Although none of the editors of InsideSurgery are participating in her care, we have noted with interest the Natalie Cole interview last night with CNN’s Larry King regarding her need for kidney dialysis and subsequent listing for a kidney transplant. Natalie Cole is the daughter of famed singer Nat King Cole.
Natalie Cole was quoted as saying that she was diagnosed with hepatitis C in April, 2008 and underwent “aggressive” chemotherapy to try to eliminate the disease. Her loss of kidney function is a result of complications of this treatment.
Hepatitis C is a serious and sometimes fatal viral infection of the liver. It is found in many body fluids, including blood, saliva, and semen. One common transmission route is through the use of shared needles that have been exposed to the blood. Cole has a known previous history of heroin and cocaine abuse.
One treatment for hepatitis C is the use of inteferon, although cure is problematic, especially in established, chronic infections. The use of interferon is thought to be more effective if the patient receives it in the first 60 days after infection.
Interferon is a difficult drug to tolerate and many patients abandon its use due to side effects. One known side effect is kidney failure, particularly in high-dose, aggressive regimens. Interferon and treatment for hepatitis C is usually administered by hepatologists (doctors that specialize in diseases of the kidney) and not oncologists who are traditionally thought of as “chemotherapy” physicians.
The presence of kidney failure is very easy to track with a simple blood test and would be checked routinely by a hepatologist. Ms. Cole reportedly was administering the injections to herself in a leg muscle, instead of reporting to a physician to receive the shots. It is not clear from reports how closely her kidney function was being monitored or if Natalie Cole was compliant with a planned course of treatment that incorporated regular, frequent Kidney function tests.
Because of her kidney failure, Natalie Cole has apparently started dialysis. Based on her statement that she is receiving dialysis three times a week, she is undoubtedly receiving hemodialysis, as opposed to peritoneal dialysis.
In hemodialysis, a large needle is placed in a surgically constructed fistula or graft in the arm or a large catheter is placed in subclavian or jugular vein to allow the patients blood to be withdrawn and sent through the dialysis machine for filtration before being returned to the body. A typical dialysis regimen is three treatments a week for about four hours for each treatment.
A dialysis fistula is fashioned by sewing a vein in the arm directly to an artery, thus creating a large volume capacitance vessel that can support the flow required to keep the dialysis machine from clotting.
As there is no artificial material placed in the body to create this access, risks of infection are low. Dialysis fistulas if probably maintained can last for years, although they tend to become unsightly as they dilated and appear as a very large “ropey” vein on the forearm.
Dialysis fistulas take several weeks to “mature” for best functioning and should not be used during this time. These arterio-venous fistulas are the preferred method of dialysis access.
If patients are not thought to have “suitable veins” in the forearm to receive a fistula, the second option is placement of a dialysis graft. This procedure involves sewing a tube made of Gore-Tex into one of the arteries of the wrist or forearm, typically the radial artery. The intent is to shunt enough blood from the artery into the graft to provide adequate blood flow for dialysis, but allow enough blood to go distally to perfuse the hand.
Although dialysis grafts can be used immediately after they are placed, the longevity and risk of infection and clotting is lower if 1-2 weeks is allowed to elapse before using.
Many patients on dialysis opt for placement on a kidney transplant list. The average wait time for a cadaveric donor kidney (i.e., from a brain dead patient where the kidneys are recovered and placed in preservative solution) is four years, depending on the regional organ procurement organization where the patient becomes listed. In order to improve their chances for a cadaveric kidney, some patients list at multiple OPO’s.
Because of this long wait and the difficulty of maintaining a reasonable quality of life on dialysis, many patients like Natalie Cole seek a living kidney donor. Kidney transplants from living donors generally have better outcomes. It is illegal in the United States to purchase or offer remuneration to a donor in exchange for their kidney.
Kidney transplants from donor to recipient are matched by several criteria, the two most important being blood type and tissue typing. The most important tissue typing is determining the human leukoctye antigen (HLA). There are six different HLA’s that are tested for with the more matches between the donor and recipient the better.