The Medical News Report #62

March, 2017

Samuel J LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for March, 2017

1. An update on the value of Chrondroitin sulfate/Glucosamine in arthritis patient

2.Single Payer healthcare-Part 1-Woulda single payer healthcare system work in the U.S. if “Trumpcare” falters? How socialism plays a role!

3. Human Abuse Series—Part 2—Domestic Abuse

4. Big Pharma and TV advertising

5. Benign Prostate Enlargement—BPH-diagnosis and treatment

6. Urinary System Series-Part 5-Kidney Failure, Dialysis, and Transplantation

7. CDC Update on adult immunizations released

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

   Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, instructions for care, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Now, on with the report!! Thanks!! Dr. Sam

Influenza is having a heyday in the South and Northeast, according to the CDC. The most prevalent strain, Influenza A (H3), was covered by the flu shot this year, however, the latest information is it is only about 50% successful in preventing the flu. That means some will still get the flu even after having had the shot, but the disease is usually less severe because of the increased immunity even if partial. Pneumonia is still killing children and elderly people from the flu, therefore it is always recommended each year, even with some limitations. The vaccine saves lives!

1. Update report on Chondroitin Sulfate/Glucosamine for arthritis

  There continues to be no evidence that the combination of chondroitin sulfate and glucosamine has greater value than a placebo for arthritis patients who have moderate to severe disease. There have been trials in the past that demonstrated similar benefit to arthritis medicine in some patients back in 2006, but this new study compared 1200-1500 mg daily to a placebo and did not find greater benefit than the placebo (a sugar pill). Higher doses were not studied.

  I know orthopedis surgeons that recommend it, but I just report what is in the medical literature. The supplement industry makes $billions on a store full of pills that have never been proven to be effective by traditional research methods. Since there is no regulation by the FDA, these supplements, herbs, and extracts can be marketed freely as long as they don’t advertise they treat disease.

  Many of these supplements are potentially harmful to certain populations of patients, especially those on medications that may adversely interact with them, especially those on chemotherapy or are prescribed immunosuppressive drugs or are immunosuppressed from a disease.

Journal of Arthritis and Rheumatology, Jan, 2017

2. Single Payer Healthcare-Part 1-If Trumpcare falters, the U.S. will likely default to a single payer system! What will it be like?  Are we ready for socialized medicine?

Unless our healthcare system is not reformed successfully, in my opinion, we are headed for a single payer system. We must give the President Trump administration a good chance to repeal and replace or alter Obamacare, and President Trump must come up with an alternative plan to replace Obamacare that we can live with and afford. It won’t be easy and will require sacrifice by many, even seniors. Some will work hard to see it does not work, but the alternative may not be acceptable to many.

  There must be cooperation from all parties to reduce costs including Big Pharma, the insurance industry, and increasing responsibility from patients. We gave Obama almost 8 years to improve healthcare, and it failed to meet its goals even though 20 million residents were added to the system.Although Obama’s plan could have been successful, thanks to high costs, many did not use it because the deductibles and co-pays were unaffordable.

Obama tried to finance his plan by requiring younger Americans to buy insurance at the rates of sicker older people when they did not think they needed or wanted it. (the individual mandate). Healthy young Americans paid the fine.

What about Medicare, Medicaid, and military medicine?

Part of the solution might be to segregate groups based on age, wellness level, and ability to pay. There are many solutions being proposed, but this accounts for only half of Americans. The other half is already on a federal single payer system—Medicaid, Medicare, and VA. Many would say at least Medicare is doing just fine, but it’s affordability, proper management, fraud, andover-regulation are in serious question. That will have to be addressed. Medicaid and the VA have real problems. Medicare (a universal healthcare system) is another story entirely. President Trump must come up with a better solution, or we will likely have no choice but to go it.

  A recent article in Medscape, an online medical internet site,had some important points to make about what Americans will give up if our country becomes a socialized one payer system. Here are some of their thoughts.

  With Obamacare, the high cost created the failure, not necessarily the ideology. The premise of Obamacare was miscalculated. The insurance companies started losing too much money and some of the biggest carriers (9/16) withdrew from the system, narrowing the available number of health networks available (some to one in certain areas of the country). The population increases of poor people and refugees have created a huge cost issue.

Many plans (especially Obamacare) have provided poor reimbursement to doctors, and they are refusing to see many of thesepatients, thus reducing access to care, requiring many to flood the emergency rooms. Obamacare was supposed to solve the ER over-use.

The enormous cost of healthcare

Overall, healthcare in America is good. Medicare has provided good care for our poorer and older populations. Is is, however, subsidized greatly by the federal government and most people do not know this. The overall cost is skyrocketing because of the number of seniors turning 65 years of age.

1/6^th of our federal budget goes toward healthcare, and 25% ($938 billion) of thatbudget in 2015 went toward 4 programs (Medicaid, Medicare, CHIP, and Obamacare). Nearly 2/3 of that money ($546billion) went to subsidize Medicare. Even though Americans paid a Medicare tax with every paycheck, it is still not enough to sustain it.

Greed by corporate hospitals and large healthcare systems has increased as they decrease salaries to employed physicians and staff. As private practice disappears and doctors have been forced to become employees (because of the high price of administrative and federal regulatory costs forcing them out), the care we receive could suffer in quality.

Consider the following possibilities and realities with a single payer system (i.e. socialized medicine, universal healthcare):

1. Lack of access for chronic diseases and delay in getting necessary but elective procedures (i.e. joint replacements).

2. Healthcare choices will be taken away from physicians and put in the hands of the government with layers and layers of bureaucracy which has paralyzed the system thanks to the university academicians who were put in place to make medicine unaffordable ultimately forcing the country to socialized medicine.

3. Strict allocation of care will be imposed by a socialized system with restriction of costly care (nursing care, hospice, etc.) especially surgery on elderly or higher risk candidates (rationing of care).

4. Recipients consider a single payer system essentially “free care” and abuse it easily. Access to doctors for routine care will be delayed, which is going to be a huge issue.

5. Waiting time for diagnostic procedures will be prolonged. In Canada and other countries, it takes months to have diagnostic procedures such as MRIs, CTs, angiograms, etc. Many Canadians purchase additional healthcare policies from the U.S.(since Canada does not allow any insurance other than the Canadian socialized system). As refugees flood Canada, it will be interesting to see how their healthcare system will suffer.

6. It will continue to deteriorate the doctor/patient relationship as we know it. Patients will see PAs and nurse practitioners instead of physicians (already happening but at least under the jurisdiction of MDs).  Universal systems on average pay their professionals 27% less than our current system for Medicare and Medicaid patients, 70% less than what public payers pay, and 120% less from private payers.

7. Taxes will have to rise with a federal single payer system, but as long as Republicans are in control of Congress and the White House, how will that happen? Trump has also promised Medicare recipients their system will remain the same. Can that happen? There is already talk of increasing deductibles and copays for Medicare patients and increasing the eligibility age to 67 (will not affect anyone over 50 years of age).What is the country willing to tolerate?

8. The loss of competition in any business raises cost including a one payer system.

9. The cost will escalate as the number of people continue to flood the borders and more refugees are accepted.

10. More corruption will occur, when it comes to who gets contracts to provide services to a universal system. There is well-known corruption and fraud with military contracts including the VA. Right now, there is a scandal of opioid theft within the VA. This drives up the cost as well. Fraud is a serious problem as well.

11. A single payer system will lead to a two tiered system, which raises the cost of healthcare to Americans. Those that can afford it will buy private insurance to access systems not available through a socialized system (which occurs in the UK). This would be similar to Part B of Medicare, essentially covering some of what the single payer did not cover. Only the wealthier Americans will be able to afford it.

12. Having access to a world class center could be excluded. Mayo Clinic does not accept direct Medicare or Medicaid payment now. Some other major centers may follow suit.

13. The average waiting time to see specialists will be greatly prolonged. Here are some figures from Canada: orthopedics-42 weeks, neurosurgery-31 weeks, plastic surgery-27 weeks.

14. In Great Britain, the government owns the entire system-hospitals, clinics, lab, x-ray, etc. That is a classic monopoly that our government does not allow in business.

15. The VA, which is a federal system, is currently an unsatisfactory system and very costly because of the regulations and multi-tiered bureaucratic system.

16. Unionization of physicians could occur and strikes will occur. Doctors in Great Britain have already begun this effort to protect themselves from their system.

17. Vermont has already abandoned their single payer system, because they could not afford it.

18. Half of Americans opposed Obamacare but now are scared what replace it. Trump must come up with a workable plan.

  Despite all the rhetoric of Obamacare to reform and make healthcare “affordable”, many experts saw it as just alternate plan waiting for it to fail so that a socialized single payer government system would be the only alternative.

 Reference—Medscape Business of Medicine, June, 2016

Socialism and healthcare

How does a federal single payer system play into a socialized country?

“Equality for all in healthcare is a myth, because no matter how medical care is provided, there will always be inequality in access, disease intervention, responsibility of patients, and results from treatment. The only thing socialism has ever created is equality inmisery and poverty”. Want to read more from the author of these comments ? Check out Thomas DiLorenzo-The Problem with SocialismSaul Alinsky is often linked to creating steps to a socialistic society, which includes a single payer federal healthcare program. This original community organizer was the author of 1971 book “Rules for Radicals”.  He went to undergraduate andpostgraduate work at the University of Chicago. I am sure Dr. Bill Ayers found his work fascinating. Hillary Clinton did her master’s thesis on Saul Alinsky.Senator Bernie Sanders and Barack Obama (originally)proposed a single payer system and Sanders a socialistic country. Many of the millennials are totally in favor of a socialized system with free college and healthcare when they have no skin in the game as their parents were footing their bills.

32 of the 33 civilized countries have some form of universal healthcare. Can America accept it?

Although Snopes states that the rules for the creation of a socialistic society came from the “Communist Rules for Revolution”, not Alinsky, it really does not matter who created them, but it is important to see what is said. There is a lot of misinformation out there about these principles, but it is for the reader to decide if they agree with the ideology or not. Dr. Ben Carson spoke of Alinsky when he was a presidential candidate and greatly condemned him:

This issue is not going away with our country so split ideologically. I hope it is not our downfall. Even with differing passions, we all want for America to survive and thrive. How this is done in this world is the question!

Below are the 8 rules for creating a socialistic state, no matter who wrote them:

As Trump tries to replace Obamacare and reform our healthcare system with reduced cost and continued high quality care, realize what is at stake if we don’t give his system a chance…..socialized medicine.

To be fair with this subject, next month, I will report on why proponents favor a single payer healthcare system.

3. Human Abuse Series—Part 2-Domestic violence

The National Domestic Violence Hotline

Statistics

1- Nearly 20 people are victims of abuse every minute in the U.S. (nearly 10 million people per year). 1 in 3 women and 1 in 4 men report some type of physical abuse in their lifetime by an intimate partner as reported by the National Coalition against Domestic Violence.

2- 1 in 7 women are stalked by an intimate partner at some time in their life to the point of fearing for their life.

3- Domestic violence hotlines take as many as 20,000 phone calls per day.

4- Intimate partner violence accounts for 15% of all crimes.

5- 1 in 15 children are exposed to domestic violence in the home (3.3 million).

6- 72% of murder-suicides involve an intimate partner (92% of the victims are women).

7- There is a direct link between depression and thoughts of suicide and domestic violence.

8- Those patients who are impaired or disabled are at much greater risk. 50% of those with dementia are abused. Elder abuse in nursing homes is at a 30% rate.

9- Domestic violence is one of the most under reported crimes.

10- Children in the home will demonstrate psychological problems from exposure to abuse.

11- These issues have only recently been addressed in the past few decades. Before the 1900s, wife beating was considered a man’s way of controlling his spouse. Children had no protection from their parents until recently in the U.S. In many parts of the world there are still no laws protecting them.

Types of Domestic violence

  The common thread for domestic violence is power and control!

Physical, emotional (including threats of violence), and sexual (including marital rape) abuse are the most common.

  There is an enormous amount of information on this subject on the website, Medline Plus, a great resource for information:

www.medlineplus.gov/domesticviolence.html

  I am limiting my report to violence in the U.S., since violence of other humans in certain countries is beyond the scope of this report and personally hard to comprehend. Abuse based on certain religious, racial, and ethnic/cultural practices can occur in the U.S. especially with the influx of multi-cultural refugees. This will escalate greatly.

Underlying causes of domestic violence

There are many danger signs of domestic violence. Drugs and or alcohol abuse, a history of abusive parents, juvenile delinquency,the belief that domestic violence is acceptable, unemployment, and mental health issues commonly are present in abuse cases. Personality traits may include a hot temper, poor impulse control, and poor self-esteem. Borderline personality disorder is not uncommon.

  So often, abusers seem nice for short periods of time, but over time, behaviors begin to surface including name calling, threats, possessiveness, and distrust. Abusersapologize profusely for their transgressions only to repeat their behaviors.

  Common behaviors include jealousy, degrading comments, accusing the spouse of cheating, discouraging a spouse from seeing family or friends, shaming the person, and putting them down. Controlling the family finances, demanding a person dresses in a certain way, stalking or monitoring the person’s every move, intimidation with weapons, forcing the person to have sex, preventing the victim from working, and destroying property or abusing animals all can lead to more abusive behavior.

Restraining orders can lead to fatal consequences.  1 in 5 family members who have restraining orders on abusers are murdered within 2 days of the order. Victims must escape these dangerous situations or hire protection.  Shelters are available in most cities and secretly contacted.

Cycles of violence are common with abusive events followed by apologies, reconciliation, good behavior, and amends only for tension to rise again leading to violence and abuse once again and often more severe.

Management of abuse

  For abuse to be addressed, underlying issues must be managed using counseling, law enforcement support, and a change in the home environment. Easy to say…….!

The scars of abuse last a lifetime. It is an underlying factor in so much pathological behavior.

  Treating someone who has been chronically abused must include working on re-establishing trust, relieving fear of more abuse, restoring intimacy, self-esteem, confidence, and treating underlying psychological disorders. Individual and group therapy has been successful, but it will require considerable time to work through these issues and allow a survivor to go on with their lives.

A good resource I found online for information is:

www.goodtherapy.org/learn-about-therapy/issues/abuse

  Safe haven facilities are gods-send for families of abuse. There are centers in every state. I have been a longtime supporter of the FAITH center in Rabun County, Ga. God bless what they and all these centers do!

www.faith-inc.org

Centers like these need your support, as they do such a wonderful job with these families in crisis providing shelter, food, clothing, and counseling. Another national site for immediate help is:

www.womenagainstabuse.org

Next month, I will report on child abuse!

4. Big Pharma and TV Advertising for off-label medications

Big Pharma won another battle over the FDA. Currently, drug companies must have FDA approval to advertise their medication for certain medical indications. A drug company won a court battle over the FDA to be able to advertise their drug for other non-approved illnesses as a “freedom of speech” issue.

What is the function of the FDA? www.fda.gov

There is a real ethical question whether drug companies should be allowed to advertise on television. They are spending billions on these ads instead of spending it on research. But, the other issue is off-brand advertising.

 Many drugs may help other FDA unapproved diseases, but research has not been performed, or is incomplete to prove efficacy. Until there is evidence, the FDA cannot officially approve these drugs for new indications. However, listen carefully when a drug company advertises these unapproved indications.

  What this means is Big Pharma has used our court system to go around the FDA. Usually insurance companies will not pay for a medication that is used for something that the FDA has not approved. This is very common with some cancer drugs and in othermajor fields of medicine. I don’t blame Big Pharma for that, but tremendous pressure is being put on President Trump to streamline the process to get them to market faster. In exchange, Trump is negotiating prices to be dropped. We await the results of this negotiation.

It is understandable that the federal bureaucracy has hampered drugs being approved in a more timely manner. The average time is 15 years from beginning of research to market approval.

The lawyers are licking their chops for side effects of any drug to occur after an FDA approval. Some effects take years to show up. There needs to be a balance between safety and common sense.

  There are many examples of drugs that were promoted by drug representatives to doctors that turned out to have major side effects. One example is Bextra, a Cox-2 inhibitor very similar to Vioxx (used to treat arthritis). It was pulled off the market in 2005 because both these drugs caused severe elevations of blood pressure and caused many deaths. Pfizer promoted this drug for off-label use for acute pain. This caused serious damage to a great number of patients.

  Many of the antidepressants were promoted for very young patients (not approved by the FDA) and caused a rash of suicides. Antidepressants were promoted to help pain (off-label) without solid evidence (i.e. Cymbalta).

  You must know if your doctor is prescribing a drug that is off-label. He or she may well have a good reason—i.e. other approved medications weren’t effective, but they should tell you it is not FDA approved for the disease that they are prescribing it for. Ask your doctor about any drug you are prescribed, especially about side effects and cross-reactions with other drugs.

  If a person is on a clinical trial, off-label use of a cancer drug, for instance, may be very justifiable, and after all that is the goal of clinical trials.

  Lawyers are arguing that it is a first amendment right of a drug company to promote their drug for other indications.  Have you noticed that diabetic drugs indicated for reducing blood sugar is now being promoted as a weight loss drug?

Our government needs to prohibit Big Pharma from advertising on TV all together, in my opinion, but with this ruling, Big Pharma is now protected by the first amendment (freedom of speech) to do as they choose. Some drug companies are spending more on advertising than research.

Reference—Health News Review.org

5. Benign Prostatic Hypertrophy (hyperplasia)—BPH

I have previously reported on prostate cancer but not benign non-malignant enlargement of the prostate gland. To read the reports on prostate cancer, click on:

 www.themedicalnewsreport #32, #33, #34, #35, #36, #38

A. Anatomy

  Below is an actual photo of a surgically removed prostate through the old open technique (rarely necessary today). A probe has been inserted to show the route of the urethra..

These drawings (above) demonstrate the position of the prostate in the pelvis and the route of the urethra from the bladder through the prostate and out through the penis.

  It is important to note that prostate obstructive symptoms are the same for benign or malignant process. Therefore, when symptoms occur, see your doctor for an exam.

B. Symptoms of prostate enlargement (benign prostatic hypertrophy-BPH)

a) difficulty with urinating, b) getting up at night to urinate (nocturia), c) difficulty starting or urgency to void, d) the need to strain to empty the bladder, e) difficulty emptying the bladder entirely, f) a decreasing size of the urinary stream, with or without dribbling, g) pain, frequency of urination, or discolored urine or blood in the urine are also all signs that an infection is present in the system. A fever, flank or lower abdominal pain, in addition to the above symptoms implies an actual kidney infection.

It is estimated that as many as 14 million men develop urinary tract infections as a result of BPH.

C. Incidence and time of onset

  Over 50% of men begin to have symptoms in their early 50s (20% in their 40s and 90% in their 70s), and continue to worsen throughout life.

  Certain men are more prone to having enlargement of their prostate: family history, obesity, heart and other circulation disorders, diabetes, and those with erectile dysfunction.

  Theories of why the prostate grows include increasing estrogen as testosterone decreases as men age. Another theory is the elevation of dihydrotestosterone in the face of a reduction of levels of testosterone , which encourages prostate cells to grow.

D. Diagnosis of BPH

   1- Rectal exam-- the prostate is easily felt to be enlarged with a spongy rubbery feel, as opposed to cancers which are felt as a hard area in the prostate. An inflamed prostate (prostitis) is very spongy and extremely painful when touched.

2- Urinalysis—analysis for infection, blood, and protein.

3- Urine culture (and sensitivity)—to determine the specific bacteria causing the infection by growing the bacteria. Also antibiotics can be tested to see which ones are best suited to kill the bacteria causing the infection (called a sensitivity test).

4- Blood tests—BUN (blood urea nitrogen), creatinine, and electrolytes (sodium, potassium, carbon dioxide, and chloride) to determine the function of the kidneys.

5- Cystoscopy--It is very important to determine the effect of an enlarged prostate on the bladder, therefore, a cystoscopy can be performed to directly look at the lining of the bladder. Certain abnormalities of the bladder wall can be determined as well as the possibility of bladder polyps, stones, thickening of the wall from recurrent infections, etc.

6- Urodynamics—Flow cystometry--Cystometric examinations are frequently performed at the same time. The bladder is filled with saline, and then the patient is asked to empty the bladder and the flow capability can measured, calibrated, and how well the bladder is emptied. This test can also determine whether there is a bladder muscle problem caused by such neurologic diseases as diabetes, spinal cord difficulties, etc. (neurogenic bladder).

7- PSA—Patients with prostate symptoms should be tested for cancer with the prostatic specific antigen. I discussed this at length when I reported on prostate in themedicalnewsreport #33

8- Ultrasound—may be helpful in assessing the size of the bladder and any defects in the bladder.

E. Other diseases to rule out besides BPH

Prostatitis (infection), prostate or bladder cancer, bladder infections (interstitial cystitis), bladder stones, and urinary tract infections must be ruled out.

F. Medications that aggravate prostate enlargement

Cold and allergy medicine containing antihistamines and decongestants, tricyclic anti-depressants, NSAIDs (non-steroidal anti-inflammatory medications), diuretics, caffeine, alcohol, and even spicy foods can all make emptying the bladder more difficult.

G. Treatment

  The goal of treatment is to treat whatever underlying disease is present and address the enlargement of the prostate so that symptoms are relieved. It should be noted that treatment is not necessary until the symptoms warrant them.

1. Lifestyle modifications

Restriction of fluids in the evening will prevent the bladder from filling after going to bed. Fluid from the lower body will return into the blood stream and increase bladder urine as well. Restriction of alcohol (irritates the prostate), spicy foods, caffeine, double voiding, regular physical exercise, timed bladder voiding, and treatment of constipation all will assist in the medical treatment of BPH.

2. Medications-categories

a- Alpha-1 receptor blockers—these medications act on the smooth muscle in the prostate by relaxing them allowing for better urination—examples-tamsulosin (Flomax), alfuzosin (Uroxatral)

b-Phosphodiesterase-5-enzyme inhibitors—tadalafil (Cialis daily), which treats erectile dysfunction and BPH by relaxing the smooth muscle and detrusor and prostate tissue to make urination easier.

c-5-alpha reductase inhibitors—finasteride (Proscar or Avodart) is a hormonal treatment that reduces the actual  size of the prostate and improves BPH.

d-Muscarinic receptor antagonists interfere with smooth muscle receptors allowing relaxed urination. Tolterodine (Detrol) or fesoterodine (Toviaz) are examples.

e-Combination therapy may include 2 of these categories.

f- Side Effects include erectile dysfunction, abnormal (retrograde ejaculation-ejaculate into the bladder) or difficulty in ejaculation are two of the most common symptoms and keep many men from taking these medications.

Fatigue and a drop in blood pressure especially when standing up can be serious. Avodart and Proscar can cause gynecomastia (enlarged breasts). Dry mouth, muscle pain, and indigestion can also occur.

3. Surgical methods

Surgery needs to be considered when more conservative measures fail to relieve symptoms or urinary tract infections persist, or significant urinary retention is present. If kidney failure has begun because of obstruction, bladder stones are persistent, or there is bladder weakness from neurological causes, a TURP is indicated. Also if bladder diverticuli (outpouchings of the bladder wall just like in the colon)are present, surgery is indicated. Occasionally, persistent prostatitis is an indication or a method for biopsy of the prostate when trans-rectal biopsies cannot be done. Thanks to the medication benefit, surgery does not have to be recommended that often.

a-TURP-trans-urethral resection of the prostate

This is the benchmark procedure, which is performed with an instrument inserted through the penis to remove the portion of the prostate that surrounds the urethra.  Regardless of the technique, the portion of the prostate immediately surrounding the prostatic urethra must be removed to provide a free flow of urine.

It is rarely indicated to remove the prostate as an open procedure (supra-pubic prostatectomy).

b-Less invasive techniques have been utilized more frequently including microwave (thermal) and laser removal. Freezing, electro-vaporization, and radiofrequency ablation techniques can also be performed, since these techniques are minimally invasive. The evidence that is available is that most are initially as successful as the standard procedure, with less bleeding, a catheter may be needed for a shorter time, and hospitalization is shorter or can even be outpatient. Getting well is about the same, but the results may be less successful requiring  repeat procedures. This is the price you pay for more conservative options.

Consider going to a very experienced urologist who has confidence in the procedures they perform. Ask about complications such as success rate, recovery time, retrograde ejaculation (semen shooting into the bladder instead of coming out the penis), temporary incontinence, scarring, damage from these specific techniques.

c-Side effects

Urinary incontinence is a common post-operative side effect for months following the procedure. Pelvic muscle exercises (Kegel technique) are highly recommended. The microwave techniques uses a very hot probe which can do damage to the system. All of these procedures are fairly successful, but individual results must be discussed depending on the technique and need for a more or less aggressive approach.

Erectile dysfunction should also be discussed. 14% risk is reported and more common in diabetics and older men who are already having ED issues.

A comment about men with elevated PSAs and negative prostate biopsies!

When a man has an elevated PSA (less than 10) but has negative prostate biopsies under ultrasound, has a 5% chance of developing and dying of prostate cancer and a 60% of dying of other causes. From this report, it appears that repeat biopsies are questionable in value without the problem of over-diagnosing and over-treating a cancer that would not likely kill the patient. That is not to say that PSAs should not be followed and the patient closely monitored. Of course, the age of the patient must be considered, family history, etc.  Lancet Oncology, 2017

6. Genitourinary Series—Part 5—Kidney Failure, Dialysis, and Transplantation

A. Definition

I have discussed the anatomy and physiology of the kidney in this series. I have also discussed the tests normally ordered to assess kidney function.

Kidney failure implies malfunction of the kidneys. Minor or significant kidney function abnormalities can be totally asymptomatic. While I was on Indocin for arthritis, this NSAID damaged my kidneys causing my creatinine and BUN to elevate. I had no symptoms. If my doctor was not conscientious about monitoring my kidney function, I could have had irreversible damage. I was lucky since my kidney function studies returned to normal, but it took a year.

Kidneys have crucial functions (clearing waste out of the urine (urea), secreting hormones that regulate blood pressure (renin), electrolyte balance (sodium and potassium), and regulating red blood cell production. If these functions stop, the body is affected in many ways.

B. Symptoms of Kidney Failure

  Not removing waste products from the blood will create fluid retention, swelling, fatigue, elevated blood pressure, weakness, confusion, and later anemia. Not removing potassium from the system will lead to heart arrhythmias, sudden cardiac death, heart failure, etc.

C. Types of Kidney Failure-acute and chronic

  1—Acute Kidney Failure

  Causes—direct physical injury, blockage of the kidneys from kidney stones, a blood clot blocking blood supply to one or both kidneys, stenosis of the main arteries to the kidney from atherosclerosis,  acute infection (acute glomerulonephritis), toxic poisons, alcohol, illegal drugs,  autoimmune diseases including scleroderma and lupus, gout, medications, certain antibiotics, chemotherapy, NSAIDs including ibuprofen, naproxen, and aspirin, acetaminophen (Tylenol), vasculitis syndromes, blockage from cancers of the kidney and surrounding organs, kidney dyes if allergic, to name a few.

Diabetes is notorious for causing kidney damage. 

Before taking any medications for a prolonged time, it is good to get baseline kidney function studies, and then follow up on a regular basis as prescribed by the primary care physician.

  2-Chronic kidney failure

  Hypertension can damage the kidneys over time, especially in patients with diabetes. Elevated blood pressure can damage the basic functional unit of the kidney--the glomerulus.

  Diabetes mellitus (type 2) is a common underlying reason for renal failure. 10-40% will have some diabetic renal damage.  Since the blood vessels are damaged with diabetes, so are those in the kidney. Diabetes can also directly damage the kidney’s most basic structure. It can also damage the nerves to the bladder which can indirectly damage the kidneys from obstruction. The diabetic can slow the process down maintaining strict control of the diabetes and taking a blood pressure medication which increases blood flow to the kidneys (ACE inhibitors-Vasotec, Prinivil, etc.).

  Dehydration over time can damage the kidneys. Healthy hydration is extremely important to good kidney function.

  Patients with generalized atherosclerosis are prone to damage of the kidneys in the not only the large blood vessels but those tiny vessels supplying blood to the basic units of the kidney (glomerulus).

  Gradual elevation of the creatinine indicates continued loss of kidney function.

D. Stages of Kidney Failure

  There are 5 stages of chronic kidney disease are determined by performing a test called the glomerular filtration rate(GFR). This measures how well the kidney can function. These stages indicate how much damage has occurred. Treatment changes with each stage.

Stage 1- normal GFR>90mg/ml-indicates the beginning of CKD and other tests (CT, MRI, etc.) and there may be abnormal levels of protein (albumin) and blood in the urine. Patients are not symptomatic. Treatment includes a healthy diet with reduced intake of sodium, maintain a normal blood pressure, control diabetes, no smoking, treat lipid abnormalities, maximize hydration, exercise regularly. This stage may reverse.

Stage 2-mild-GFR-60-89mg/ml-these patients are usually not symptomatic but much have a stricter diet limiting fat, sodium and protein, careful monitoring of blood sugar and creatinine levels, maintaining normal blood pressure. This stage will progress over time and is irreversible. 

Stage 3A-moderate- GFR-45-59mg/ml

Stage 3B-more moderate-GFR-30-44mg/ml; Stage 4-15-29mg/ml; Stage 5-End stage disease-<15mg/ml

Stage 3 A and B are treated the same. Symptoms begin with fatigue, swelling of the ankles, shortness of breath, kidney pain may be present with darker than normal urine. Sleep difficulty and restless legs are common. Diet should be managed by a dietician limiting phosphorus, calcium, low saturated fats, sugar, sodium, and avoiding over the counter dietary supplements. Blood pressure should be treated with ACE inhibitors, and ARBs, as they have shown to slow the progression of kidney failure, blood sugar, and other chemistries are carefully monitored.

A nephrologist should follow these patients.

Stage 4-GFR-15-29mg/ml—patients are considered uremic and have severe kidney disease. As the waste products in the blood accumulate, blood pressure is harder to treat, and bone disease, anemia, and renal induced heart disease occur. Patients are more symptomatic with nausea and vomiting, fatigue, muscle cramps, a metallic taste in the mouth with bad breath, nerve abnormalities (numbness and tingling), and difficulty concentrating.

  Dialysis is recommended at this stage. Diet is even more strict limiting protein as well.

Stage5-<15mg/ml—this is end stage disease and dialysis is a must and consideration for transplantation is entertained. The patient will die in this stage without dialysis.

  In the earlier stages of chronic kidney failure, the same drugs I discussed in the treatment of heart failure (the classes of anti-hypertensives) also helps kidney function by inhibiting the same mechanisms that create fluid overload in heart failure.

  If you want to review those classes of drugs, just go back to February’s report under heart failure treatment.

  The latest successful treatment (still in clinical trials) to some degree is theuse of the Aldactone, a mineralocorticoid receptor antagonist, and has been found to be valuable, but can raise the potassium levels, which is detrimental to the kidneys and heart. Now, there is a new drug, patiromer, which binds potassium, thus making the use of the drug, Aldactone, safer, as an added drug. There are other drugs (i.e. finerenone) being tested as well in this type of receptor antagonist that does not create the potassium retention issue. These drugs can be also be used a few days before transplantation.

  The best that can be hoped using these different classes of drugs (just like in heart failure) is to slow down the process of kidney failure. 

E. Dialysis

Dialysis mimics the function of the kidneys especially removing the breakdown products of protein and other chemicals in the blood including keeping the sodium and potassium levels in the normal range. Also keeping the water levels at a normal range and maintaining a normal blood pressure is critical to not overload the heart and create heart failure. The dialysis machine runs the blood through it to perform this filtering and returns it to the patient.

  An arteriovenous fistula is the performed method of performing dialysis. This procedure is performed usually in the arm connecting an artery directly to a vein. One needle is placed in the arterial side for blood to go into the dialysis machine and another needle is placed in the vein side to return the blood back to the body.

Hemodialysis involves removing the blood and filtering it with a dialysis machine. Peritoneal dialysis involves filling the abdomen with a special fluid and removing many of the impurities performed in hemodialysis as it is drained back out of the abdomen.  These procedures require 4-5 hours, and peritoneal dialysis can be performed at home, and does not require a machine.

  The frequency of dialysis may vary, but is usually at least weekly. It likely will be necessary for the rest of the patient’s life or until they can get a new kidney.

  Dialysis centers are present in most major cities.

  For more detail dialysis, click on:

www.kidney.org/atoz/content/dialysisinfo

G. Kidney Transplantation

650,000 Americans have end-stage kidney disease and 430,000 are on dialysis, while 185,000 had a kidney transplant in 2011. Diabetes and uncontrolled hypertension lead the reason for a needing a kidney transplant. Glomerulonephritis (chronic inflammation of the kidney), and polycystic kidneys make up the top 4 reasons.

  1) Sources of donated kidneys

  They come from a deceased donor, a live donor, or a pre-emptive transplant can be performed before dialysis is needed. The latter is the preferred manner, but only 20% get a kidney in this manner, because of the shortage of kidneys, etc.

  2) Compatibility studies

  3 types of blood tests are performed to match up a donor to a recipient—a-blood type b-crossmatch c-HLA testing

    a- The same rules for donating organs applies for getting blood from a donor. Type O blood can donate to all blood types, type A can donate to Type A or AB, Type B to B or AB, and Type AB can only donate to an AB. Those with Type O are universal donors and those with Type AB are universal recipients.

    b- HLA testing is called tissue typing. HLA stands for human leukocyte antigen. 6 out of the known 100 antigens are important for transplantation. These 6 antigens are inherited from each parent (3 per parent). Antibodies can be made against these antigens, which could lead to rejection. However, transplants can be very successful when none of the antigens match between the donor and recipient. If antibodies to these antigens are found in the perspective recipient, they could reject the kidney.

   c- Crossmatch testing is performed by adding blood from the donor and recipient. If the recipient’s cells attack the donor’s cells, this is considered a positive test which would prevent that patient from receiving that kidney.

To be a donor requires extensive investigation of the person including having good health and passing intensive psychosocial testing. Screening for cancer is also part of the testing. They must be tobacco free for at least 4 weeks prior to the transplant, have no history of recent drug abuse, not be obese, and be free of a host of diseases.

For a list of requirements to be a donor, log on to the Mayo Clinic website.

3) Anti-rejection medication

Immunosupressive drugs are necessary to prevent rejection of a kidney. There are 4 classes of drugs that may be used:

    1-Calcineurin inhibitors-Tacrolimis, Cyclosporine

    2- Anti-proliferative agents-Microphenolate, Azothiaprine

    3-m-TOR inhibitor-Sirolimus

    4-Steroids-Prednisone

Immunosupressive drugs do interfere with all the immune processes and make the patient vulnerable to disease. Below is a table defining some of the common side effects.

4) Transplantation of a kidney was the first successful (1954) organ routinely transplanted. It requires a donor with a match for many blood factors. Transplant centers are present in all major cities. Qualifying for a transplant requires a workup by the transplant team. The patient will be required to take immunosuppressive medication for life. Rejection can occur, but success in major centers varies from 89-95% (4% rejection in the first year and 21% after 5years).

  There are specific risks for transplant patients including a 5 times greater chance of developing skin cancers (squamous cell carcinoma), and these patients must wear protective clothing when out in the sun. Regular skin checkups are mandatory to catch these early.

  There are numerous blood tests that are used to match blood types from a donor to a recipient.

Living with a Kidney transplant

I would recommend interested people click on the National Kidney Foundation’s website on ‘living with a kidney transplant

www.kidney.org/atoz/content/immunosupression

Consulting a transplant center through the National Kidney Foundation is a good start. To navigate through the entire process, call 1-855-653-2273 Toll Free

www.kidney.org/transplantation

7. Update on adult immunizations released

  The CDC’s Advisory Committee recently released some updates on adult immunization schedule. 

  These recommended schedules can be found on the CDC website by searching for that subject.

  There were some highlights I will report on here, and they are:

This completes the first report in the beginning of my 6^th year writing these medical updates. I have learned so much updating my knowledge, and I know you feel that way. Many of these topics were not even taught when I was in medical school.

  Next month, the subjects will be:

1. Heart Valve Disease-part 1

2. Stem Cell transplants

3. An update on youth and tobacco and medical marijuana

4. The latest information on sugar and artificial sweeteners

5. A new treatment for psychiatric illnesses—back to psychedelic drugs-psilocybin

6. Human Abuse Series-Part 3-Child abuse

7. Single Payer System-part 2-The advantages

As always, stay healthy and well, my friends, Dr.Sam