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Decisions

March 13, 2013 2 comments

Decisions. We all make them from the time we get out of bed until the end of the day when we go to sleep. Which shirt should I wear to work? What are we going to eat for supper? iPhone or Android? Cable or satellite? Do I drive an extra 5 miles to save a penny a gallon on gas?

For those of us with chronic illness, decisions are even more complex and the stakes are higher. I was pondering this on the way home from my 3 doctor appointments today (my mind never seems to stop, which is probably why I need Trazodone to help me sleep).

My first 2 appointments today were with the Transplant Surgeon and Transplant Nephrologist. Everything is going well with my kidney. My creatinine is still rock stable at 1.2, and although I again have BK Virus in my urine after 2 negatives, there were only less than 6000 copies in my last urine specimen 2 weeks ago, far below the 2 million copies that my Transplant Surgeon said is the level that he would be “worried” about. It was my last appointment, with the Neuromuscular Neurologist, that got me thinking about the topic of decisions.

As I posted last Spring, I was on Leflunomide, which was used to keep the BK Virus at bay. Not an FDA approved use of the drug, but then again, there IS no standard treatment for BKV. I agreed with the decision by the Surgeon to start Leflumonide. But when my hands were so weak and shaky that I couldn’t get a key into the door, it dawned on me that something was terribly wrong. I figured out that it was not progression of my neuropathy (Charcot Marie Tooth), but rather, was the Leflunomide ravaging my peripheral nerves (and yes, ravaging is an appropriate term). At the time, I phoned my Transplant Coordinator, and was told to stay on Leflunomide, and to see a Neurologist. The referral was made, but 2 months later, I still hadn’t even been contacted about an appointment. As the neurotoxicity worsened, I stopped taking the Leflunomide, and contacted the Transplant Department. The Transplant Coordinator covering for my regular Transplant Coordinator spoke with the doctor, and called me back. When I told her that I stopped the Leflunomide, she asked me if I wanted to lose my kidney. Sheesh, another decision. My first reaction was that she had a helluva lot of nerve putting it that way (I still think that), and being that she is not living with the effects of the med, it wasn’t too professional of her to put it in those terms. Putting the cart before the horse, she continued on by telling me that I may have to receive a last ditch treatment, intravenous Cidofovir, to get rid of the BK virus, since I had stopped the Leflunomide. The problem would be that Cidofovir is VERY toxic to kidneys, and would put my transplant at great risk. Damn, another potential decision. When she went back to the doctor, it turns out the plan was watchful waiting. It obviously turned out well, as my kidney is doing just fine.

Just last Fall, I had a reconstruction done on my right foot. Of the 8 surgeries I’ve had in my life, this was by far THE most painful surgery I have ever had. I was literally screaming in pain when I got to my room after the surgery, but today, for the first time in years, I am walking without a hard plastic orthotic bracing my leg, and my foot is straight. That was a good decision, although during the recovery period, it would have been easy to argue that it wasn’t.

Which brings me to my Neurology visit today. The Neurologist and I had a long talk (my first visit with this doctor), and a good portion of that was on the topic of medications. It turns out that the drug I take to suppress my immune system to prevent my body from rejecting my kidney, Tacrolimus, is a known toxin to peripheral nerves. It’s not likely to cause the damage that the the Leflunomide did, as it’s a “lesser” toxin, but over time, it most likely will cause SOME damage. Risk vs benefit. Progressive damage over decades vs dialysis within months if I don’t take the Tacrolimus and reject my kidney. I’ll take the former. It all boils down to risk vs. benefit.

But being a glass half full kind of guy when it comes to health, there are people far worse off than me. Like the 7 year old local girl who recently lost her life to cancer (Neuroblastoma). Or many of my patients who have disease such as heart failure, cirrhosis, or COPD whose diseases will progress to end stage within a matter of months or several years. I see it every day in my job as a Case Manager.

A doctor will oftentimes make decisions for you – here’s a pill that I’m going to prescribe to help with your blood pressure or cholesterol. A GOOD doctor will explain the risks and the benefits and then ask for your input and decision. Life is full of risks. Too many people today are under the illusion that risks were something we face “in the old day”. Surely, with all of the advancements in science, we shouldn’t have to take risks…. Sorry to burst those people’s bubble, but that’s not the way it works. In fact, with advancements come even MORE risks and more complex decisions. Science and medicine can fix a blockage in the arteries of your heart, and you’ll live longer, as long as you follow the Cardiologist’s instructions. But as we live longer, there is an increased risk that other problems will pop up. And this leads to more decisions.

Unless you are a child, you’ve probably made a decision in the past which you have come to regret. Last year, I had surgery to “tie off” my dialysis fistula. I was told that I would get inflammation in the vein of my upper arm, and it would become red and painful. It did, but when I had a fever of 102, along with the fact that my immune system is suppressed, I made the decision to seek treatment in the Emergency Department (it was a weekend). The doctor decided to admit me to the hospital, and the pharmacist recommended a specific antibiotic. The nurse that was working was a friend of mine, and looked a little nervous when she brought the antibiotic in. It was Vancomycin, which is known for it’s potential to cause kidney damage. Not only that, but the dose was very high-3 grams, followed by 1,750 mg (1.75 grams) every 12 hours after that. I knew it was a high dose, but the facts were that I had a potentially life-threatening infection. Do I risk not treating that and saving my kidney, or risk my kidney to decrease the risk of death or potential problems of an untreated infection? I chose to get the antibiotic, and ended up with Acute Renal Failure from both the med and dehydration. Did I make the right decision? Well, probably not, because they could have used a lower dose or a different antibiotic, but in the end, everything turned out ok, other than the fact that I was in the hospital a few extra days. Hindsight is 20/20. I learned from that one…

Just yesterday, I spoke with the adult child of one of my patients who has had a steady decline in her health over the past year. Her chronic diseases have been well managed up until recently, prolonging both her life and QUALITY of life, but recently, she’s had one problem after another. She made the decision to not get out of bed yesterday, and to not go for her endoscopy today because she has “given up”. She’s not tolerating the medicines that for so long have kept her illnesses at bay; they “come right back up”, probably due to a newly diagnosed disease that may be a result of one of the medicines used to fix an abnormal heart rhythm. Her decision is probably due to her thinking that things just aren’t going to get better no matter what she does, and she’s probably tired of all of the appointments, procedures, and drugs she has to take just to stay alive, and yet still live with her health declining. It’s her decision, and we’ll respect that.

I guess the point of all of this is that if you are faced with a decision, get all of the information you can so that you can make an INFORMED decision, consider risk vs benefit, and don’t beat yourself up when you make a wrong decision.

 

Latest BK Levels and Foot Fix

February 27, 2013 1 comment

From a kidney standpoint, I’ve been doing well. I had 3 negative BK urine tests in a row, but the last one 2 weeks ago was positive for 5800 copies. Not bad, but another negative would have been better.

I still have some residual burning in the fingers from the nerve damage due to the Leflunomide I was on to treat the BK, but I’m off that now, and I can live with it. It’s interesting to note that I never had a negative BK Urine, but once I was off of it, I eventually had 3 in a row. It doesn’t mean anything as it’s anecdotal, but maybe they will do more research on BK to figure out a definitive treatment.

I am a RN Case Manager, and deal with several transplant patients, and a lot of patients with hypertension. I was able to “pick the brain” of a Nephrologist today who specializes in hypertension. I was not aware of this, but Prograf, which is a calcineurin inhibitor, is a potent vasoconstrictor. That means that it causes arteries to get smaller, thus raising blood pressure. Thus, the best antihypertensive choice would be one that causes blood vessels to relax.

I am currently on Lisinopril for my bp, as well as another antihypertensive, Inderal, which is used to treat my hand tremors that worsened after the Leflunomide damaged my peripheral nerves. It’s still not great, but my BP is controlled. I’m going to work on shedding a few pounds, so that should help a lot.

The latest big story is my foot reconstruction.

I had a major foot reconstruction of my right foot in November, and of today, for the first time in many years, can now walk without any orthotic in my shoe.

It’s strange not having my ankle in a fixed position, and I pretty much have to learn to walk normally. I have a tendancy to not flex my ankle, but I know I eventually will be back in the habit of doing this when I walk, based on when I had the other foot reconstructed.

The surgery itself was very painful, and the recovery long (non-weight bearing from Halloween to after New Year’s), and I’ve been in a Bledsoe boot since, but it was well worth it. My foot is very straight now, and although still swollen, it looks great.

I’ve posted x-ray images taken in January, after the surgery, and as you can see, have a lot of hardware.

 

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Foot Reconstruction A Success!

December 7, 2012 2 comments

I made it through my 2nd foot reconstruction with flying colors! On November 19, I had a cavovarus foot reconstruction of my right foot, to fix the the deformities caused by Charcot Marie Tooth. As I posted before, a non-healing neuropathic foot ulcer necessitated me having the surgery at this point. I knew I would have to eventually have it, but I was hoping I would have been able to put it off a little longer. However, I’m glad it’s now behind me.

For those familiar with medical “lingo”, the procedures I had done included a Dwyer calcaneal osteotomy, peroneus longus to brevis transfer, first metatarsal losing wedge osteotomy, 5th metatarsal head ex osteotomy, Jones transfer, posterior tib release, toes 2-4 hammertoe corrections.

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As you can see from the pics, the surgeon did a LOT of sewing!

I had a similar “reconstruction” done last year, although I didn’t have the hammertoe corrections.

The pain has been manageable this time. Due to the neuropathy, the Anesthesiologist didn’t do a nerve block, but due to excruciating pain (despite a Diluadid infusion/PCA pump), I was taken back to the PACU that night and another Anesthesiologist did 2 nerve blocks, which made the pain tolerable. Now, I’m able to get by with Tylenol and an occasional Tylenol #3.

I’m looking forward to FINALLY getting back to walking. I haven’t been doing any due to the pain from the pressure on the outside of my right foot while in my Ankle Foot Orthosis; there was an extreme amount of pressure on the outside of my foot due to the deformity. I can now get rid of the AFO, and once the cast is off, will be put in a “boot” (Bledsoe?) for a few weeks, and after that, will only need a hard plastic in-the-shoe orthotic insert.

My hemoglobin did drop down to 10.1 post op, but as of last week, I’m back up to 11.8.

As for my kidney transplant status, no “medical misadventures” this time. (here and here)

As you may remember, I had gone off of the Leflunomide back in May, which was used to keep the BK virus suppressed. I had a jump in BK in October from 600 to 5100, and was mildly concerned that it may become a problem, but as of my last check (last week), NO BK! If I’m not mistaken, this is the first that it was negative since April 2009!

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I’ve been off CellCept since August 2009, but since my kidney is doing well just on Tacrolimus, the Transplant Surgeon told me that he probably won’t restart the CellCept, even if the BK goes into remission.

I sure hope that I’m done with any medical “speed bumps” for the foreseeable future.

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BK Virus Role In Prostate Cancer

September 16, 2012 Leave a comment

A team of Swiss investigators has found a link between the polyomavirus BK and prostate cancer.

It’s an interesting concept.  Viruses are well known to be linked to development of cancers.  For example, those of us who are immunosuppressed, either purposely through medications, as in the case of transplant or to treat autoimmune diseases, or through disease, such as HIV, are more prone to Lymphoma via Epstein Barr Virus (commonly known to cause mononucleosis).

With more research, there may be the impetus to find a treatment for BKV, given the prevalance of prostate cancer.

As kidney transplant patients are now being screened and monitored for BKV, it will be interesting to see if Prostate Cancer affects male kidney recipients moreso than the general population.

Link via ScienceCodex

Lab Error

September 13, 2012 2 comments

I had great news today.  Apparently, the last urine BK virus specimen that came back with >700,000 copies. was a lab error.  Or, as my transplant coordinator called it, a “fluke”.

I had a repeat urine done on Monday, and there are only 500 copies of virus in my urine.  Not 500, 000, but 500.  I was diagnosed with BK virus in July, 2009, and at the time, I had greater than 39 MILLION copies in my urine.  Since then, it has intermittently been in my blood as well, but my serum BK was negative last week.

So I have to wonder how effective the Leflunomide actually was.

Now, I’ll get my urine checked for BK monthly.  That’s a BIG load off of my mind!

I Dodged the Bullet

September 9, 2012 1 comment

I had labs a week ago, a serum BK.  I’ve found in the past when I’ve had  5 digit BK levels in my urine, I would have it in my blood as well.

However, my serum BK was negative!  I had myself all worried about having to go on IV Cidofovir (a nephrotoxic drug), but at this point, I’m not.

I spoke with my Transplant Coordinator Friday, and she told me the good news, and for now, no Cidofovir.  She said it’s not unusual to have a high BK level in the urine, and then for it to be much lower the next time.  So, to the lab tomorrow to have my urine checked again, and hopefully, it will be down.  ‘

I dodged the bullet this time, but IV Cidofovir remains a possibility in the future.

I’ve done some reading, and it’s not known whether the BK comes from the donor, or whether it was in the recipient’s urinary tract.

It’s a virus that usually affects children as a respiratory illness, and my donor was 16 and in a group home.  Maybe she had a respiratory infection before she died? I’ll never know, and it’s academic at this point.

Decisions, decisions…..

September 1, 2012 2 comments

More speed bumps since my surgery, although unrelated. (speed bump is my turn for a medical issue that I face, deal with, and move on, as opposed to looking at it as a problem that consumes me; it’s all in the approach).

Through the Spring, I had been having a subtle increase in numbness/tingling, tremors, and loss of fine motor skills in my hands. Right after my April hospitalization, it noticeably worsened, to the point where I was having significant burning pain as well, and the one day, I wasn’t even able to get my key into our front door. I racked my brain, and then figured it out. I had a dose increase of my Leflunomide back in January; this is the drug used to treat the BK virus in my transplanted kidney. I looked it up, and sure enough, one of the side effects, although rare, is neurotoxicity. Paired with my existing hereditary peripheral neuropathy, Charcot-Marie-Tooth, this explained my symptoms. I notifed my Transplant Coordinator, and she referred me to a Neurologist but told me to CONTINUE the Leflunomide. The symptoms worsened, though, so I stopped it.

It took 3 months to get in with the Neuromuscular Neurologist, but I finally saw her (for the first time) in mid-August. My suspicions were confirmed-it was the Leflunomide, and the symptoms were mostly irreversible. So she started my on Inderal LA for my hand tremors (my new wonder drug), and did a bunch of labs to check several of my vitamin and mineral levels, all of which were good.

I had my routine transplant labs this past week, and got a call from the Transplant Coordinator; the BK virus level in my urine has skyrocketed since going off of the Leflunomide. In June, the number of BK viral copies in my urine was 2300, and this past week, I have 733,000. They told me to go back on the Leflunomide.

Of course, I refused to do that, given what I went through. I was a bit annoyed when the response to that was “don’t you want to save your kidney?” Yes, of course I do, but I also want to be able to be able to use my hands, so that I can continue to function. While we were talking, she still continued along the same “save your kidney” path, so I finally asked her, for the sake of argument, that if Amoxicillin was effective against BK virus (it isn’t, but Cipro is), and I was allergic to it, would she/the doctor still put me on it? She got my point (I think).

So, she went back to the doctor, and later called me back, telling me that the doctor is “very concerned” (and I’m not?), and he wanted me to get blood work to check for BKV in my blood (I’ve had BKV in my blood before, so I suspect it will be positive), and is considering other treatment.

That treatment would most likely be Cidofovir IV every 2 weeks to try to “clear” me of BKV (which I’ve had for 3 years, albeit controlled prior to this).

The problems are that 1. there is no set treatment for BKV, as it’s discovery has been very recent and 2. IV Cidofovir is potentially toxic to the kidneys.

So it’s come down to this: use of my hands and feet, or saving my kidney.

I’m hoping that I can save my kidney and prevent further damage to my peripheral nerves, and have confidence that I will, but it would be really easy to to let this consume me.

In between all of this, I was in the Emergency Department last month for a foot cellulitis. Every few months, I go to the Podiatrist when needed so that he can pare down the recurring callous I have on the outside of my foot. The callous occurs due to the way I walk-with most of the pressure of each step on the outside of my foot. This is a result of the CMT, which causes gradual loss of nerve conduction, and thus shrinkage of the muscles that keep the foot in a natural position. I wear a padded hard plastic orthotic, but still get a callous. It took a month to get in to the Podiatrist, and 2 days before my appointment, my foot became infected due to an ulcer underneath the callous (much like last year, which led to a bone infection in my other foot and then surgery). However, this time the ulcer was not deep, and it is just about healed now.

So, it’s wait and see for now in regards to the BKV. I hope to blog much sooner to keep you all updated on what happens.