Lalo's Kidney Data

[hermanding]

First, about four months before leaving Bogotá, Lalo began incontinence at night. It was not apparent in day. After he got to the States, over time 3 months or so, it was worse, and I noticed that when I came up from Bogotá to see him. He also had a right hydrocele - and guys, this thing was the size of a small tennis ball - just gigantic. You could put 10 of my pelotas inside the volume of it.

Anyway, I am going to quote from his medical records on various days, before asking a question. Remember that he went to emergenci on 24 august with 186-129 pressure and never walked again, although he walked into the er room unassisted.

26 aug - a US renal bilat complete
the bilat hydronephrosis persisted even after foley catheter insertion, which demonstrated a markedly thickened bladder, likely due to muscular wall hypertrophy secondary to cronic outlet obstruction due to enlarged prostate. still incomplete drainage of bladder, even following foley catheter isertion. urinary bladder is markedy distended, even though patient indicated he voided prior to arriving in ultrasound. bladder volume is judged to be 1000 cc.
ct scan of abdomen and pelvis revealed bilat hydroneprosis with dilated ureters down to bladder.

27 aug - from a cardiac dignostic report
patient heart failure status assessed as NYHA class II, with CHF symptoms of DOE

28 aug - from a comprehensive metabolic panel
CREAT 1.7H BUN 15 Potassium 4.0 and others

30 aug - after CABG, pulmonologist consult for respiratory failure (impressions)
coronary artery disease, status post coronary artery bypass grafting.
substantial blood loss anemia with multiple transfuions
shocks likely hemorrhagic, but cardiac tamponade is not excluded
renal disease and other problems

02 sep - bilat renal ultrasound
severe bilat hydronephrosis again seen
foley catheter noted withn bladder
appears to be 7 cm. echogenic focus within bladder. may represent blood or mass or clot
prostate gland is enlarged

10 sep - MRI of brain WO contrasts
multiple focal lacunar infarcts in basal ganglia bilaterally & in parasagittal frontoparietal regions bilaterally & in temporal lobes bilaterally
on previous CT presumed to be old infarcts but in fact are acute infarcts & have occurred in the watershed distribution
///question here - can someone talk a little about 'lacunar' and 'watershed distr'? please. could this be an area where infarcts could cause destruction of bowel control?

18 sep - from basal metabolic panel
BUN 33H creatinine 1.8H among others

23 sep - from an MRI brain wo contrast
multiple focal areas of restricted effusion are aqain noted scattered in periventirulcar white matter. consistent with multiple small lacunar infarcts in watershed distribution. minimal changes of microangiopathy identified.
/// question - again, does any of this help to confirm bowel control loss?

02 oct - report from a chest XR
advanced heart failure pattern

14 oct - from a basic metabolic panel
creat 2.5H BUN 74H potassium 4.5 among others

//he failed a swallowing test by speech pathologist, although later he became able to swallow and not aspirate more than not.

21 oct - from a cystoscopy by urologist - perhaps to me most fascinating of all
procedures - cystoscopy/bilat retrograde pyleogrm/inertion of bilat ureteral stents/evacuation of bladder clot
in the operative notes during the cystoscopy -
prostate was not particular obstructed. bladder mucosa examined. some inflammation, but also a large amount of ORGANIZED clot, which had obviously been there for a considerable length of time. this could not be easily flushed out. an ellik evacuator was used to flush out a part of clot. since the clot was so solid that a resectoscope needed to be used in order to break the clot down into smaller pieces for flushing out. there was moderate trabeculation......ureter was so dilated i was never able to get enough dye into upper collecting ystem. i suspect ureters are obstructed at the UVJ from cronic bladder outlet obstruction.......i started continuous bladder irrigation since patient's INR was significantly elevated. h opefully, we can stop the CBI tomorrow.
///question - organized? for a clot. trabeculation? and such a solid clot. the urologist says - considerable length of time. could this possibly have been going on for say 5 years, 1 year, 2 months - any reasonable ideas on this?

29 oct - from a basic metabolic panel
creat 1.7H BUN 25H potassium 4.6 among others

well, enough records.
it is obvious that Lalo had really bad issues that one would not think arrived at the point of what was seen in the hospital all that quickly. whether he was asymptomatic of everything or not, no one will ever know still on earth.
Although he died 168 days after walking into the emerg room, i am inclined to feel he would have died before that if he had not gone. Many nights as I lay in the bed, I feared i would wke up to find Lalo dead. He was very tired all the time.
If he had symptoms etc - outside of the obvious hydrocele - then he contributed to his own death. If he did not, then he went to emergency under my prodding, and SEEMED to be worse than before - certainly from the point of the probabilities that strokes destroyed smooth muscle functions that are so heavily taught in our society. Before 24 august, I feared he was a death waiting to happen, so different from what I had known.
I APPRECIATE so much any medical experience and lay experience that you might offer. I am at peace with his going, maybe mostly because I saw it coming for much of those 168 days. Accepting his death of course is a process. I am trying to offer you guys clues to maybe answer the medical reasons for his death. Why in the grand scheme does not interest me at all. We all die, some less painfully that others. I am so glad I was with him when he gave it up. He was destroyed, except in his mental capacity - and, even that may have been importuned last Saturday, because the last day he never gave me anything to indicate he was responsive.
my gratitude to all of you
ding

 

[upyrkilt469]

I am so sorry to hear that Gary has gone. He will be greatly missed. Our prayers are with you.
Vic

 

[kevin7620]

I am so sorry for your loss.

So he died just a few days ago (around 2/8/09), although the progress above ends in October. It sounds like he came in with one issue, got open heart surgery for blocked coronary vessels, and then didn't do well after surgery and ultimately passed away of something (renal failure? heart failure? infection? bladder or other form of cancer?)

At this point, I doubt it will be helpful to keep going over the medical records. It sounds like you and his doctors did everything possible for him.

 

[hermanding]

I stopped at this point, because none of this got better afterwafds. He went back into emergency new years day. with chest pain.
The pain was from a huge infection in the chest cavity from the original surgery that had progressd to the point of attacking the sternum. HE HAD TO be opened up again to be cleaned out and was on antibiotics from then on. At death, they had not beaten off the infection.
He had no reserves to last that either
In the final week, both kidneys failed totally. That had not happened during the medical records time. But he did finally get ESRD. He died saturday 07 february 1135 AM en houston
ding

 

[jockboy01]

Okay, so based on those my best guess is this....

He had two problems.... the long standing prostate obstruction that let to his kidney insufficiency. It looks based on the creatinine that it go a bit better after the cysto.

Second, it sounds like he had a lot of blood loss during/around the time of the surgery leading to low blood pressure (shock). This is likely what led to the lacunar infarcts in the watershed regions. Lacunar infarcts basically means small infarcts...

http://emedicine.medscape.com/article/1163029-overview

Watershed region basically implies it is an area of the brain that has a tenuous blood supply because it is in between the areas fed by two major vessels. They are the most sensitive areas for ischemia when blood pressure drops.

Could they have led to his incontinence... sure. It's hard to tell exactly with infarcts what is affected just by looking at a scan. Generally it's what the patient can or can't do.

Likely his worsening medical condition coupled with what I would guess to be longer areas of low blood pressure probably was the last shot to the kidneys that caused them to fail (ESRD).

Once again, I'm so sorry for your loss and I'm sure it was a very long and painful time for you.

 

[hermanding]

jockboy,
thank you for your insights and conclusions. It would seem that the odds were very very high against his surviving it,and absolutely impossible to have been as he had been before.
I am more at peace with the process, now that I have had the benefit of those of you with knowledge.
many of you have been very comforting to me. I don't fear knowledge about lalo's (gary's) condititon. It is the lack of knowledge that has frustrated me. And fascinatingly, HE would never do any proactive inquiring of his doctors - WHEN he had the strength to do so. Perhaps another indication of not wanting to know, perhaps another indication of symptoms from the past that were denied. And, it is all just a debating exercise at this point, isn't it?
Your kindnesses are deeply appreciated.
ding

 

[Georgiadude]

Ding,

Sorry it has taken me some time to post. I have had a lot going on and haven't been feeling well myself.

I can give a bit of information. Just some thoughts really. It is hard to give complete answers without ever having seen Lalo.

He obviously had kidney disease. Hypertension, diabetes and a lot of other illnesses can cause renal disease. He had a large clot in his bladder. The clot most likely acted like a valve. He was able to get some urine past it but it most likely would slide over the opening from the bladder to the urethra thus blocking urine from leaving the bladder. They were able to get a foley into the bladder but it didn't drain it completely. The clot probably covered the end of the tube and in the same fashion wouldn't allow urine out. All of that pressure in the bladder backed up into the ureters causing them to dilate enlarging the kidneys and damaging them as well. His kidney kind of had a "double whammy" so to speak. the hypertension and the increased pressure in the urinary tract. It did look like they improved after the clot was discovered and removed. The urinary system takes the backseat to the cardiac so his heart problems were addressed first. Who knows why the clot formed. A pure guess and that is all it is really. The kidneys are very vascular. They use a lot of blood and have a large amount of very small vessels. The hypertension could have caused some of these smaller vessels to pop, leaking blood out of the circulatory system, into the urine. Another thought is he may have been on asa or other medications that "thinned" the blood to extend the clotting time, reducing the chance of a thrombus (blood clot) The blood clotted in the bladder and over time formed a large clot. He had an enlarged prostate in the beginning. He probably wasn't able to empty his bladder for a long time thus allowing the clot to grow. Like I said Ding. That is just a guess.

I don't know about the hydrocele. I mean I know what they are and all but why his formed I really don't know. Unless they cause a lot of pain or fertility issues they aren't really a priority. With all of the problems Lalo had this was probably the lowest on the list.

Ding. I know your working through this and I really think your doing a pretty good job of it. It's a terrible thing to watch someone you love die. When I was married we had to watch my father in law slowly suffocate from lung cancer. My mother in law and my wife would have a lot of similar questions during and after the "dying process". I explained it to them like this. His body was shutting down. His circulatory, respiratory, urinary systems were all failing. Certain treatments, procedures and medications could improve the functioning or ease the symptoms but there is nothing to replace those systems. The body can only compensate so long before it has to fail. Unless someone is suddenly struck down by a heart attack or major stroke the body has to go through a "process" to shut down. Our bodies are amazing works of engineering. One system will compensate for the other and the bodies will to live is an awesome thing. However the systems can only back each other up for so long. It just takes a while for the dying process to occur. That is the worst part. While it gives us time to be with our loved ones it puts everyone through hell watching them slowly slip away. I'm sure you would give anything to have just 1 more day with Lalo be comforted to know his suffering is over. Start putting these last difficult months to rest and remember the better days you had. May I suggest a thread telling us about how Lalo lived. I would love to hear about the life you shared with him.

I truly hope that my ramblings have helped in some way. My heart goes out to you. I can only hope to be able to share my life with someone in the way you have.

Steven.