Not Rejection?

Yesterday was the start of a new week at CMH. New week means new attendings on service. Dr. W is back as the attending for liver service and we knew things would get shaken up once he was back in the mix. He did not fail to please. First thing in rounds yesterday morning, he questioned whether Jaisal really was experiencing rejection. He said he would personally review the biopsy (a biopsy he would not have ordered in the first place) and get back to us as to whether we should continue treating with Solumedrol (steroids).

Since we knew the rejection seen in the biopsy was mild, we had no doubt that Dr. W was going to come back and say it wasn't rejection. You could tell in rounds that he was predisposed to thinking that, particularly after he gave Jaisal a physical exam to check to see if he (Dr. W) could feel the rejection, and of course we were right. After reviewing the biopsy himself, Dr. W said no rejection, no steroids, stay the course with the prograf (primary immunosuppressant). Umm okay.

For those of you confused about how Jaisal can have rejection one day and not another, let me explain how this whole story unfurled.

The liver doctor on service last week, Dr. P, wasn't a liver doctor at all, but actually a GI doctor that specialized in small bowel and intestinal transplants. And even at that he's a new attending, so even peripheral experience with liver transplants. (Kirk and I speculated that we were older than him, but it turns out that he's got a couple years on us. Yup that's right, all semblance of manners has disappeared, we outright asked the doctor how old he was. Anyway, back to the story.) Since liver transplants aren't Dr. P's area of expertise, he chose to get a biopsy as a safety net when Jaisal's numbers were going up. The specimen obtained from the biopsy was reviewed by a pathologist who regularly looks at liver biopsies. The specimen was evaluated for three things (which I can't recall at this point) and was graded 0 to 3 in terms of rejection. Jaisal was rated a 1 for each, giving him an overall rejection score of 3, enough to be classified as having  mild acute rejection. These results were then relayed to two other liver attendings, who each have 6 or more years of liver transplant specific experience, and they jointly decided to treat for rejection. A safe plan on their parts, because a) they aren't on service and treating the patient and b) they are not reviewing the biopsy themselves. I view it as a CYA move, and were I in there position, I'd do the same thing.

So Dr. W comes on service yesterday and is able to act more specifically since he can see Jaisal and the biopsy. His view is that nearly all transplant patient, particularly one this close to surgery, is going to show some signs of rejection. And his review of the biopsy showed that each of those three categories really should be graded a .5 (which actually isn't an option), rather than a 1. For that reason, Dr. W believes that once we get Jaisal's prograf in the therapeutic range and keep it there, his liver function numbers will normalize. This is the preferred path of treatment because apart from the short-term mood affects of the high dose steroids, steroids also have a cumulative effect on the body resulting in growth issues, bone density problems, and blood sugar issues. Jaisal may or may not get full blown rejection some day in the future or he could end up with chronic rejection, each of which would require steroid treatments, so it's best that we avoid using steroids unnecessarily. For a kid that has been taking copious amounts of medication since he was two months old and likely will need to take at least some medication for the rest of his life, I am all for reducing his medication intake whenever possible.

As you've probably gathered from previous blog posts, Dr. W grates on me a bit. He is domineering, egotistical, and seems very impressed upon when he has to explain why he has made a particular diagnosis or treatment plan (and that's if he is even willing to explain anything in a manner other than "I've been doing this for X years"). Unfortunately, he's kind of a liver bad ass, so despite my personal opinion of him, it makes sense to trust his judgment (most of the time) about Jaisal's care. Overall Kirk and I are pretty happy that Jaisal does not have to go through the dreaded high dose steroid regimen.