And now another surgery....

Yesterday I drained ~600cc of fluid from my abdomen.  Combine that with the diuretic effect of the lassie I took and I lost 3.8kg since Monday!

That might have taken it a bit too far, but I feel much better.  I got my albumin/creatinine results back from this morning and the amount of protein spillage doubled.  Obviously this is not the direction I want it to go, but I can only deal with one problem at a time right now.

While at Mayo I met with both my doctor and the surgeon who did my transplant.  They believe that the fluid pocket is a lymphocele (there are lots of different fluid pocket types like serum and urinoma), and they both agreed that, based off of the amount of fluid that's coming off, that the best long-term solution is surgery.

This little passage is from an article titled "Perirenal Transplant Fluid Collections" written by Howard M. Richard, III in 2004:

Lymphoceles are well-known complications occurring after transplantation and can be seen in up to 50% of patients.2 Up to 18% of these collections are symptomatic. Symptomatic collections can appear from 2 weeks to 6 months following transplantation. The term “lymphocele” (lymphatic collection lacking an epithelial lining) originated in the Japanese literature and was described as a complication of pelvic lymph adenectomy by Kobayashi and Inoue.3 Lymphoceles may result from drainage of the lymphatics divided during surgery to expose the iliac vessels and from injured lymph channels in the donor kidney hilar vessels. Factors predisposing to lymphocele formation include acute allograft injection episodes, acute tubular necrosis, transplant biopsy, retransplantation, and even adult polycystic kidney disease in the recipient.4,5 More recently, addition of sirolimus to cyclosporin, immunosuppression that is commonly employed in transplant patients, has been associated with an increased incidence of lymphoceles.5

Now I'm going to layman's terms that paragraph above according to my discussions this morning:

Typically, there isn't available space in the abdominal region where they put the transplanted kidney.  They have to move my bowels to one side and my muscles to the other to create a pocket.  In the process of doing this, there are microscopic vessels containing lymphatic fluid that are damaged/cut in the process.  This fluid then ends up draining around the kidney, and in my case, they build up because my body can't absorb that amount of fluid in that location.  The placement of the drain really helped, but they can't keep this drain in long-term, so the solution is to essentially create a passage to my peritoneal cavity where the fluid from this lymphocele can drain permanently and my body will be much more efficient at absorbing.

So, I'll go back to Mayo Monday morning for plasmapheresis and some extra frozen plasma that will cause me to get awful hives unless I pre-medicate with Benadryl, which means Joacim will need to drive me because I won't be able to.  We'll plan on doing the surgery Tuesday, which means I'll have to stay in the hospital Tuesday night inpatient for observation because of the general anesthesia.   They'll go through the same incision that was created when I got the transplant, and the procedure itself will take very little time, but they'll also remove this external drain at the same time.  Pending any issues, I should be able to come home Wednesday.  My surgeon did warn me that I might be in quite a bit of pain as the 2nd surgery is usually more painful.  This part sucks a little bit because who wants to be recovering from surgery over Christmas, but there really isn't a good alternative, so recovering is what I'll be doing.  I hate that I'll probably need to take oxycodone for the pain because I finally feel like I'm figuring out this whole bowel issues I'm having, so it's like starting over with that whole nightmare, but I'll deal with it.

I do hope that, once this surgery is done, that we can re-focus on the protein spillage.  I'm sure I'll have to have another biopsy after Christmas to see if the rejection is resolved, but at least the fluid pocket issue should be resolved.  Having all of these issues at the same time has made it difficult to focus on one thing, so by knocking them out one at a time we'll eventually get to the protein.  The good news is that my creatinine went down to 1.5 (from 1.7) so that tells us that the kidney is a little bit happier than it was on Monday.