Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the optimal age at which a patient with sickle cell disease should undergo allogeneic stem cell transplant?
Ideally, would be at diagnosis to limit sickle related injury and generally, younger patients have less complications but since curative treatment is not perfect, it depends mainly on the donor. For matched sibling donor transplant, under age 5yrs has best outcomes with over 15yrs having more GVHD a...
For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?
Your approach to incidental thromboembolism found on the workup of malignancy should be similar to any evaluation of a thrombosis. It should be a structured approach with the following questions evaluated before deciding on long-term or short-term anticoagulation. First, one should determine the loc...
For patients with essential thrombocythemia who develop venous thrombosis in the setting of elevated platelet counts, would you continue lifelong anticoagulation even after cytoreduction is achieved?
This is a fantastic question, a true real-life scenario, with unfortunately little data to drive clinical decision making. What we do have to work with is that the combination of ASA plus anticoagulation increases the risk of bleeding, but does not decrease the risk of recurrent thrombosis in MPNs. ...
What would be a reasonable radiation approach and dose for a patient with multiple myeloma with brain involvement?
I would first wish to clarify what is meant by "brain involvement."When plasma cell neoplasms of the brain occur, they are usually the result of significant marrow involvement of calvarium and/or skull base with focal intracranial extension, or plasma cell infiltration of the leptomeninges and dura....
How do you treat refractory cold agglutinin disease?
If the patient has refractory cold agglutinin disease not associated with malignant lymphoproliferative disease, I have used intermediate dose Cytoxan. However, there is recent evidence that inhibition of C1s and thus complement activation by a monoclonal antibody sutimlimab markedly reduces hemolys...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.