This afternoon I met with the kidney consultant. His aim was firstly to assess me ahead of any potential chemotherapy/stem cell treatment in order to determine whether I needed dialysis first. Secondly to answer questions about the way forward. There are a number of different scenarios but before I delve into each one the answer to the first question.
Do they go ahead with the chemotherapy treatment?The answer is yes. The consultant feels that although my kidney function remains weak, having observed me, there is no reason not to proceed with the treatment. I will be closely monitored throughout and action will be taken if the kidney function is adversely affected by the chemotherapy. The cause of my kidney failure is undoubtedly the Myeloma and the effect of the light chains proteins on the nephrons. The chemotherapy drugs may push the kidney into failure but not necessarily so. The removal of all light chains may see kidney function improve or stay the same. The scenarios are listed below alongside potential long term effects / solutions.
Scenario 1: No adverse effect on kidney and longer term improvement
This is the ideal scenario and obviously the one we would most like to see. Even a modest improvement in kidney function would prevent the need for dialysis in the long term. I would need to be continually monitored to ensure the kidney function did not decrease and may need a regime of drugs to keep it under control. It has happened that the removal of the remaining light chains has led to a slow healing of the nephrons and a rise in GFR up to 25 (currently for me it is 9 and has fluctuated below 14, creatinine levels have hovered between 400 and 500 down from 800 in April ). I would be able to return to work, though I might always be a little more fatigued than others.
Scenario 2: Adverse effect on kidney in the short term
In this scenario the kidney is affected by the chemotherapy drug and GFR drops further. I would be closely monitored by the Renal team and would be put onto haemodialysis whilst in hospital. This short term measure will ‘get me over the hump’ due to the toxicity of the drug but will be stopped once my kidney has regained its function to the current levels. A modified version of my Hickman Line would be used or a new deep vein cannula introduced. The longer term prognosis would be the same as scenario 1 although functionality might not be gained.
Scenario 3: Adverse effect on the kidney in the longer term
In this scenario the short term dialysis has not improved the kidney function and a longer term solution is required. This will require a longer term dialysis this could be haemodialysis (blood) of peritoneal dialysis (stomach). Both of these processes could occur at home but would require different strategies. Haemodialysis could also be carried out at hospital.
Peritoneal Dialysis (PD)
This is only carried out at home. It is the preferred solution as it maintains the kidney function for longer, being a continuous process. It does not involve the extraction of blood, so veins remain healthy. Longer term this increases the chances of successful kidney transplant. To make it happen a catheter is inserted into your tummy and connected to your peritoneal cavity. The tube and it’s exit wound will need daily care. The PD solution stays in the peritoneal cavity and is used to extract toxins which are removed regularly. Anita would need to be given training to allow this to be done safely at home. It uses a machine which is delivered to the home and can be taken away on holiday etc supplies can be delivered anywhere in the world. The dialysis can take place over night (automated) or else 4 sessions of 30 -35 minutes each day (manual).
Haeodialysis requires aspecially formed blood vessel called a fistula, made by combining a vein and an artery into one large blood vessel. Needles are used to take blood out and return it to your body. Blood passes through an artificial kidney which removes the waste products. An alternative is to use a haemodialysis catheter which is similar to my Hickman Line though the tubing is larger..
If this process occurs at hospital then it will be carried out in four hour sessions, three times a week. However, it is better to do this at home where it can occur more regularly. The home haemodialysis requires the patient to take fewer medications. As with peritoneal dialysis training is given and equipment and supplies are delivered to home. The dialysis can take place over night or for 2-3 hours on 5 or 6 days a week. Unlike peritoneal dialysis the equipment does not travel and so a suitable hospital needs to be located when travelling on holiday.
Scenario 4: Transplant
Kidney transplant is a better option than dialysis, but this will not be possible until at least two years after my Myeloma has disappeared.
Plan of Action
Speaking with my haematology consultant late in the afternoon it was agreed that the Melphalan (chemotherapy drug) will be reduced and there will be an extra day between the administering of the Melphalan and the stem cell introduction, meaning stem cells will be introduced on Thursday. None of this will affect the outcome, but will ensure that a) the kidney is protected and b) the stem cells are not destroyed by the Melphalan, which will take longer to disperse.
Obviously in all this the hopes and prayers are that scenario 1 is followed, failing that scenario 2.