Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Is fetal monitoring recommended when administrating IV iron to a pregnant patient?
There is no evidence of fetal harm with IV iron, and recommending this is inconvenient and unnecessary, and it does harm as it discourages necessary care. Two guideline papers, Van Doren et al., PMID 38282557, and Benson et al., PMID 40306833, as well as Anemia in Pregnancy in UpToDate, support this...
How do you manage refractory myelofibrosis with thrombocytopenia, significant leukocytosis (>150), and ASXL1 mutation?
The answer to this question requires, first, that like any patient with a malignancy, this patient must be staged according to the clinical and laboratory data that define the clonal tumor burden of the disease in question, as well as its extent clinically. In the spirit of full transparency, my ans...
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...
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...
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...
Do you repeat images in patients with venous thrombosis to inform decision about duration of anticoagulation?
The short answer is "no". I do reimage many people near the end of the 3-6 months of treatment, but it doesn't really change my mind about duration of treatment in most instances. I use repeat imaging to help me understand how much of the clot resolved and thus, determine what their new baseline is....
How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?
I recommend indefinite anticoagulation for most patients with portal vein thrombosis, and at least 3-6 months if there are risk factors for bleeding. Once they complete anticoagulation for the first 6 months, I re-evaluate their risk of recurrent thrombosis vs bleeding, and if there is an underlying...