D+40 & D41: Pick your poison

Day 40:

WBC 1.0
ANC 760

Day 41:

WBC 1.5
ANC 1005

Last Saturday, Cheryl and I met with Dr. Graham to discuss weaning Ryan off of the pain meds so we could get out of the hospital. At that point, it looked like we might be out in 2 weeks. This Saturday, we have a completely different picture. A number of things have been gaining momentum over the past 4-5 days:

* Worsening rash
* Persistent fever that seems to be getting higher
* Creatinine and BUN levels increasing

It's clear now that the first two are the result of acute GVHD. The creatinine and BUN measure kidney function, so increasing levels indicate that Ryan's kidneys having trouble. The kidney issues aren't a huge surprise, because Ryan is on a ton of nephrotoxic drugs right now. Last time this happened, we just pulled back on all of the drugs that affected renal function and waited for Ryan's kidneys to fix themselves. We are following a similar path this time around, but his kidneys are not cooperating. On the plus side, the levels are not getting worse -- his creatinine topped out at 0.9 the other day and has stayed in that range (0.7 - 0.9) ever since. The problem is that they aren't getting better either.

The kidney function issues take on a whole new significance when you consider that we can't give him Cyclosporine during this time. Cyclosporine is the standard (and most effective) treatment for GVHD, so each day off of it means that the GVH can get worse. Frustration abounds. The docs are going to try and increase Ryan's fluids to alleviate some of the burden on his kidneys. Everything we do seems to have positive and negative consequences, and the fluid increase is no different. Additional fluid will help the kidneys, but could harm his lungs and heart which are prone to fluid accumulation.

There are no easy choices here.