Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage hemophilia A carriers with no history of bleeding complications but with mildly low factor VIII activity (6-40%)?
This is a wide range, if no history of bleeding then do not need factor on a regular basis. But for invasive procedures/surgery/trauma depending on what their levels are at baseline and the bleeding risk of the procedure, you will need to use factor 8, antifibrinolytic agents, or DDAVP. Same about t...
When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?
Our primary concern would be our patients with systemic lupus erythematosus. There are reports of severe flares in SLE patients treated with G-CSF (vasculitis and nephritis; Vasiliu et al, PMID 16832843) and even reports of cardiac arrest (Ragsdale & Hall Zimmerman, PMID 34748466).Of course, this ne...
What dose and fields would you use to treat a low grade CNS lymphoma that presents as an isolated single mass in the brain?
De novo presentations of low-grade lymphomas in the brain parenchyma are very, very rare. Suppose a patient had a relatively small, well-localized, low-grade NHL such as FL or MZL in the brain parenchyma, without any evidence of disease elsewhere (negative PET-CT, bone marrow biopsy, etc.). In that ...
When and how do we do cytoreduction in CLL?
Cytoreduction is almost never needed in CLL just for the sake of lowering the number. Rare case reports exist of leukostasis with WBC counts over 700k, but these are exceptions. If there are leukostasis symptoms with lower WBC counts then the diagnosis of CLL should be questioned. Having said that, ...
Is there any benefit to using desmopressin over vWF replacement therapy for vWD?
For mild type 1 and 2A, we do offer DDAVP testing and use. It was a much more useful drug when it was widely available as a nasal spray. It still has its place, but with patients whose level of VWF is <20% baseline, we have a lot of treatment failures and end up using factor.
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
Does the degree of elevation in free light chains/ratio correlate with a probability of AL amyloidosis?
YES, the difference between the kappa and lambda free light chains (dFLC) correlates with the probability of a diagnosis of AL amyloidosis. A significant dFLC indicates a higher likelihood of the disease and can also provide some moderately valuable prognostic information.But NO, I have not seen dat...
In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?
According to the ISTH guidelines (Martin et al., PMID 34259389) in patients with a BMI >40 kg/m2 or weighing >120 kg, it is suggested to use the standard doses of apixaban or rivaroxaban for VTE treatment and prevention regardless of BMI and BW. The ISTH did not discuss dose reduction after 6 months...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
How do you optimize a beta thalassemia patient on luspatercept who is interested in becoming pregnant?
Unfortunately, luspatercept is not approved to be used during pregnancy - there is no data available on the safety of the drug during pregnancy. So would say that if the patient is planning a pregnancy, would stop luspatercept at least 3 months prior. It is strongly recommended to optimize iron bala...