The Transplant Team made several decisions today and developed a plan for Mark's care while we are here. With respect to what the physicians believe are clots in Mark's heart, the plan has not changed. Mark is receiving the blood thinner heparin through his IV. The hope is that the blood thinners will prevent the clots from getting any bigger. Mark will have another echocardiogram next week. At that point, the Cardiologist and Cardiothoracic Surgeon will determine if the blood thinners are working. As we posted yesterday, if the clots are any larger when they repeat the echocardiogram next week, open heart surgery may be required.
Yesterday evening, Mark's potassium was very high. The Team had hoped to avoid replacing the dialysis catheter for a few days as catheters often set up infection. Also, they wanted the antibiotics to have time to completely clear his infection. However, going without dialysis was not an option. So, last night, the Nephrologist placed a temporary dialysis catheter in his groin. Mark had dialysis last night.
Another complex issue with Mark's health is deciding upon a long term dialysis plan. All of the dialysis options have their own risks and none of them seem to really be a great solution given Mark's history. Hemo dialysis, or the type of dialysis that uses the blood and is typically completed at a dialysis clinic, typically involves use of a vascular access or fistula in the forearm. Mark does not have a fistula. This is why he has been using a temporary catheter in the chest that is tunneled next to the heart. However, Mark's clots in the heart make continued use of a tunneled catheter risky and problematic. Catheters can be tunneled other places like the groin. However, catheters in the groin are not used for long as they often are easier to get infected. Creating a fistula in the arm requires a surgery. The surgeon joins an artery and vein in the forearm. However, even after the fistula is created, it cannot be used right away. It may take several weeks or even months for the fistula to mature and grow big enough to be used in dialysis. Although fistulas are less likely than catheters to become infected, they are prone to clot. This is a real concern with Mark given Mark's history of clotting. Peritoneal dialysis, or the type of dialysis that uses the peritoneal cavity or "gut" and is done at home, is the other dialysis option for Mark. Peritoneal dialysis involves the use of a catheter in the abdomen. Placement of this catheter requires surgery. The catheter cannot be used right away either. However, it typically can be used sooner than a fistula. However, because peritoneal dialysis uses the "gut", Mark's repaired hernia site and placement of the meshes over the hernia and transplanted kidney may make peritoneal dialysis difficult. In addition to these concerns, it is uncertain whether Mark's infection has cleared. Although Mark's blood is getting drawn each day, it takes several days for cultures to "grow" infection. The catheter that was removed on Tuesday did have some type of infection on it. The Transplant Team is consulting with the Infectious Disease physicians to determine what type of antibiotics are needed to treat Mark. They are also trying to decide how long they should wait before any surgery is completed. Typically, physicians do not want to do surgery with a known infection.
With all of these things taken into consideration, the Team decided to continue the blood thinners and IV antibiotics over the weekend and schedule a surgery next week (possibly Wednesday or Thursday) to place a fistula in Mark's arm and a catheter in Mark's abdomen for peritoneal dialysis. We will be trained on peritoneal dialysis while we are here. They will not be tunneling another catheter in the chest. If all goes well, we will leave here on peritoneal dialysis.
Thanks for all the prayers, thoughts, emails, and calls. We appreciate all the support and are asking for continued prayer that the clots in Mark's heart will not require surgery to treat. We will update the blog as we learn the exact date of the surgery next week.