The Medical News Report #62
Samuel J LaMonte, M.D., FACS
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!
Abuse Series—Part 2—Domestic Abuse
4. Big Pharma and TV advertising
Benign Prostate Enlargement—BPH-diagnosis
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
Not medical advice!! I am not your doctor, and decisions about your
health require consultation with your trusted personal physicians
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
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
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
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.
1/6th 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
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
(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
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
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
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
“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
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
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
4- Intimate partner violence accounts for 15% of all crimes.
5- 1 in 15 children are exposed to domestic violence in the home
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:
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
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
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
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:
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 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:
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?
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
It is understandable that the federal
bureaucracy has hampered drugs being approved in a more timely
The average time is 15 years from beginning of research to market
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.
Benign Prostatic Hypertrophy (hyperplasia)—BPH
previously reported on prostate cancer but not benign non-malignant
enlargement of the prostate
gland. To read the reports on prostate cancer, click on:
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.
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
It is estimated that as many as 14 million men develop urinary tract
infections as a result of BPH.
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
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.
Diagnosis of BPH
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.
for infection, blood, and protein.
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
(blood urea nitrogen), creatinine, and electrolytes (sodium,
potassium, carbon dioxide, and chloride) to determine the function
of the kidneys.
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,
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
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
be helpful in assessing the size of the bladder and any defects in
Other diseases to rule out
Prostatitis (infection), prostate or bladder
cancer, bladder infections (interstitial cystitis), bladder stones,
and urinary tract infections must be ruled out.
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
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.
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.
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)
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
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)
may include 2 of these categories.
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.
can cause gynecomastia (enlarged breasts). Dry
mouth, muscle pain, and indigestion can also occur.
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.
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).
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
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
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
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.
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
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.
Types of Kidney Failure-acute and chronic
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
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
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
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).
elevation of the creatinine indicates continued loss of kidney
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
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.
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.
moderate-GFR-30-44mg/ml; Stage 4-15-29mg/ml; Stage 5-End
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.
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.
is end stage disease and dialysis is a must and consideration for
transplantation is entertained. The patient will die in this stage
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
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.
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.
involves removing the blood and filtering it
with a dialysis machine.
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
For more detail dialysis, click on:
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.
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.
3 types of blood tests are performed to
match up a donor to a recipient—a-blood
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
are necessary to prevent rejection of a
kidney. There are 4 classes of drugs that may be used:
2- Anti-proliferative agents-Microphenolate,
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.
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%
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
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
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 6th 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
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
4. The latest information on sugar and
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,