Tuesday, July 22, 2014

Day +53 A Day in the Life of a Transplant Patient & Small Victories

Ryan’s platelet count has rebounded a little bit. They jumped up from 78K to 119K in just four days.  I felt so relieved when I found out.  I know that platelets will fluctuate and that he is doing fairly well, but anytime I see his platelets go down, I panic.  I just can’t help it.  I watched his counts go down over and over for almost a year and it was always bad news.  I am now conditioned to be disappointed to see numbers go down and it will take me awhile to get over that.

I went into yesterday’s appointment with my usual list of questions and concerns.  After not seeing an increase in platelets for a few weeks, I wanted to know if Ryan had been tested yet for platelet antibodies and, if not, I was going to request it.  If someone has platelet antibodies, it means that their immune system is mistakenly creating antibodies that attack and kill platelets.  So, my question “Has Ryan been tested for platelet antibodies?” was met with “Well his platelets are almost 120K, that’s pretty good.”  The team acknowledged once again that they know I am worried, but they want me to know that they are not worried.

Another piece of good news is that Ryan hasn’t needed any anti-itch meds in over 24 hours. He still has a slightly visible GVHD rash and, since we lowered his steroid dose again Sunday, his cheeks are a little pinker. However, so far he hasn’t had a major GVHD flare up. The PUVA therapy seems to be helping some. Being off the anti-itch meds (which also act as sedatives) has certainly increased his energy level and overall happiness. He has been a lot more loving the last couple days and has been downright silly at times.

On a non-medical note, Ryan’s latest hobby is mopping.  Yep, you read that right. He has been asking every day this week if he can mop the floor.  I figure he can’t do much damage with a Swiffer, so why not? It also gives him some additional exercise so it’s a win-win.  I am secretly hoping he will want to continue mopping everyday when we return home.

In case you are wondering what Ryan’s days are like, below is a sample of a typical clinic day (This was yesterday, Monday 7/21/2014):

I wake up and jump in the shower

Wake up Ryan and disconnect the IV used for overnight fluids

7:15 AM
Leave for Clinic

7:45 AM
Arrive at SCCA Clinic

8:00 AM
Blood Draw at Lab

8:30 AM
Take morning medications & grab quick breakfast in the SCCA cafeteria

8:45 AM
Hickman Line Dressing Change (Ryan’s most dreaded appointment every week – it hurts…)

9:30 AM
Appointment with Nutritionist:
Weight/height recorded. Nutritionist advises that Ryan needs to continue working on getting more fluids, eating more potassium rich foods and adding calcium as much as possible.  We hear for the first time that Ryan’s last chest x-ray showed some bone de-calcification, therefore, calcium and vitamin D are really important right now.

Take Psoralen in preparation for 11:15 PUVA treatment (must be taken precisely 1.5 hours before treatment to be effective)

Clinic Appointment with Transplant Team
Vitals are taken and we discuss medications, fluids, skin symptoms, lab results, ekg results, hickman line function, appetite, nausea, and so on. The de-calcification shown on the last chest x-ray is brought up again. The team re-assures us that it is reversible, but we need to continue to address it.  Note: Ryan already takes two Viactive calcium chews a day, along with Vitamin D.  The bone issue is a common side effect of transplant and the high-dose steroids – all the more reason to keep tapering him off the steroids, if possible.

Mid-day Medications

PUVA Therapy (a.k.a. “The Tanning Bed”)

12:00 PM
Lunch back at the RMH apartment. Ryan sneaks in some SpongeBob on TV while I work on Laundry.

2:00 PM
Physical Therapy at Seattle Children’s

3:30 PM
Return to the SCCA clinic to pick up new prescriptions and IV fluid bags to be used until the next clinic appointment on Thursday.

4:30 PM
Return to RMH apartment


7:30 PM
Start prepping IV pump (gather supplies, check pump battery, program pump, attach tubing to bag and prime)

7:45 PM
Clean and flush Ryan’s Hickman line and hook up IV.

8:00 PM
Evening Medications

8:30-9:00 PM
Ryan goes to bed (by this time, Ryan is normally asking if he can go to sleep…)

Around this time, I generally go to bed, but I am so busy processing everything that I have a hard time going to sleep.  About the time I finally drift off, I hear Ryan wake up and yell from the other bedroom “Mom! I have to go pee!”  My job is to get up with him and hold the backpack that contains his bag of fluids and IV pump so that he can do his business…

Note: This week’s schedule is an improvement over last week when Ryan needed anti-itch medication around the clock, including at 11:00 PM, 2:00 AM and 5:00 AM.

Saturday, July 19, 2014

Day +50 Half Way to the First Major Milestone

There is nothing magical about Day +100 other than, statistically, transplant patients have better survival rates if they make it to day 100.  It is also the time when, if Ryan is doing well, he can get his Hickman Line removed and, most importantly, we can go home. It feels good to be half way there.

Overall, Ryan is doing well for where he is in the process. Below are updates on a few random topics:

Platelets dropped a few weeks ago from a high of 155K, but have leveled out around 78K. The team is not concerned about it.  They often see platelets decrease when a patient has GVHD. Ryan is also on some medications that can artificially lower counts.  Once he is further along and off some of the medications, his counts should start increasing again.

ANC has been in the normal range (around 4,500 most days).

Hematocrit has been steady in the 33-35 range.  The team told me at his last appointment that they had expected his hematocrit to drop because they have been taking so much blood for lab tests and research, that no person would be able to produce enough new blood to keep up.  Again, this is temporary and it is not hurting anything.  I have agreed to the additional research blood draws because Ryan had a very rare diagnosis and I think it is important to allow experts in the field the opportunity to learn from him.  Maybe they will find something in their research that will help another child in the future.  It is the least we can do to pay Ryan’s gift forward.

Ryan is still fighting some skin GVHD. He has been on high dose steroids now for about 35 days.  At the highest doses, he had quite a few side effects, so the team slowly began tapering him off of them.  However, once the dosage was lowered to a certain point, his skin rash and itching flared back up.  I was sure the team would bump the steroid dosage back up.  However, to my relief, they offered to try an alternate therapy called “PUVA” (psoralen + UVA treatment).

PUVA is a therapy done three times a week for several weeks.  It involves taking psoralen, a drug that makes the T cells that are attacking the skin sensitive to UVA light, an hour and a half before treatment and then laying in a tanning bed with special bulbs for a few minutes. The UVA light then “zaps” and knocks down the offending T cells.

It was really difficult to convince Ryan to get into the tanning bed.  I am sure it looks really scary to a 5-year old.  Plus, he knew it would get warm and his skin was already itchy and bothering him, so he was afraid the hot bed would make it worse. It took some real convincing, and thankfully the nurse that administers the treatment is really patient and good with kids, but Ryan finally let me lift him in and he stayed still the entire time.  He had his second treatment Wednesday and now he says it’s fun and he likes it.  I am also seeing some slight improvement in his skin already.

A Chimera was a creature in Greek mythology usually represented as a composite of a lion, goat, and serpent.  Contemporary use of the term “Chimerism” in bone marrow/stem cell transplant derives from this idea of a “mixed” entity, referring to someone who has received a transplant of genetically different tissue.

At Day +28, a chimerism test is performed to analyze the bone marrow recipient’s DNA to determine what percentage is the donor’s DNA and how much of the recipient’s DNA remains, if any.  It’s not too uncommon at this stage for transplant patients to be 95-98% donor and still have some of their own DNA.  In fact, some people never achieve full chimerism, which can create a risk for future graft failure if the original cells start to multiply and take over again.

I realized the other day that I hadn’t received Ryan’s results yet, so I asked and was thrilled to hear “oh, he is 100% donor.”  Woo hoo! It’s one less thing to worry about right now.

Monday, July 7, 2014

Day +38 Decreasing Platelet Count & GVHD Flare

Last week, Ryan was admitted to the hospital because of breathing problems and a low oxygen saturation. They observed him for 24 hours. The breathing and oxygen saturation didn't change much but the CT scan of his lungs was clear, and they couldn't think of anything else to work him up for, so they released him. We are now back at the RMH apartment.

I am feeling a bit discouraged because Ryan's platelet count has started dropping. I know it is normal for it to fluctuate, but it was up to 155K a few weeks ago, then it hovered between 135K-145K for about two weeks. Then, last Thursday it had dropped to 105k and today it was 79K.

So far, the team says they are not concerned about Ryan’s counts.  However, when I was on the phone with the SCCA nurse last Thursday and I mentioned the count dropped to 105K she said "Yeah, we noticed that too" in a voice that had a hint of concern in it.

I haven’t had a chance to discuss today’s drop to 75K with the team yet, but if it keeps decreasing at this rate, he will need a transfusion in a little over a week. I thought we were done with transfusions!  I am really freaking out a bit and am worried that he might be having graft failure. It makes me feel sick to think about that possibility.

Also, his skin GVHD flared back up this morning, so we have stopped tapering the steroids and are keeping him at the same level for now.

Ryan has really been missing home.  His dad and sister stayed with us this weekend.  It was a surprise to him and it really lifted his spirits.  However, today he was talking about how much he misses his cat, Dexter.  He tried to convince me that we should “stop by the house” (as if it were close).  I had to remind him that we are not allowed to leave the city until summer is over, at the earliest.