Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
There is no high-level evidence to inform the decision of how long to continue chronic transfusion in this scenario. Decisions on whether to continue indefinitely are affected by multiple factors like the presence of RBC alloimmunization, whether the patient was on hydroxyurea at MTD or not at the t...
Do you repeat antiphospholipid antibody testing in a patient that previously met criteria for APLS?
I would repeat APL Ab testing if I am trying to risk stratify a patient in preparation for pregnancy or surgery, for example. In some cases (see a recently posted question about stopping anticoagulation in people with prior APLS history), I would also consider rechecking if I am thinking about disco...
Would you retry rituximab in steroid refractory warm autoimmune hemolytic anemia which responded to rituximab before?
Yes, I would utilize rituximab a second time for treatment of AIHA in light of a response during the first episode. The first response was not that durable in this case, and it would be anticipated the response after the second round of rituximab may not be even as durable as the first. As usual wit...
Does ASC4FIRST data justify the use of first-line asciminib for all newly diagnosed CML over other TKIs, considering that post-progression survival data is not yet mature?
Ideally, every patient gets the newest and greatest, but the elephant in the room is asciminib’s $145,000 per year cost compared to imatinib’s $600.
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
Do you recommend work up for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
How do you choose between therapies for newly diagnosed ITP that is refractory to steroids and IVIG?
The important questions here are what are the symptoms and what are the platelet counts? In patients who fail to respond to either corticosteroids or IVIG, the concern is whether this is actually immune thrombocytopenia or another cause of thrombocytopenia. With "normal" flow and bone marrow results...
How would you manage presumed gestational thrombocytopenia with moderate thrombocytopenia for delivery planning?
Thanks for this question. First and foremost, it's critical to rule out a placental-mediated complication such as pre-eclampsia and HELLP, and to evaluate for other more nefarious causes of thrombocytopenia (TTP, aHUS, etc., though of course rare). While a diagnosis of exclusion, gestational thrombo...
Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?
Lupus anticoagulants are a heterogeneous group of antibodies that do not have uniform activity in all assays. Furthermore, testing procedures are not well-standardized. Since relevant clotting factor deficiencies have been ruled out and the long PTT does not correct with mixing, and since there is o...
How do you do risk stratification for patients with light-chain-only MGUS?
This is a great question, Dr. @Dr. First Last. Apologies for the delay in responding.Light-chain disease is not as clearly defined as heavy-chain disease.There is some guidance here based on current studies, such as Maeng et al., PMID 40295472, revised free light chain reference intervals enhance ri...