I mentioned in my last post that Babygirl had seen a vascular surgeon (more on that later, remember?). Vascular surgeons fix problems with peripheral arteries and veins. (Cardiovascular surgeons do the central stuff.) So why go there?
Since the middle of January Babygirl has had a dialysis port hanging out of her chest. It's big. It's uncomfortable. It's an alleyway from the outside of her body to the inside. She can't get it wet (so Saran Wrap and cloth tape are standard equipment in our bathroom these days). She is DYING to take a shower. She wants to be able to swim when the season hits.
She needs a fistula.
Fistulas (in general) are abnormal connections between one place and another. Rectovaginal fistulas occur during rough childbirth, and connect the rectum to the vagina. Colovesical fistulas connect the bowel and the bladder. There are others, but you get the idea. What Babygirl needs is an arteriovenous (AV) fistula, a deliberate connection between an artery and a vein.
Dialysis happens 3 hours a week for 4 hours. Ordinary veins are not cut out to handle the volume of fluid that has to go IN and OUT of the needle. Veins just aren't that tough. Connecting an artery to a vein pushes arterial blood at high pressure, and makes it get bigger. And tougher.
They scanned all of the veins in her arms to get ready for this. Anticipating that she will likely be on dialysis a while, and perhaps again after the NEXT transplant fails, the hope was that they would find a vein and an artery big enough to work with in her wrist, so that when it inevitably fails, they'd be able to place one above it in the forearm, and then the lower arm, then upper arm, and so on, using up available sites in her non-dominant arm before having to move to the dominant side (since during dialysis the arm with the needle in it has to be STILL).
Sigh.
The veins in her wrists and forearms are all 1-2 mm in size, too too too TOO small to connect to the (equally too small) arteries. So her initial fistula will be above the elbow, on the inside of her arm. It's not ideal. But it WILL be waterproof.
She had preop testing today, and, once again, her hemoglobin is below 7, not safe for a procedure that opens up an artery on purpose.
Which takes us to the question, "Why?"
Her hemoglobin was in the 11's before the kidney died, and dropped like a ROCK when it happened (a process that should have taken some considerable time, honestly, not less than 3 weeks).
So. Is she bleeding somewhere? Is there some new issue that is stopping her from making blood despite IV iron infusions and erythropoietin replacement? She's been vomiting almost daily since we got home, and it was vomiting that apparently started the rejection. Everybody's been assuming that the initial vomiting was a "bug" and the current vomiting has something to do with dialysis, but....
All of a sudden there's talk of a GI referral, and a hematology referral. Considering she has lost 30 pounds since January, I'm thinking that somebody needs to look at something.
I DON'T want this surgery delayed. It takes a minimum of 4 weeks for a fistula to mature, and the fistula has to prove functionality with 2 weeks of use at dialysis before they can pull the port from her chest. That means that the port will be in place for a minimum of 4 months, which scares me a little.
Surgery is schedule for a week from today. Dialysis is MWF from 5:30 AM to 9:30 AM. The odds of them doing all they need to do by then seem small.
DeeDee
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