Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you offer BM biopsy as the next step for progressive thrombocytosis when peripheral blood is negative for JAK2, CALR, and MPL mutations for MPN diagnosis?
Yes, definitely. Always need bone marrow morphology to diagnose MPNs. Triple-negative ET or PMF comprises 5-10% of all ET and PMF and lacks the 3 canonical driver mutations, i.e., in the JAK2, CALR, and MPL genes.
How accurate of an indicator is reticulocyte hemoglobin equivalent for iron deficiency?
I am not sure that question is answerable right now. I can tell you if I had an autoanalyzer with a RET-He, I would use it to determine who needs iron and who does not using a value of 30.7 as the cutoff for iron deficiency and 28.5 to determine the likelihood of responsiveness to iron [remember tha...
Would you recommend complement testing in a kidney transplant recipient with chronic antibody-mediated rejection and biopsy-proven thrombotic microangiopathy to determine the need for eculizumab?
There is basic and translational data to support the role of IL-6 in acute and chronic humoral rejection, with small single-center trials investigating the use of agents that blockade IL-6/IL-6 receptor interactions for humoral rejection in kidney transplantation. In many of these studies, there is ...
How would you approach microcytosis without anemia with high TSAT and ferritin?
This is likely thalassemia trait with iron overload. I would look at the smear to confirm, consider hemoglobin electrophoresis. Sometimes HFE mutations are cofactors that can add to the iron overload so I look for those. If the ferritin is >300, I consider careful phlebotomy to assess mobilized iron...
How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?
This is an interesting and challenging question that would require a case-by-case review by a team of rheumatologists, hematologists, and hepatologists, as well as an in-depth discussion of the potential risks and benefits with the patient. This reference, O'Leary et al., PMID 30986390, provides a g...
How do you treat a patient with warfarin failure, with therapeutic INR 2-3 at the time of DVT, and no underlying malignancy or hypercoagulable state?
I would give DOACs a shot in this case. The INR of 2-3 at the time of DVT "Diagnosis" might have been <2 at the time of DVT "development/occurrence" depending on how frequently the INR had been checked. I would, of course, maximize risk factors control as well.
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
What is your approach to MRD testing in the frontline treatment of multiple myeloma?
Outside of clinical trials, I am not ordering MRD testing for patients in the newly diagnosed setting, regardless of transplant eligibility. While there are substantial data showing that MRD status correlates with survival outcomes (e.g., Munshi et al., Blood Adv 2020), there is a dearth of informat...
Would you consider post-BMT maintenance therapy for patients with Ph-like ALL with a JAK2 mutation?
In brief, I would not.Here is the evidence I have that leads to this conclusion: The activity of targeted therapy for Ph-like ALL has not been established. There are a number of ongoing studies that are attempting to address this (e.g., AALL1521/INCB18424-269; see Tasian et al., ASH 2022). What data...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.