Day +14: some liver issues popping up

Two weeks out from the transplant today. Mina Brigitta's white blood counts continue to inch upwards. She's at 600 million today (normal: 5-17 billion), and 270 million neutrophils (normal: 1-8 billion). 500 million is kind of a magic number for neutrophil recovery, so we're getting there. Her skin rash is still there a little bit, but still seems to be improving.

Her liver function tests (http://www.gastromd.com/lft.html) have become a bit worrisome, however. Several of them are registering elevated levels, indicating some type of trauma. For example, her Alanine Aminotransferase (ALT) went from 22 to 68 to 166 (normal: 11-54) over the last three days, and her Aspartate Aminotransferase (AST) went from 16 to 32 to 67 (normal: 16-41). There are a variety of potential causes, including:

• Viruses such as CMV or hepatitis
• A continued reaction to the chemo and radiation treatment
• Veno-occlusive disease (VOD, http://www.merck.com/mmhe/sec10/ch138/ch138c.html)
• Graft vs. host disease (GVHD)

Apparently, the donor managed to acquire the CMV antibody between the time he took his preliminary blood test and the day of cell harvest. This doesn't mean he had an active infection, and even if he did the risk of tranferring it to her is low. Her CMV test came back negative in any event, so it's not that. The doctor thinks it's late to be a reaction to the chemo, and she's not showing other signs of VOD such as liver enlargement, elevated bilirubin levels, or jaundice, but they aren't ruling it out.

That leaves GVHD, which commonly occurs in the liver, skin and gut in the acute form. Some GVHD was likely given that the donor was only a 9/10 HLA match, and mild cases don't usually cause too many problems. Unfortunately, there aren't that many treatment options for severe cases, which are often fatal. We don't know she has it yet, and the prednisone seemed to work pretty well on the rash. We're hoping she gets a mild case that results in graft vs. leukemia effect but doesn't advance into anything severe.

Otherwise, Mina Brigitta had a pretty nice day again. Grandpa had an 8-hour shift at the hospital today, and they played all kinds of games. She does seem to be in some kind of discomfort, though. Amber gave her morphine a couple of times, which she said seemed to put her in a more normal state of mind. Tonight she's been very restless again -- I had to sit with her in the chair from 8:30 to 11:30 while she tried but failed to get into a deep sleep. Finally the nurse gave her some Benadryl, which seems to have knocked her out pretty good.

Grandma and Grandpa leave early tomorrow morning after a two-week stay. It was great to have them, and sad to say goodbye. It's such a strange time. Oh, and Mina Brigitta is losing her hair. She still has some wisps, but will probably be shiny bald in a week or two.