Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach the treatment of HSCT-associated thrombotic microangiopathy?
TMA can be due to multiple insults: If the patient is on tacrolimus or cyclosporine, the dose should be reduced. These drugs cause the renal afferent arterioles to spasm, and RBC fragmentation can occur on that basis. It typically responds to a dose reduction If the patient was conditioning with TB...
How do you approach deciding which patients with hemophilia B to recommend for gene therapy?
There is no standard protocol for who gene therapy is recommended for, but certainly, potential candidates must meet all criteria according to the manufacturer's recommendations. Gray areas may exist if there is some preexisting liver disease, where hepatology consultation is desired to help determi...
What is your approach to managing iron overload in children with transfusion-dependent beta thalassemia who have adherence challenges or toxicity with standard chelation regimens?
I would divide the adherence issues into two populations. The younger children where a caregiver is responsible for administering the chelation, and adolescents where caregivers have passed on the responsibility to the patient. For the former, adherence is reinforced with an explanation of the possi...
Do you use lenalidomide for patients with MDS with 5q- without other cytogenetic abnormalities but with one or more mutations on NGS?
For patients who meet the definition of del(5q) syndrome, I typically utilize lenalidomide regardless of the molecular features of the disease. The original publication (List et al., PMID 15703420), the phase III MDS-004 study (Fenaux et al., PMID 21753188), and the phase III SintraREV study (Díez-C...
When do you consider certolizumab for pregnant women with antiphospholipid syndrome with positive lupus anticoagulant?
Certolizumab is a TNF-α antagonist with minimal or no transfer across the placenta. It was evaluated in the phase 2, open-label IMPACT (Improve Pregnancy in APS with Certolizumab Therapy) trial to prevent placenta-mediated adverse outcomes in pregnant patients with antiphospholipid antibody syndrome...
What whole brain radiation dose would you recommend for primary CNS lymphoma with partial response to HD-MTX-R and R-ICE and planned for concurrent ibrutinib?
There are many uncertainties in how to optimal treat patients with PCNSL. It is clear that high-dose MTX-based regimens should be pursued when feasible. The role, if any, of RT is controversial. If pursued, a WBRT-based approach is generally considered most appropriate.With that said, if a patient o...
How do you treat diffuse large B cell lymphoma (DLBCL) in a patient with cirrhosis complicated by thrombocytopenia?
Thank you for the question. This is a very challenging case. There are different factors to consider, such as age, PS, stage, and actual liver function. Liver function may have been affected by lymphoma.Most likely, the patient will require dose reductions of standard R-CHOP (such as mini R-CHOP). A...
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...