Sunday, July 2, 2017

The Transplant Went Great. Why Do I Feel So Sick?

Dave’s Great Adventure
Transmogrifying From Leukemia to Stem Cell Adventures
July 2, 2017

The last time you got a synopsis…this time you get a DGA “War and Peace.”  (Has anyone ever really read that whole tome?)
I have to admit, again, that I completely underestimated what this stem cell transplant would take out of me and what I’d feel like afterwards.  For the longest time I feared the transplant, was almost panicked at the thought of going through it, but as I approached the actual procedure, I thought that things ought to go pretty well.  I had few other illnesses to complicate the procedure, I had a great, ten out of ten, donor, had achieved Minimal Residual Disease  (MRD) state (very little disease left in my marrow for the transplanted cells to have to deal with) with the use of the wonder drug, venetoclax, I was in one of the very best transplant centers in the country and had, as my doc, Dr. Issa Khouri, one of the pioneers in this business.  He was doing this stuff back in 2002 when I first got sick.  He knows his stuff.  I actually thought (or fantasized, actually) that after a possibly rough month in the hospital, I’d be up and around seeing the sights of Houston for the rest of our putative, predicted 100 day stay!
And then the transplant went so amazingly well.  The infusion of the cells didn’t cause any problems at all and in the first thirty days, they completely took over my marrow, eliminating the residual leukemia cells, changing my blood type to hers, and building up my weakened immunity (actually, she replaced  it with hers.).  And, other than feeling weak, I was doing very well indeed.
Yeah, I hit a few bumps along the way.  I wrote up a quick synopsis a couple months ago highlighting the most exciting features of these bumps, but I’ve got to say now, and I’ll say it again later, my problems, GVHD rash notwithstanding, are trivial for a transplant patient.  I’ll touch on this again shortly.  Back then, everything was exciting to me because I'd never had a stem cell transplant before!
I’ve been keeping mental notes about what has been going on here, with all the good intentions that pave the road to Hell, intending to write them down.  But the story keeps getting ahead of me and I haven’t caught up.  So, I’ll put another bit of a synopsis together (can a synopsis be way, way too long?), stitching together various communications I’ve sent out to various folks in the interim.
My communications in recent weeks have been in the form of scattered emails, Facebook updates, texts and more, none of which went to my DGA community, which in any case, has probably gotten bored with the whole thing waiting for updates that never come.  But, I’ll try to catch you up with snippets of stories I’ve managed to send out in recent weeks.  These are collected below in journal form, in easy-to-read (or completely ignore) “chapter-lettes.”
After my outbreak of the GVHD rash, which was absolutely the most miserable, itchy rash I’ve had in my life, things began to be getting better rapidly on the huge doses of steroids I was taking.  Remember, I was taking 160 mgs/day of prednisone, which is probably eight to ten times as many steroids as I’ve ever had in my life to treat an acute bronchitis, backache or anything else.  Heck, with that many steroids, anything would feel better…for a while. My appetite came back enormously and I began easting furiously.  I went to a local ice cream shop named “Hank’s” and had daily 16oz malts.  Life was good.  I even sent out a joke Facebook update saying I’d applied for and gotten a job there. (If you’re ever in Houston, and love homemade ice cream, try Hanks’s, a little family run shop down on South Main.  Sixteen varying flavors, all great, and wonderful folks.  Try their “custom” Dr. Eckberg chocolate malt!).  Anyway, this real Facebook update followed;
DAY 59 UPDATE (May 5th) (All updates are counted from transplant day, Day Zero, which was March 7th). So, no, I'm not really working at Hank's, but I support them a lot. I wouldn't be allowed to work there or any public place anyway because of all the folks who wander in and out, exposing me to whatever infections they might have. Plus, I'm much too weak to stand behind the counter. If you see me in pictures, I look great, hearty and... healthy. When folks come to see us they invariably tell me I look wonderful. And I can fool you, too, if I'm standing still or sitting on a chair with my hands hidden.
But I'm not well. I'm very weak, I can't walk so much as hobble, and my hands shake most of the day. I cannot write anymore. I owe a lot of Thank You cards for folks who donated to my TNT (Team In Training) fund that Megan set up for me (DGA story to follow at some point) and when I can again write, I'll get them out. The problem is the GVHD rash and the steroids we have to use to keep it under control. Steroids are great meds but with lots of side effects. When I first got my GVHD rash, I started on huge doses of prednisone and then we tapered the dose rapidly. But after having reduced the dose from 160 mgs/day to 60 mgs/day, the rash returned.
When I started on the steroids, knowing they were going to weaken me, I started an exercise program of walking around the neighborhood, climbing stairs and such. But instead of maintaining my strength, I was getting slower and slower. And weaker. Finally, about ten days ago, as I was climbing the stairs in the apartment complex, my legs gave out. I collapsed on the stairs and I could not, absolutely could not- could not- get my legs to lift me up. Fortunately our friend Lou was with me to help get me upright so I could get back to the apartment. So, now I'm enrolled in a PT program which is just kicking my butt, so weak are my muscles. And despite the prolonged use of the steroids orally and the three times daily smearing on of full body steroid creams, the rash persists.
So, we're changing plans. My doc is getting me into a treatment called photophoresis. This is a procedure friend Stacey Campbell mentioned to me weeks ago, wherein they remove portions of my blood through a large bore catheter in my chest (inserted today!) and treat it with a chemical. Then it is zapped with UV lights to weaken the T cells which are mostly responsible for the GVHD reactions. We start this on next Monday. If this works, I should hopefully be able to get off the steroids somewhat sooner. The treatments can last six months or more. Meanwhile we continue our daily infusions of anti-fungal meds, which will also go on for six months or so, and continue to take about 35 pills a day of various sorts. And I think that's all that's of importance for now. More later.
--So, at a point in my recovery at which I had fantasized about visiting museums and taking in the sights of Houston, I was weakened, hobbled, shaking, slow and very immunocompromised.  Not what I had expected. I have yet to visit a single museum, even though they're less than a mile from where we live.  I don’t feel at all well.  But then, I did okay for a while.  I was going to PT three times weekly trying to regain my muscular strength, even as I was taking steroids which were tearing down my muscles at the same time.  Then this update;
 Day 76 (May 22nd)  I am so tired. So very, very tired. And weak. I think I feel the weakest today that I've felt since shortly after we started the steroids weeks ago. I even collapsed in PT today...just couldn't make my legs support me again, like they failed me on the stairs a few weeks ago. And I suppose that's going to have to generate lots of official paperwork for my therapist since I fell to the floor. No blood, no foul, in my opinion, but I guess they have to report it up the chain of command. I'd been feeling poorly since last weekend when it felt like I was coming down with a sinus infection. My muscles had been quivering and shaking since I got out of bed this morning, and when we went to the hospital, I couldn't make it to our elevator without resting on a bench before we got there. That's a first. It was really hard for me to navigate the hospital, so weak did my legs feel. Man, this whole thing has been a lot harder than I expected. I should have known. I was given fair warning by a lot of folks. "It'll take 18-24 months before you feel normal again." I just didn't believe it could be so long.  I didn’t want to believe it. I’m an impatient man.
We got the photophoresis procedures going a couple of weeks ago, to try to ease the symptoms of GVHD, but to do so they pulled my "small" central venous catheter (which looked plenty big to me) and immediately jammed a bigger one into the track in my chest which led to my right subclavian vein, which runs just under the collar bone. The photophoresis procedure, which I mentioned in the last update, collects some of my T-cells, which are donor white cells and are primarily responsible for the Graft Versus Host Disease (GVHD), and these are treated with a drug called Uvelox to sensitize them to UV light. Then they are given a little suntan and put back in my veins. We're doing this three times a week so far but eventually will taper down to twice, then once weekly when things start to improve. Hope that's soon. The machine randomly collects about a third of my T-cells with each treatment so it will never "catch" all of them but gets most over time.
But even as we were doing all this, other problems were simmering in the background. Despite using the whole body steroid cream daily (neck to ankles!), and taking oral steroids continuously, the rash persisted. No itching, fortunately, but its very presence showed that GVHD was still around. Then, slowly but on a daily basis, my liver tests were becoming abnormal, going up a bit with every twice-weekly blood count, This suggested GVHD might be invading the liver. It was looking like Grace's T-cells were upset with my liver cells too. The liver is another organ, after the skin, that GVHD likes to go after. But it's more ominous to have your liver damaged by the disease. My doc has done tests to look for other causes of this hepatitis, like viruses and such, but nothing has shown up so far. We'll keep watching these for a while longer but if they don't start trending downward, I'll probably need a liver biopsy. Not looking forward to something like that.
And now I'm just getting weaker and weaker; probably a combination of the whole stem cell process, the steroids, the hepatitis/liver inflammation (?), and, oh yeah, the fluids I'm carrying around because of the steroids. I'm on occasional Lasix ("water pills"), as well, to unload extra water which has been showing up in my ankles and my chest. And my hands still shake, thanks to the steroids and the anti-rejection drug, the tacrolimus, which makes eating an adventure and writing still next to impossible. But, you know, I'm still around to write these little updates, so I still have much to be grateful for.
I want to sincerely thank so many of you out there who have been praying for my health and survival during this process and, in many cases, praying for me long before we even began this procedure. Despite my many trivial complaints, I am doing, overall, very well. Hopefully this trend will continue and I'll get over these little roadblocks.
I also want to give an enormous "Thanks" and "GO TEAM" to so many members of TEAM ECKS FACTOR [please Google this if you’ve not heard of our team] who volunteered many, many hours at the Byron Nelson Golf Tournament last week. They raised money for the team, to be able to name a $100,000 grant to be donated specifically for research into finding a cure and/or better treatments for CLL (Chronic Lymphocytic Leukemia) which is what I had until Grace (my donor) wiped it out! That's all for now. Thanks everyone.
--But after feeling poorly for a while a few days, I began to gain strength back again and I thought I’d weathered the storm, and sending out this optimistic update;
A Day 86 (June 1st) Last week, just a few days after I sent out my "Woe is me" message, about how tired I was, I was getting ready to send a follow-up message that told you that things were much better already. But then things went south again....
But, before I get to that, let me first tell you how much better things really are for me in so many ways. First, in a major turn-around, my liver functions, which had been a major worry for me as they had been going up week after week and becoming more and more abnormal, since mid-April, have started to normalize. They have dropped with every blood test in the last 2-3 weeks. My liver is healing from whatever was hurting it. My doc thinks it was the green tea which I drank daily in the afternoon just to keep my fluid intake up to par. I wasn’t taking anything exotic, not an extract or anything weird, just Lipton's Green tea (decaf, to boot). He told me to stop drinking it and, ta da, the liver functions have started to return to normal that week. In any case, my liver seems not to be a problem now.
And my doc, in the face of normalizing liver functions has been able to further reduce my dose of steroids. I had been kinda stuck at 20mgs a day for several weeks, but now I'm at 10mgs a day and likely will drop to 5mgs tomorrow. And with that reduction, I have been regaining strength and am doing better in PT with most of my exercises and routines. I walk much better now and don't need to stop for breaks any more.
And, also in conjunction with the reduced steroid doses, I have lost about ten pounds and am getting close to being able to get back into my regular jeans. And I don't eat so much. My family can attest to the fact that when I was on high dose steroids, I ate everything in sight, even when I wasn't hungry, even when I felt stuffed...I would eat more. I'm happily past that now.
I'm still doing the photophoresis treatments, but they are down to twice a week now. They aren't at all painful or anything, but they consume time, about two or more hours at a time; more if they combine them with the infusion of my antifungal meds. But it is a cool procedure, watching them take out three units of blood and pull off the white cells, put them through what is essentially a "white cell tanning bed," and then put them back. The process weakens them somewhat so they're less likely to cause "graft vs. host disease." Seems to be working well.
But, last week, about the time I was going to send an update, I got a headache. Now, I get headaches all the time, all kinds of headaches. But over the course of the evening and into the night it got worse and worse such that I ended up in the ER at 3AM. It was the worst headache of my life.  When I was an intern, working in the emergency room, if someone told you they were having the worst headache of their life, I was told that they might have a brain bleed…so after waiting five hours to think about this possibility, I went in to the MDA Emergency Room!)  They found that my blood pressure was 187/114, a blood pressure I've never had in my life. In any case, they gave me meds to lower my BP and the headache went away. But that event sent me to cardiology, who now wants to do a cardiac catheterization because of a minor abnormality found on a previous stress test done weeks before! I've put that off for now but we'll talk about it again in the near future when I'm past a few other of my pending procedures, like another bone marrow biopsy, PET scan, post-transplant eye eval, derm checkup and such.
The bottom line is that the transplant is, overall, doing real well. All these complaints I have are, really, trivial compared to the issues so many other folks out there who have had this procedure are having. I am indeed fortunate.
We are at Day 86 of our 100 Day post-transplant stay. But, now it looks like it's going to be a bit longer. We may be here into July dealing with residual GVHD issues, photophoresis and such. We'll just take it as it comes. But, I have to say, having spent 86 straight days in the hospital is getting to be a grind, spending every  single day here, weekends, holidays, Mothers' Day and such is getting old. However, I'm fortunate to be where I am and to be doing as well as I'm doing.
Then, more problems. Update from our daughter.
Day 90 (June 5th) After a fairly optimistic Day 86 update, the past few days have not been great for Pops/Mascot Dave. He's made three trips to the ER since then and is currently in the process of being admitted/incarcerated once again. Over the weekend he had to visit the ER twice for his blood pressure skyrocketing once again (measured as high as 202/128 or so). I don't think we have a root cause yet for that. One doc speculated that it could be the meds that he takes for his frequent migraines. We're expecting another visit to the cardiologist in the near future.
Yesterday Pops started developing a "chest cold." The folks he normally sees for his daily infusions told him that if his cough progresses he needs to go to the ER, so that's what he did this morning. He's since been diagnosed with the flu (technically, parainfluenza virus) and a CT scan shows some pneumonia on the right side. Alas, it's time for another incarceration. He's been isolated in the ER while they find a room to get set up for him. Let's hope that all of the medications and photophoresis haven't zapped so many of Grace's t-cells that he's not able to fight off this virus!  This is yet another reminder that the stem cell transplant process is not an easy road. Thanks to everyone who has continued to keep him in your thoughts and prayers. It looks like it's time for another round of support.
Day 91 (June 6th) Pops is hanging in there. His GVHD rash has returned with a vengeance and made it very difficult for him to sleep last night. It's still bothering him today, but not quite as badly as last night. Interestingly, the flu and pneumonia symptoms aren't making him terribly miserable. Hopefully that's a good sign. Earlier today the cardiologist changed his heart meds to something that will hopefully control his arrhythmia without the blood pressure issues. Tonight he'll be getting IVIG all night to help boost his antibodies. Later he’ll be getting a blood transfusion.  And he'll get his vitals checked hourly, so it's likely to be another night without a lot of sleep. But we know he's in great hands, and that's what's most important!
--Hospitals are lousy places to try to get some rest.  There is always something going on; vital signs, meds being administered on the computer’s schedule, not yours, beepers going off, labs to be drawn.  Plus, during my week in the hospital, testing went on as usual.  I had another PET scan (which was read as stable and no malignancies seen) and a bedside bone marrow biopsy ( a first for me) which eventually came back, again, as showing negative residual disease…no leukemia!  And all the cells found are donor cells now.  Mine have disappeared.  Plus there were drug levels drawn throughout the night, weights being done in the early AM…I hate being an inpatient.  I am always so very tired when I’m released that all I can do is sleep, yet I have to go right back to my clinic, lab and PT schedules.
Day 97 (June 12th) He's been sprung! After another fun-filled day at MD Anderson, which included a ride in a pink wheelchair down to get photophoresis, Pops/ Dave managed to get released from his incarceration. He's very happy to be out and looks forward to a night of sleep without nurses knocking on the door all night.  Another important note is that his heart meds have been changed, and the new one doesn't have the drug interactions with the oral anti-fungal, so he's able to take that now instead of the daily infusions. So... one of these days, hopefully very soon... they should have a day without a trip to MDA (the first day “off” since late February). We thought it was going to be tomorrow, but his doc wants to see him tomorrow. And Wednesday he has photophoresis again. So maybe Thursday. I don't think my parents will know what to do with themselves whenever it finally happens.
Day 110 (June 25th) update--ROLLER COASTER GOING DOWN!
Yep, that what it says; Day One Hundred and Ten Update. When I signed up for this transplant it was strongly suggested that I'd be finished and on my way out of town by about Day 100. But stuff happens. That 100 days is a very flexible number. I've recently talked to another transplant patient who was at about Day 134 or something. We're all different and getting different stem cells under different circumstances and undergoing different transplant protocols. And encountering different complications along the way. Lots of us have some form of GVHD. It's not predictable so you can't really plan for it so much as watch out for its signs and deal with it.

Actually, we were on a great glide path to exiting Houston in about 100 days when I ran into the little parainfluenza ("paraflu") episode. That disrupted so many things. I was doing quite well, gaining back my strength, walking better, eating less, the GVHD rash was virtually gone and I was generally feeling much better. We had been able to taper my steroid doses down from the max of 160 mgs/day to just 10 mgs/day, and were primed to drop to just 5mgs in a day or two. But now I'm back to feeling just about as weak, tired and miserable as I have been since I got here. This is what happened.
A few weeks ago I woke up with a bit of a cough, no fever or anything, but my transplant team has trained me well into knowing infections can run rampant in folks like me within hours. Doc Khouri was out of town but I called in and the team advised me to go to the ER for testing. There they found I was infected with the parainfluenza virus, and a chest CT showed what appeared to be an early pneumonia. I was immediately started on a couple of powerful antibiotics (to help prevent a secondary bacterial infection) and admitted for what would be a week's stay.

Now, there's no treatment for the paraflu, you just ride out the symptoms as best you can. It causes croup in babies and can do serious harm to older, immunocompromised folks like me, but I was getting excellent supportive care to prevent problems. The real "problem" was what your immune system does in response to an invasion by the flu virus. It ramps up to fight off the invaders.
So, in my case, when the paraflu hit me, my donor, "Grace's" white blood cells also ramped up to fight off the infection. Just what we really didn't want just at the moment since we were still fighting off the residual rash from my GVHD attack of weeks previously by trying to suppress her cells' ability to mount an immune response, which were causing the rash. But she's got really strong cells, and despite the steroids and the tacrolimus doses she's subjected to daily, her cells came to life.
Within a day of admission the rash reappeared on my chest and belly. Then a day later it started crawling down my arms and legs. Then the itching started up all over again! Everywhere. So how do you treat GVHD? More steroids. My steroids went from 10mgs a day to 20 a day and then to 30 a day. And, with the steroids come swelling, weight gain, blood pressure problems, abdominal swelling and more. And, more importantly to me, a delay in getting off the drugs entirely and going home.
Meanwhile, in a separate but parallel story, cardiology came by my ward and changed my heart meds a bit to some that would allow me to take oral antifungals instead of having to get the daily infusions which we've been doing daily for three months. Great news, but the oral antifungal I was put on apparently interacts strongly with tacrolimus in high concentrations and before I knew anything about it, my tacrolimus levels were supra-therapeutic and four times what my doc wanted them to be (I should mention that he was out of town for this entire adventure). That can result in kidney problems and damage, reduced urine flow, headaches, blood pressure elevations and a lot more. Indeed, my kidney functions are now reduced but slowly seemingly heading back toward normal. My blood pressure is still out of whack, however and runs all over the map. I take a couple of meds now to try to keep my pressures below 160/100! I am loathe to say anything bad about my care at MDA, because I LOVE the place, but someone didn't do their homework when they made this change. Didn't read the package insert, apparently. My doc is a bit upset about the changes made in his absence, so I've heard.  But there is probably a lot more to this story than I’ll ever hear.
But the paraflu, with all the immediate care I received, turned out not to be a big deal at all. It was pretty much completely resolved within a week. Now we're dealing with all the residual problems resulting from my medication changes.
So, I'm about back to where I was a month ago. I'm now back to hobbling through the hospital on weakened legs, taking rest stops at benches along the way, feeling constantly and deeply fatigued and exhausted, so exhausted at the end of a day of appointments that I've had to pass on opportunities to go to Hank's, if you can believe that. And my hands still shake, my legs quiver, we're back to full-body coatings of steroid creams again, three times daily. And, of course, I'm again on elevated doses of the double-edged drugs, the steroids. We won't be able to taper off these for another three weeks or more, I'm guessing. Hope we can see some fireworks from the apartment.
However, having said all that, my problems, for a transplant patient are really trivial. I can still soldier on through the day, though slowly, do the things I really need to do, and I don't have any of the so-very-common symptoms of more serious GVHD, involving the liver, gut, lungs, pancreas, eyes and so much more. I've never had intractable nausea, vomiting or diarrhea.  I am absolutely exhausted at the end of a day of appointments, but I'm here and moving. I still have a great deal to be grateful for, despite some setbacks.  I sometimes compare myself to the poor souls I see in the Transplant Clinics; bald, emaciated transplant patients huddled under blankets in their wheelchairs. I feel badly for them since they're having so many apparent problems yet I’m doing so well. It's sobering to walk through the transplant ward and see the chart of the progress of the nursing staff with their Bereavement Committee program. It's a grim reminder that not everyone does as well as I'm doing. 
Thanks again for all your support and well wishes. And thanks yet again for all you who have been supporting the Team ECKS Factor fundraising. You guys are just amazing! I hope to be able to see you at some event or another when they reduce my restrictions on being around crowds, but that may well be far into the future.
--So, here’s where I stand at the moment, on Day 116.  The transplant has gone extremely well.  I’m totally engrafted, my blood is now Grace’s blood, her immune system is now managing my body, I have assumed her blood type (having morphed from A negative to A positive) and most importantly, the transplant has apparently (per two bone marrow biopsies) eliminated the leukemia from my marrow.  I am now like so many transplant patients, dealing with the side effects and complications of the transplant rather than the graft itself. 
And these complications can and have included high blood pressure, headaches, GVHD full-body rashes, collecting fluid in our lungs and bellies, swelling of the feet and ankles, ongoing fatigue and weakness, muscle wasting from the steroids, significant tremors of the hands and extremities, memory issues, sleeplessness, oral thrush, recurrent jock itch and so much more.  But, this is very important to note; most/many of these side effects are relatively temporary and can be dealt with.  And in my case, we're actively dealing with them and will overcome them with a bit more time.

But now my hair is falling out. That's another story.

I was going to intersperse some humorous anecdotes and stuff into this DGA but my editor tells me that it's already way too long.  So, maybe next time.  Or maybe a special issue just with funny stuff.  In any case, more later.


"When a person doesn't have gratitude something is missing in his or her humanity."--Elie Wiesel
“Some people call me a hero and tell me that I’m very brave to keep battling against all the problems that have come my way over the fifteen years I’ve been dealing with chronic lymphocytic leukemia (CLL) and now the transplant problems.  And I truly appreciate these comments. But I’ve told my family and others that I’m just a stubborn old curmudgeon who doesn’t like to see problems get in the way of my progress. So I try to get around, over or through the obstacles.  Problem is, recently the obstacles have been coming at me much faster and  are bigger and more at a time than I’ve had to deal with in the past."--Dave

Wednesday, April 19, 2017

Transplant update and synopsis

DGA—Synopsis; very late, but a quick review of events surrounding my transplant.
April 19, 2017
I am alive and, really, very well.
This is very late.  I had good intentions.  I bought a new laptop and took it to M. D. Anderson with me to try to keep up with events.  I never took it out of its case.  I’ve been chemobrained, immunosuppressed, febrile, vomiting, weakened, rashy, fluid overloaded and short of breath, and more.  But, nothing serious.  Really.  Here is a short synopsis of events.  More anecdotes will probably follow as I slowly improve.
1)      Left home in early February for MDA, to be admitted for a stem cell transplant.  Delayed yet again (sore throat) but ultimately admitted on March 1st for the procedure.
2)      Had six days of pretransplant “conditioning” chemotherapy; rituximab x1 day, bendamustine/fludarabine x 3 days, anti-thymocyte globulin (nasty stuff) x 2 days. The last caused high temps (102.9) with almost convulsive type rigors, nausea, vomiting, and weakness.
3)      March 7th, Grace’s (my donor) stem cells went in without drama. No fever, chills, shakes, rash…nothing.  Nothing but Grace.
4)      Next nine days, post-transplant chemotherapy.  Methotrexate, Rituxan, anti-rejection meds (tacrolimus), and a few other things.  I feel weak, but continue to walk around the ward daily as instructed by physical therapy and the nurses.  In fact, I get the idea to try to do a slow half-marathon while on the ward.  I succeed in completing 13.1 miles of laps around the ward on my day of discharge.  Do I get a medal?
5)      Day nine post-transplant.  Discharged to “home-ish,” our apartment near MDA.  Kinda early.  The schedule called for up to 21 days post-transplant hospitalization. Feeling tired but otherwise not too badly.
6)      Spend the next 40+ days returning to MDA daily for infusions of magnesium solutions (seems the anti-rejection drug, the tacrolimus, eats up magnesium and so frequent replenishment is required), anti-fungal drugs and fluids, to keep my kidneys functioning in the face of all the drugs I’m getting.  Taking about 35 pills a day.
7)      Day 28, post-transplant.  Had a bone marrow biopsy.  Results show “negative minimal residual disease.”  That’s basically “remission.”  No leukemia cells seen.  That’s amazing after just 4 weeks post-transplant.  Let me just stop here, just for a moment.  I have to be just a wee bit cautious in interpreting these results, because I have been in “complete remission” so many times, only to see the disease come back.  But, this could, and should, be the real thing.
8)      DNA testing on the marrow shows 92% of the blood forming cells in my marrow are already donor derived.  100% of my T-cells (part of the immune system) are already donor cells.  That’s great news.
9)      Fifth week, post-transplant.  GVHD!  (graft versus host disease, where the new stem cells attack me because I look “foreign" to them). I develop a rash on the nape of my neck and behind my ears.  It rapidly spreads all over my body, neck to ankles.  We’re treating it with full body steroid creams (triamcinolone cream) three times daily and big doses of oral steroids (160mgs/day) of prednisone.  Worst itching of my life.  Feels like 1000 chigger bites; can’t stand to have anything touching my skin.
10)  Rash subsides slowly over a week or so; continuing the steroids for now.  Gained 10-12 pounds in less than a week on all the steroids, blood pressure getting high.  Had to go out and buy bigger, "relaxed fit" pants that I could fit into.  Ravenously hungry on all the steroids.  But, muscles getting weak from the prednisone.
11)  Two weeks out from GVHD rash. Starting to taper steroids now.  Hopefully I’ll lose some weight and my blood pressure will subside.
12)  And that’s where I am right now.  I’m weak, but otherwise doing very well.  We’re just watching out for further signs of GVHD.  We’ll likely be here at MDA for another six to eight weeks and then transition back to our home base, if everything is still doing this well.
Sorry for the very long delay.

Saturday, January 28, 2017

The Transplant; On, off and on again.

Dave’s Great Adventure
Book 7, Chapter 1, Verse 1

“Desperate times call for desperate measures”--Hippocrates

Hey, my donor has a name!  But more about that just a bit later okay?

First, my deep and sincere apologies to friends and family, as well as anyone else who may have been following my story.  I have been seriously remiss in updating things.  I last wrote that I was headed for a transplant and then, seemingly, disappeared.  It would be easy to think that I had succumbed to transplant complications.  The truth is more mundane.  Plans have been made, postponed, made again and revised yet again.  But…now we’re on!

When we decided on the transplant, last fall, we decided to put it off until after the holidays, not wanting the procedure to override the family activities of Thanksgiving and Christmas and not wanting my donor in far-away Sweden to have her holidays interrupted on my behalf.  We planned to start the process immediately thereafter.  But, shortly after setting things up in October, I fell ill, with a curious condition I’d never before heard of, called SIBO; small intestinal bacterial overgrowth.

Now, the small intestine is generally pretty much bacteria-free, unlike the large bowel which is full of lots of various bacteria, many of which are beneficial to your health.  In fact, bacteria in your large bowel help with the manufacture of your vitamin B12, which you need to prevent certain kinds of anemia.  In SIBO, the balance of beneficial bacteria is disturbed and causes the large bowel bacteria, normal though they may be, to start invading the small bowel.  Here, they cause cramps, diarrhea, gas and malnutrition.

I had developed SIBO after a series of minor issues that required antibiotic treatments, and so I ended up with five courses of four different antibiotics over about a two month period.  This led to persistent cramps and diarrhea. Of significant concern was that I may have a bacterial infection with Clostridium difficile, often called just “C. diff.”  This can be a very serious problem, and even deadly, in folks like me who have compromised immunity.  So I was treated with a medication called metronidazole (Flagyl) for a week.  The problem went away, only to relapse about ten days later.  So, I was treated again with a longer course of Flagyl, this time taking it three times daily for ten days.  Again, it resolved, only to recur within a couple weeks.  By now I’d had a couple of stool samples tested and neither had shown the presence of C diff, so my gastroenterologist decided that I likely had this SIBO thing.  The thing is, the treatment for SIBO is…more antibiotics!  And relapses are common.  And it’s a diagnosis made mostly by educated guessing, as there’s no reliable test for the condition.  Great!  And, get this, if nothing else works, sometimes they can restore your bowel’s bacteria balance with a “poop transplant!”  Yeah, they take someone else’s “healthy” poop and put into your colon.  Is that not a bizarre concept?  I wonder if they have Poop Banks like they have Blood Banks and Sperm Banks.

But I digress….

By now, we were into mid-December and the start of the transplant protocol and testing was about three weeks away.  When getting a transplant, you MUST be optimally healthy to help you survive the procedure. So, Doc Khouri, my transplant doc, postponed the procedure until we could get the SIBO under control.  He prescribed two more weeks of antibiotics, this time a combination of things.  But it worked.

But then, over Christmas, I developed a cough which lingered for weeks.  I commonly tell Kathy, “It’s always some damn thing!” as there always seems to be some issue to deal with when you have leukemia.  Compromised immunity leads to many, many different issues.  So, back on antibiotics. 

We went back to Houston in early January to try to get the transplant back on track.  I had an appointment to see Doctor Khouri at that visit to start things up again and set dates once again.  However, after we’d gotten there, scheduling issues ended up cancelling that appointment after we’d seen only the leukemia docs and so we left without restarting the transplant.  I was angry and disappointed at that delay.

We went back, yet again, two weeks later to try to get the transplant back on track.  This visit went better and now the schedule has been set, the donor is agreeable and it’s time to get going.  It’s a long process, which I’ll tell you about, but at present, my new cells are scheduled to flow into my veins on March 2nd.

I really wish I could tell you that I’m thrilled to have this set up and on the way.  I wish I was happy, overjoyed and filled with anticipation.  I’m not.  If I had an acute leukemia, like AML or ALL, and had been told I had just months to live, I would be thrilled to have this opportunity, especially with such a great matching donor. 

But I’m not thrilled.  In fact, I am filled with anxiety about this process, almost terrified, because of all the potential complications, not the least of which is a miserable death.   I’ve previously written about my other options.  All of them, including doing nothing, include the risk of death.  There is no right or wrong answer as to which option would be best.  It’s a crap shoot no matter what I do.  I’m simply playing the odds, no matter which way I go. My docs, Dr. Phil Thompson and Doc Keating, recommend the transplant now.  So I’m going for the transplant while I’m still healthy enough and before I get so old that I will not be eligible for a transplant. Heck, I just turned 70 and that would put me beyond eligibility by many transplant protocols.

Right now, I am doing extremely well on the venetoclax.  My FISH test (looking for abnormal chromosomes) is negative!  The leukemia cell count in my last bone marrow biopsy in November had dropped from about 50% or so down to just over 0.1% of all the cells present.  My blood tests are getting back to normal.  I feel well. I don’t feel sick and don’t feel like I need a transplant!  But, as I’ve mentioned before, it’s exactly when you’re doing great that you have the best chance of surviving and doing well with a transplant, maybe even being cured.  So, unlike a patient with ALL who is looking an imminent death in the face, I don’t have that motivator.  The result is that I see too much of the downside rather than the upside to all this.

The factors which make this risky for me are, first, my age.  The older you are, the harder the procedure is.  Plus, I have the 17p deletion chromosome type, which is a risk factor, and I have failed several other courses of treatments, another risk factor.  But, in my favor, I have no significant co-morbidities (other diseases, like diabetes, heart disease, lung problems, strokes, etc.), I have very little remaining CLL for the transplant to have to clean up and I have a very good donor, close matches also enhancing the outcome of the procedure.

So, we’re moving to Houston.  I’m required to be within 30 minutes of the hospital for about 100 days after the transplant.  We have signed a contract on an apartment and will be moving in soon.  It’s a “corporate” apartment, meaning it is furnished and stocked with linens, towels, kitchen ware, utensils, glassware and more.  All we need bring along, basically, are our clothes and supplies.

The process will start on February 10th or so.  I’ll be getting, in no particular order, a PET scan, bone marrow biopsy, an echocardiogram, EKG, lots of blood tests, pulmonary function tests, a chest X-ray, and more.  Then, in between a lot of permits, financial counselling and such, I’ll get a large tube inserted into my chest, which will remain there for the duration of the transplant.  It’s gonna drive me nuts, I know.  Through this triple lumen catheter (having three channels within it), as it’s called, I will get medications, fluids, the stem cells, have blood drawn for studies and more.

This will all take about a week.  Then, I’ll be getting my first dose of immunosuppressive medications, stuff called CD22, I believe, intended to keep my body from rejecting the new cells when they meet up with my more established and usually friendly cells.  I’d hate for my new cells, having come all the way from Sweden, to feel rejected!

A week later I will be admitted to the transplant ward, where I will stay for about four weeks.  The first week I’ll be getting more chemotherapy, so-called “conditioning.” That’s a very benign term.  Sounds like putting something in your hair, or maybe it’s working out to get into shape, or some other pleasurable activity.  But, in this case, “conditioning” is chemotherapy, designed basically to suppress one’s immune system even more to allow the new cells to enter your body without provoking an intense rejection.   The conditioning lasts about a week.

And then the cells go in. 

The transplant itself is anticlimactic.  The cells simply flow into me from a small plastic bag, and it looks much like a pale blood transfusion.  That’s the easy part. Then things get exciting.  But, more about the aftermath later when I have something to report.

But what of the donor; what is she up to during all my pre-transplant activities?  Well, she’s been busy too.  Before she donates her precious stem cells, she has to be made to make a lot of them.  This is done by stimulating her marrow with a drug commonly called Neupogen.  It’s an injectable medication which is usually used in folks like me to drive up their white blood cell numbers after or during chemotherapy.  But Neupogen also drives up stem cell numbers and pushes them into the peripheral circulation, into the blood stream, where they can be collected.  The Neupogen can be uncomfortable and can cause mild bone aches.  I’ve had it many times and can tell you, it makes you feels mildly ill, but usually nothing too bad. My donor will be getting the Neupogen for about a week or a little more and then her stem cells will be collected.

The collection process is not what many folks think or fear.  Many have an image of a “bone marrow donation” as being a literal donation of bone marrow, it being extracted from the bones of the hips.  This is pretty much ancient history now.  It is still done rarely, but in the majority of cases, the stem cells are collected from the blood, where they have been sent by the Neupogen.

In the best case scenario, the donor is set up much as if donating blood, with a large IV in each arm.  Blood is taken out of one arm, the stem cells are collected from the blood by an “apheresis” machine, and the rest of the blood is put back in the other arm.  The process can take several hours. If the donor does not have great veins, they will sometimes have a large IV line inserted into the veins of the neck or chest for a short while, much like I will have, and the collection will be done by this route.

And my donor’s name?  Well, of course she has one; I just don’t know her real name yet.  For many, many months there will be a thick wall of anonymity between us.  However, with my Swedish heritage, I'd like to imagine she has a classic Swedish name like Kjerstena Bengtsdottir or something, as they did in my Swedish grandparents’ days. But, more likely, in these days she has a name like Anna Larsen.

But rather than calling her “my donor” all the time, I wanted to give her a better name I could use for her.  For a while I thought I should call her “Bo,” after the central character in the movie “10.”   Bo Derek starred in that movie as the lovely woman who drove Dudley Moore to distraction with her “perfect ten” beauty.  Remember, that my donor is a perfect 10 out of 10 match for me, too!

But the slightly raunchy overtones of that movie aren’t really appropriate for someone who is doing so much for me and doing so out of the goodness of her heart and character.  She will derive nothing from this other than the satisfaction of helping out an anonymous stranger.  So a different, better name would be appropriate.  Donna, one of our neighbors and good friends, after reading my last message a couple of months ago,  and noting my closing passage from the old hymn, “Amazing Grace,” suggested that her name, for now, should be Grace, or even, “Amazing Grace.”  So, henceforth, I will call her Grace.  Look at my last message’s closing and it will make a lot of sense.

I want to close this already (again) lengthy message with some “fun facts” about stem cell transplants.  This is amazing stuff…really!

First, I will assume Grace’s blood type.  My blood type now is A negative.  Grace’s is A positive.  After the transplant, my blood type will become A positive.  Cool, huh?

Next, I will in fact, have her blood, not mine, in my veins.  If I were to leave blood at a crime scene (!) and its DNA was examined, they will find Grace’s DNA, not mine.  Even cooler, huh?

Next, after the transplant takes and her immune system has taken over mine, it will be a “brand new, never been used” immune system, which will not be prepared for any of the usual, childhood diseases and such.  I will have to get all my immunizations yet again.  Diphtheria, tetanus, mumps, measles, rubella, polio, and everything.  Plus a flu shot and a pneumonia immunization. (I presume that I won’t have to repeat the shots I got before going to Vietnam, like plague, yellow fever, cholera, typhus and more.)

And, I hear that I may start taking an interest in pretty purses, curtains and patent shoes!  And I’ll want my towels and wash cloths to match, for unknown reasons.  I’ll grow little boobs and start getting PMS!  Yeah, okay, that’s a joke, but I have heard of folks who, post-transplant, inexplicably took on some characteristics of their donor.  I hope Grace likes barbeque and old cars and not lutefisk and Scandinavian modern furniture!

That’s it for now.  There will be more to come if I can get easy access to a computer and a connection while in Houston, and if I’m feeling up to writing.  A lot is about to happen.


“…these days, in which we can bear neither our diseases nor their remedies.”—Livy (Roman historian)