Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider TPO agonists for thrombocytopenia from low risk MDS?
There are randomized data supporting the use of TPO agonists in low-risk MDS with thrombocytopenia. A phase II study of eltrombopag vs placebo demonstrated a platelet response in ~40% of patients treated with eltrombopag and no increased risk of disease progression/AML evolution between the eltrombo...
In pure red cell aplasia, does peripheral blood-positive IgG for parvovirus have significance if persistently positive on retesting, but IgM and PCR are negative?
It is unlikely to be related; IgG will reflect past infection. The IgM is more reliable. I would treat this as autoimmune or idiopathic PRCA.
What hydroxyurea dose do you target for HbSC disease?
Based on results reported recently, hydroxyurea at an average dose of 20.5 mg/kg/day appeared to reduce substantially the rate of acute painful episodes and other sickle cell disease-related events in both adults and children with HbSC disease (Dei-Adomakoh et al., PMID 39647172). Previous studies a...
What is your goal ferritin level in pregnancy?
The goal is really to avoid iron deficiency and <30 best defines this state. Need to be wary of circumstances such as inflammation where the ferritin level may be falsely high even in the setting of reduced body iron.
Can TPO agonists, like avatrombopag or lusutrombopag, be used for patients with chronic thrombocytopenia and new acute portal vein thrombosis?
A caveat before answering - these tend to be very difficult clinical situations in a population that often has cirrhosis and has a very difficult-to-predict hemostatic picture (whether they are prohemorrhagic or prothrombotic from the underlying liver disease).I would refer you to some of the excell...
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
In what situations do you use G-CSF for patients undergoing allogeneic HSCT to facilitate engraftment?
A word of caution regarding the use of G-CSF in the setting of using ATG for GVHD prophylaxis. We published in 2021 (Orfali et al., PMID 34507002) a multicenter retrospective analysis of the interaction between ATG and post-transplantation G-CSF on allogeneic HCT outcomes for myeloid malignancies an...
How do you approach very treatment-refractory ITP?
Severely refractory ITP doesn't account for a large fraction of ITP patients, but it can be quite a challenge for treaters and patients alike. Combination therapies, varied immunosuppressive agents, and careful checks on adherence are all helpful. Some alternative agents with entirely different mech...
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
How do you approach an isolated T-cell gene arrangement found in the setting of persistent hypereosinophilia?
The lymphocyte variant hypereosinophilic syndrome (L-HES) is a rare form of reactive eosinophilic driven by clonal, phenotypically aberrant T-lymphocytes that secrete IL-5 and other eosinophilopoeitic cytokines. Diagnosis is based primarily on immunophenotyping (flow cytometry) of peripheral blood. ...