A Game of Cat & Mouse

Today hasn't been such a great day.  Elise had blood work drawn this morning at TCH. It was a hard draw-- they had to stick her 3 times to get the blood needed.  Then, I literally waited all day for results.  I was really hoping that "no news is good news," and that the results would be good and "worth the wait," but no such luck.  Elise's liver enzymes are significantly elevated.  The first thing our transplant coordinator said this afternoon was, "Let me tell you the plan before I tell you the numbers because you might get worked up."  Who? Me??  Lol.  Well, once I heard the plan, it became very clear to me what was up, besides her liver panel. I asked, "Is this early rejection?" as the following numbers glared back at me from my spreadsheet…  

AST up to 154 from 53;  ALT up to 150 from 39;  GGT up to 36 from 16. 

At this point, I spoke to our liver center director, Dr. Shepherd (currently covering for our attending liver doctor, Dr. Fishman) who said to me, "Listen to me, I'm not worried.  If I was worried, we'd have you bring her in to the hospital for a liver biopsy. This type of jump in numbers is very much expected since we have been running her immunosuppressent level so low in order to chase down her EBV level. Now we will double her Prograf and start her on an 8-day taper of the steroids, and her liver panel will get right back in -check."  He went on to say that it's quite possible that we will see another rise in her EBV, however, over the next couple of months.   I asked, "So, basically, we're looking at having to play this game of "cat and mouse" indefinitely to keep her liver happy and EBV out of the picture?" Dr. Shepherd said, "yes." I took a moment to breathe, and then asked, "Tell me again why you're not worried about her current liver panel?"  

According to Dr. Shepherd, she's in good shape for several reason:  

1) she's a "fresh transplant," just 4 months post-op, and under normal circumstances (meaning no EBV issues), her prograf level should be running at 8-10; however, in Elise's case they are having to run her level at 2-3 in order to control the EBV.  Elise's prograf level today was 2.0, which Dr. Shepherd says is typical for patients at least 2 years post transplant.

2) Although her AST and ALT are increased significantly, her GGT is still generally within normal range. GGT is the major indicator of rejection.  Dr. Shepherd explained that elevation in AST and ALT simply mean that her liver is irritated and getting a little upset w/ the current situation, so the plan needs to be tweaked. 

3) TCH liver/ transplant team is "on it." 

And now, here's the PLAN:  We are to increase her Prograf dose to 1 mL twice daily and re-start the steroid Prednisolone on an 8-day scheduled taper of 3.3 mL per day x 4 days followed by 1.7 mL per day x 4 days. She will get repeat labs next week on 7/22/13, and next liver clinic (also to include labs) will be 7/31/13. 

Our transplant coordinator and Dr. Shepherd both expressed full confidence that this PLAN will bring Elise's liver panel back down to normal, and we can all be happy and calm again.  

I"m always calm, cool, and collected though, so we have that much already in the bag!!