As director of kidney and pancreas transplantation at Mount Sinai and the medical director of the New York Organ Donor Network, Michael J. Goldstein is a transplant surgeon whose vision is to increase patient access to transplantation through an innovative clinical style, as well as enhance the number and quality of life-saving organ donors. He oversees the clinical management of donors for the New York metro area and performs over 100 kidney transplants a year.

Who's at risk

About 86,000 Americans are currently waiting for a kidney transplant. "People who need kidney transplantation have minimal to no kidney function due to chronic kidney disease," says Goldstein. "Some patients develop disease that is limited to the kidneys, but most develop kidney failure from diabetes and/or high blood pressure."

In New York state, more than 7,000 people need a kidney transplant — with 80% of them living in the New York metro area. And every group in society is at risk of kidney disease.

"The gender differences aren't significant," says Goldstein. "There are strong differences between different ethnic groups, but everybody is at risk." African-Americans have a higher risk of developing kidney failure, he said.

The only treatments for end-stage kidney disease are dialysis and transplantation, but there is a critical shortage of available organs.

"The waiting time to get a kidney transplant in New York is around four to six years, one of the longest in the country," says Goldstein. "The fewer organs we have, the more people die while waiting."

Each year, about 35,000 patients are added to the waiting list, and only 16,000 get a kidney transplant — which amounts to about a fifth of those who need them. About 60% of donated organs come from deceased donors, with the other 40% coming from living donors — mainly relatives and friends.

Signs and symptoms

"The scariest part of kidney failure is that it's silent," says Goldstein. "The majority of patients have no idea they have kidney disease." Most patients are diagnosed at a doctor's appointment when they get routine blood work.

"One of the blood levels, called creatinine, is elevated, or they have protein in their urine," says Goldstein. "But they can't feel these things." The amount of urine produced is not a gauge of kidney function.

When kidney disease goes undiagnosed until end-stage renal failure, some patients end up in the ER with complications. "Most people live their lives and feel great until they've lost 80%-90% of their function," says Goldstein. "It's hard for them to imagine that they feel so good and yet they need a transplant or dialysis."

The most common symptom of kidney disease is fatigue, which of course is not a specific warning sign. Once patients get to end-stage disease, they can develop high blood pressure, progressive anemia or fluid overload that can show up as swelling in their legs.

Traditional treatment

Patients with advanced kidney disease still have two options: dialysis or kidney transplantation.

"Dialysis is a great backup mechanism in that it's life-saving. It's disruptive of lifestyle, but it does sustain their life for a long time," says Goldstein. "Nevertheless, what they need is a new kidney."

Most patients just need one kidney from a healthy donor to get off dialysis.
Transplants are highly effective, but not curative. "People can develop recurrences of kidney disease in the transplanted kidney," says Goldstein. "And any transplanted kidney will not last forever."

The average life of a kidney from a deceased donor is 7-10 years. From a living donor, it's 17-20 years. Goldstein recommends patients in need of a kidney transplant ask themselves, "Is there anyone in my family or community who might be a living donor for me?"

There are four advantages to a living donor: Patients don't linger on the wait list, the kidney almost always has immediate function, the kidney is usually healthier, and it lasts on average twice as long as a kidney from a deceased donor.

The kidney transplant operation takes about three hours under general anesthesia. "The vast majority receive one new kidney, which we often put in a different place than their original kidney," says Goldstein. "The patient's own nonfunctional kidneys rarely need to be removed."

Most patients stay in the hospital three to five days. After surgery, patients can return to work and lead normal lives, as long as they stick to their medical regimen. "One would not be able to easily identify a transplant patient," says Goldstein. "The only difference between them and anyone else is that they're on medication to make sure their body doesn't reject the kidney."

These immunosuppressants are now safe, with minor side effects. "These meds keep the kidney from having early rejection 90%-95% of the time," says Goldstein. "It's like taking vitamins for their kidney every day."

Nonetheless, transplanted kidneys don't last forever, so many patients end up getting another transplant 10 to 20 years down the line.

Research breakthroughs

Treatment for kidney disease has improved radically in the past 50 years, but doctors are still working for better treatments. "The longstanding dream of doctors in transplantation is to achieve something called tolerance — the ability of one patient to accept another person's organ without the ability to recognize it as different," says Goldstein. "We're looking for ways to fool our bodies into accepting another person's organ without recognizing and rejecting it as foreign."

Questions for your doctor

Once you've been diagnosed with a kidney disease, the first question should be, "Is it appropriate for me to be referred to a kidney transplant program at this time?" If you've reached the point of needing a transplant, changing your lifestyle can make things easier, so ask, "How can I optimize my diet and exercise routine to make myself the best possible transplant patient?"

What you can do

Guard against diabetes and hypertension.

They are the two leading causes of kidney disease, so preventing them, detecting them early, and managing them once they've developed are key to preventing kidney disease.

Get evaluated at a kidney transplant program.

Dr. Michael J. Goldstein advises being evaluated as early in the disease as possible and certainly before you go on dialysis. The transplant center can make sure you get on the wait list as soon as it is appropriate.

Get informed.

Start with the website for organ donation, donatelifeny.org, which carries helpful information for both potential organ donors and recipients. For information on kidney diseases in general, check the National Kidney Foundation at kidney.org.

nydailynews.com

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Researchers have identified a gene that can cause symptoms of major depression and said it may be possible to use gene therapy to counteract its effects.

They have been testing a similar gene therapy technique in the brains of patients with Parkinson's disease and may be able to quickly adapt it to depression, Michael Kaplitt of Cornell Medical College and colleagues reported Wednesday.

"We potentially have a novel therapy to target what we now believe is one root cause of human depression," Kaplitt, a neurosurgeon, said in a statement.

Depression affects about 121 million people worldwide, according to the World Health Organization, and is diagnosed in at least 13 million U.S. adults each year. It is the main factor in suicide and at least 27 million Americans take antidepressant drugs.

The causes are complex and different patients respond to different treatments.

Kaplitt's team looked at the activity of a gene called p11 in a part of the brain called the nucleus accumbens.

"This is the center of the brain for reward satisfaction," Kaplitt said in a telephone interview.

"One of the major problems in depression is what is called anhedonia -- an inability to be able to be satisfied or happy or content with normally pleasurable activities in life."

The p11 gene helps regulate signaling of serotonin, a brain chemical tied to mood, sleep and memory. Many antidepressants target serotonin.

The research team used mice that lacked active p11 and acted depressed.

DEPRESSED MICE

"If you hold a mouse up by its tail, it tends to fight to get away. A mouse showing depressive behavior will just lie there," Kaplitt said.

Kaplitt's team has been testing gene therapy for another brain disease, Parkinson's, in people. They used the same vector -- the virus used to carry the new gene into the body -- to make a gene therapy replacement for p11.

It transformed the behavior of the depressed mice, they reported in the journal Science Translational Medicine. But taking out a gene and then replacing it in mice does not prove that gene causes human symptoms, or that boosting its production would alter human depression.

So they looked at brain samples taken from people with depression who had died and compared them to samples from people without depression.

Levels of p11 in the nucleus accumbens region -- the reward center -- were significantly lower in the depressed patients, they found.

Gene therapy for depression is a long way from being tested in people, Kaplitt noted, although he said the Parkinson's trials show it could be safe.

Gene therapy -- replacing or boosting the activity of a faulty gene to correct disease -- is still considered highly experimental, although there has been some success in treating forms of blindness and immune deficiency.

"One of the next key steps is to try and test this in non-human primates," he said. He said his team was collaborating with a team at the National Institute of Mental Health, one of the National Institutes of Health, to test the idea in monkeys.

The study was paid for by the U.S. and Swedish governments as well as private foundations, but Kaplitt has founded a company called Neurologix Inc, which has licensed intellectual property rights to p11 gene therapy for behavioral disorders.

nydailynews.com

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Having a miscarriage is a difficult challenge for couples to overcome, both physically and mentally, but most are eager to try to conceive again as soon as possible after the loss. It is not clear, however, how long a couple should wait before attempting to become pregnant after miscarriage to maximize their chances of a healthy pregnancy.

A new report by researchers at University of Aberdeen in Scotland suggests that sooner may be better. The scientists found that women conceiving within six months of a miscarriage have better chances of a successful and complication-free second pregnancy than women who conceive later. But the conclusion is contrary to an earlier report from Latin America that found higher pregnancy rates among women who waited at least six months to conceive; that report formed the basis the World Health Organization's 2005 recommendation that women delay pregnancy for six months after miscarrying. (See the most common hospital mishaps.)

Since then, however, the World Health Organization (WHO) has called for more studies on conception after miscarriage, and the new Scottish study is the first attempt to provide better data on optimal timing for women. Dr. Sohinee Bhattacharya, an obstetrician at University of Aberdeen, led an analysis of more than 30,000 Scottish women in the national health registry who had lost their first pregnancy but were able to conceive a second time. In line with the WHO's advice, she found that a larger proportion of women (59%) conceived six months or more after miscarriage, compared with 41% who became pregnant within six months.

But the latter group, it turns out, was also least likely to miscarry again, and more likely to have a live birth. Women who conceived within six months of their miscarriage were 34% less likely to miscarry again, compared with those who became pregnant six months to a year after the initial miscarriage. (See pictures from an X-ray studio.)

While the study did not address the causes of miscarriage, Bhattacharya speculates that age may be a dominant factor. For many women who decide to start a family at an older age, waiting six months to attempt another pregnancy may work against them, since age is itself a primary contributor to miscarriage. "If a woman is over 30, then waiting another six months will reduce her chances of getting pregnant at all and increase her chances of having another miscarriage, simply because of the age difference," Bhattacharya says. "Our research shows that there is no justification in terms of health reasons for delaying." (See the top 10 medical breakthroughs of 2009.)

Dr. David Keefe, chair of obstetrics and gynecology at New York University Langone Medical Center, notes that in developed countries, the biggest predictor of a woman's likelihood of pregnancy is her age, not when her last pregnancy occurred.

That is not true, however, in developing nations, where it is more important that women have access to health care to ensure that any infection or other consequence of miscarriage are fully addressed before they try again. Studies conducted in these areas have recommended a longer interval following a miscarriage, says Keefe, noting that such guidelines were based not only on the toll of miscarrying, but also on the impact of carrying a baby to term. Health officials assumed that it takes a woman the same amount of time to recover physically after a miscarriage as after a full-term pregnancy — about six months. But that is not necessarily the case, since a successful pregnancy may deplete a woman's body more, in terms of nutrients, than a miscarriage.

The American College of Obstetricians and Gynecologists currently has no recommendations for when to conceive after miscarriage, but many obstetricians say they allow women to dictate when they feel ready to start trying again — which in most cases is sooner rather than later. "The guidelines have told us to wait six months, and sometimes even two years. So our heads told us to wait," says Keefe. "But our hearts always told us to get right back in the game."

The new data support that instinct, he says, and may help more doctors and hopeful parents feel comfortable about following up a failed pregnancy with another one as soon as possible.

time.com

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