Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to CMML-MDS in an older patient with low risk disease who is becoming transfusion dependent?
The short answer is that we treat lower risk CMML much like we treat lower risk MDS, even though we don't have dedicated studies in CMML to support this approach. After addressing any reversible causes of anemia (iron or vitamin deficiencies, hemolysis, etc...), NCCN guidelines for MDS would recomme...
How would you approach transfusion-dependent anemia in an intermediate-risk MDS patient refractory to azacitidine?
An MDS patient with ESRD likely has multiple contributors to their anemia. It is surprising to see the EPO level >500, but this may reflect the use of ESAs. If so, I would make sure that the dose is appropriate for MDS (60,000 units at least weekly) and that it is not renally dosed. If the patient i...
How do you approach MDS patients with low/very low risk IPSS-R but high risk mutations on NGS?
This a great question and one that I think will become more frequent in clinical practice. As it stands in my practice currently, I have been managing my IPSS-R low/very low-risk patients as I always have, with either observation, ESAs, or lenalidomide (in the case of those with del 5q). Age and com...
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...