Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat a patient who received 2 cycles of R-CHOP for DLBCL who was subsequently diagnosed with follicular lymphoma?
It looks like the patient has t-FL. More information is needed: what prompted the biopsy after 2 cycles of R-CHOP? Is his disease progressing after 2 cycles of R-CHOP?
In a patient with a history of HIT, how would you reintroduce Heparin?
When patients with even remote histories of HIT are re-exposed to heparin, there is a very high risk of heparin-PF4 antibody seroconversion (Warkentin and Anderson, PMID 27114458). I have seen two patients who suffered a fatal relapse of HIT (e.g., case one in Kodityal et al., PMID 12890149). Bivali...
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...