Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...
Is there any evidence for amyloid/amyloidosis causing a spurious/false PSA reading?
This is an excellent question.Our group has been involved with amyloid/radiation effects in patients with Alzheimer’s disease Turn our initial run-up and through our most recent reviews, I have not seen any significant publications nor have I seen clinical situations that this addresses, although am...
Excluding CLL, in which patients would you screen for hypogammaglobulinemia?
Patients I screen for hypogammaglobulinemia include those with: gammaglobulin gap (total protein-albumin) less than two; advanced multiple myeloma or mantle cell lymphoma; patients who have received CAR T cells or bispecific antibodies against BCMA or CD20.
How is monoclonal gammopathy of renal significance (MGRS) different from myeloma kidney?
The terminology around renal failure and myeloma is confusing and sometimes unnecessarily complicated. Here is how I approach it: Light chain (cast) nephropathy - This is from toxic injury to the nephron tubules from excess light chains. This is usually picked up on biopsy or can be ascertained fro...
In a patient diagnosed with Multiple Myeloma, is there a role for 24-hour UPEP prior to treatment?
I’d do a random UPEP first. If no light chains or renal dysfunction, I would not do 24-hour test. If light chains present with renal dysfunction, or significant protein on UA (albumin), I may do 24-hour UPEP and protein quantitation to distinguish myeloma kidney from light chains vs nephrotic syndro...
When, if ever, would you choose a two-drug regimen instead of three drug regimen first line in patients with transplant-ineligible Myeloma?
Daratumumab is generally well tolerated so would at least consider DaraRd triplet regimen as per the MAIA trial, since there is already FDA approval of this combination for transplant-ineligible newly diagnosed MM patients. Now with SQ Dara also approved and more widely available, this regimen is mo...
How is your experience with point-of-care INR systems for home monitoring of vitamin K antagonists?
Point of care (POC) INRs are reliable and can be used to monitor patients once their INRs have been stabilized on warfarin. In fact, there is data on better time in the therapeutic range for self-testing and also self-management of dosing. However, this needs to be done in conjunction with a warfari...
Are there specific indications where you would use thalidomide over lenalidomide for treatment of newly diagnosed multiple myeloma?
I would like to preface this response by noting that this is specific to a US practice setting. The short answer is that in the US, we rarely, if ever, use thalidomide in the frontline or relapsed setting in contemporary practice. This is due to the increased incidence of severe neuropathy with thal...
How does your management of ITP change when related to CLL?
The immune dysregulation associated with ITP is not necessarily a result of the CLL but occurs alongside and might be what underlies both disorders. The CLL clone is not making the antibody. ITP that persists despite a CR of the associated CLL should be treated as one would treat primary ITP. My fi...
Would you use new DOAC loading dose or start with maintenance dosing for a stable patient on existing DOAC who needs to switch brand due to insurance/formulary reasons?
For some drugs, you need to do a loading dose to get the drugs to therapeutic levels. However, with DOACs, a loading dose is used at the time of VTE diagnosis and therapy initiation to jump start the anticoagulant effect when the clot burden is the highest. Thus, if you are switching from another fu...