 images of slices of my body, start the viewer app, and start clicking on the controls. A few samples are shown below. Very cool! I only wish the images were in pseudocolor (like red for iodine, gray for everything else) and in solid 3D so you could spin them around.

CTScanCoronalView      [This image missing]

CTscanArtPhase CTscanDelay

CT scans of my abdomen. Images from UWMC

Top left: Front or coronal view of lower abdomen before the iodine injection (low resolution pass), this view is synthesized by combining multiple cross-sectional slices (notice that my left kidney, on the right of the image, is higher and larger than the right one, also notice the slight curvature of my spine that may indicate I have a very mild case of scoliosis)

Top right: Cross-section of my upper abdomen immediately after iodine injection (notice how the iodine absorbs the x-rays making the heart show as white while the lungs, which contain little blood, show as black)

Bottom left: Cross-section of my lower abdomen immediately after iodine injection (my kidneys are the two white blobs, again notice that my left kidney, which is on the right of the image, is larger than the right one)

Bottom right: Same cross-section 6 minutes later (notice how the bladder located between the kidneys turns white as it fills with iodine, the kidneys are even whiter than before, but the other organs fade to gray as the iodine is filtered from the blood)

For more information on becoming a kidney donor, see my Kidney donor guide.

[Update: It is the contrast agent, not the x-rays that caused the tingling sensation. Also, the scanner makes 3 passes, not 4.]

by George Taniwaki

Today, I am going to the University of Washington Medical Center to meet with the surgeon, Paolo Salvalaggio. This will be my fourth appointment at UWMC.

Dr. Salvalaggio reminds me of two facts that I am already quite familiar with. First, unlike most surgery where the patient must balance benefits and risks, a donor nephrectomy (kidney donation surgery) will provide me with absolutely no medical benefits while subjecting me to several risks, including death. Second, this is elective surgery and I am under no obligation to undergo it. I may opt out of it at any time up to the point when I am put under general anesthesia.

PaoloSalvalaggio

Paolo Salvalaggio. Photo from UWMC

He also outlines the risks of abdominal surgery. The most common risk is bleeding, which occurs in 1 out of 200 surgeries. If there is bleeding, it may require opening me up to stop it, even if the original surgery was laparoscopic.

The second risk is infection, especially from methicillin-resistant Staphylococcus aureus (MRSA). This bacterial infection is highly resistant to some antibiotics and is potentially fatal. This happens in 1 out of 1000 surgeries, but has never happened during transplant surgery at UWMC.

Finally, there is a risk of dying during the surgery from cardiac arrest. This is quite rare, occurring in 1 out of 10,000 surgeries, but has never happened during a transplant at UWMC.

I am aware of these risks and am prepared to accept them.

For more information on becoming a kidney donor, see my Kidney donor guide.

[Update: Because of a scheduling conflict, I have a new surgeon, see Mar 2010 blog post.]