And Yet Another Surgery

I’m headed for another medical first for me: 2 surgeries in 1 year.  The first surgery I had this year was when I had my dialysis fistula tied off in April (along with the associated debacle in the hospital several days later).

The previous April, I had surgery on my left foot due to an infection in my foot bone (osteomyelitis) as well as a deep tissue infected from a foot ulcer, and the associated debacle 3 weeks after THAT surgery that put me in to the hospital with Acute Renal Failure from an interaction with my Tacrolimus (I was prescribed Fluconazole for the Candida Parapsilosis in my foot, which caused my Tacrolimus levels to go to 33, leading to ARF).

I just now got back from the Podiatrist, and had the persistent ulcer on my right foot debrided, and given Cipro for the beginning of a cellulitis.  It never really healed well from the cellulitis I had last month, and started “acting up” again over the past week.  He told me I probably have a multiple organism infection, which if not treated, would most certainly become much more problematic, especially given my immunosuppression.

This is all a direct result of my Charcot Marie Tooth peripheral neuropathy.  The muscles in my leg have deteriorated over my 49 years, and although I use a fitted lower leg orthotic, there is a lot of pressure on the outside of my foot, which caused an ulcer.  It will never probably heal well, so my Podiatrist suggested I talk to my Orthopaedic surgeon about reconstructive surgery on my right foot.  I had it done on my left foot last year, and I’ve had no problems at all on the left since my surgery.

I knew this was coming, and although I’m hesistant to do it, I know I need it, and will have it done.

But, there will be 2 conditions I set before having it done (doctors HATE to hear that).

First and foremost, I will insist on a PCA pump, aka Patient Controlled Analgesia.  When I had my left foot done, the Anesthesiologist wouldn’t do a nerve block (rightfully so, being that I have neuropathy).  Thus, I ended up getting “bolus” doses of Morphine and Dilaudid, with much nausea/vomiting and poor pain control.  They did this because they planned on only an overnight stay, but it ended up that I was in for 2 days.  I had PCA for my kidney transplant and gastric bypass, and had excellent control of my pain with little to no nausea.

Second, I will have the Transplant Surgeons consulted while in the hospital to avoid any errors that put my kidney at risk.  They are the ones who manage my Tacrolimus, so they will be the ones to ensure that my kidney is safe.  After my hospitalization this past April when they gave me too high a dose of Vancomycin, I want somebody watching over the meds I get.

So for now, I’m hoping the Cipro helps, and will hopefully get an appointment to see Dr. Cush within the next several weeks.

As for my readers, feel free to contact me via the comments section.  There are people from around the world who read this blog, and I’ve had questions in the past, particularly about BK Virus treatment.  Thanks for reading and following.  I hope someone finds my posts helpful.

Acute Renal Failure, Round 2

For the second time in less than a year, I had another episode of acute renal failure. 

It all started with my surgery on April 10 to have my dialysis fistula ligated (“tied off”).  The surgery went well; it was done under conscious sedation (no general anesthesia), and I felt great leaving the hospital.  My arm was hurting, as expected, but the pain medication was effective.  Being that there was no more arterial flow into the vein (which had several pseudo-aneurysms), the blood clotted and caused a thrombo-phlebitis.  Now, the fistula is very hard, probably because it’s non-functioning, and has calcified. 

The weekend after my surgery, I developed a fever of 102.1 and shaking chills during the night, so in the morning, I went to the Emergency Department on Sunday morning.  From there I was admitted, and that’s  when the problems started.  I was diagnosed as having cellulitis, and being that I just had surgery, was treated aggressively with Vancomycin, in case I had MRSA.  The dose was set by the pharmacist for this kidney toxic drug, and was rather high.  My first dose was 3,000 mg, and the doses every 12 hours after that were 1,750 mg.  The next morning, they checked a Prograf level, and that was high at 12 (unrelated to the Vancomycin).  When they checked a Vanco level Monday night, it was almost double what it should have been, so they stopped it.  My baseline creatinine is 1.1, and when I was admitted, it was 1.3, probably due to the Prograf being high, and being a bit dehydrated.  By Tuesday, it was 1.6, and my Prograf level was 16! (it should be 6-8).  Rather than do anything, they decided to discharge me with an elevated Prograf level and Acute Renal Failure!  I had a rather blunt discussion with the hospitalist, and she decided to not discharge me.  

The next morning, the Nephrology Fellow (a doctor training to be a Nephrologist) came in and told me I needed IV fluids and an adjustment to my Prograf dose.  He ordered IV fluids at 50 ml/hr (which would be a maintenance dose for a 10 year old), and the next day, came in and told me that if my creatinine was unchanged or higher, I would need a biopsy of my kidney (which, after 4 years, I have never had/never needed).  At that point, I sent an email to my Transplant Surgeon, and he was in my hospital room within an hour (he didn’t know I was admitted).  He made recommendations (500 ml of saline followed by saline at 150 ml/hour, no Prograf that night) and by the next day, my creatinine was 1.5 and my Prograf level was 7.2.  I was discharged on that day, and my creatinine is now down to 1.3.  I did NOT need a biopsy, and my creatinine should return to baseline.  The surgeon was shocked at the amount of Vancomycin I was given. 

It took until today, 10 days later, for me to start feeling almost normal.

Lesson learned-whenever I’m admitted, the Transplant Surgeon WILL be consulted. 

Hospitalization May 2011

What a difference 3 weeks make (since my last post).  At that point, I had just gotten home the day prior from the hospital after my foot surgery, and had been prescribed Fluconazole (aka Diflucan).

This past Wednesday, I went in for my routine quarterly transplant appointment that had been postponed a month due to my surgery.  It wasn’t a good week; our 15 year old Springer Spaniel died on Monday, and my son locked the keys in our vehicle when I was going to my transplant appointment.  When the Transplant Nephrologist came in, he looked at my labs, and had a look of surprise on his face.  While my creatinine usually runs between 1.1 to 1.3, it was 2.1, with a GFR of 34%!  I was admitted to the hospital that day for Acute Renal Failure, and was in for 2 nights.  I had a renal ultrasound, and there was no obstruction, and my transplanted kidney has good blood flow.

It turns out that I went into failure from Prograf toxicity (level of 21.8!).  In addition, my BK virus, which was 7000 copies in my urine last month (mistakenly reported at that time in last month’s post as 7700), shot up to 912,000 copies on Wednesday, no doubt from the oversuppression from the high Prograf level.  This was all due to an interaction between the Prograf and the Fluconazole.

At this point, they decreased my Prograf from 3mg in am and 2 mg in PM, to 2/1.  I will have labs next Thursday, and if my creatinine is improved, they will probably just watch it for now. If it isn’t improving, I’ll be getting a kidney biopsy. “Chronic disease with a positive attitude”  is a bit difficult this week, but I’ll keep trying.

Until next time….