- Hematocrit: 45% 

- Buffy coat: WBCs and platelets

- Plasma: >1,000 unique proteins

- CBC: Gives quantitative and qualitative information about values

- HCT= 3x Hb value

- WBC counts: Clonal expansion --> Neoplastic and polyclonal expansion --> Reactive/inflammatory

- Reduction in one cell line of WBCs implies a non-malignant cause

- Forward scatter: Determines cell size

- Side scatter: Determines the internal properties of the cell --> Evaluates the complexity of cells

- Cells labeled with antibodies with flourescent tags --> CD typing for cells

- Cells arrested in metaphase and fixed to evaluate the chromosomes

- Dark bands correspond to gene-poor (AT-rich) regions

- Chromosomal aberrations: Deletion, addition, inversion, translocation

- FISH: Colored probes to detect positioning of genes on chromosomes

- IL-3: Produced by T and NK cells --> Stimulates all stem cells and progenitor cells

- GM-CSF: Produced by lymphocytes, macrophages, fibroblasts, and endothelial cells --> Stimulates neutrophils, eosinophils, monocytes, and lymphocytes

- G-CSF: Produced by macrophages --> Stimulates circulating neutrophils

- Begins in the yolk sac in weeks 3-4

- Migrates to the liver by week 5

- Migrates to the bone marrow late in gestation and at birth

- Red marrow receeds to be present only in the long bones and axial skeleton by adulthood

- Red marrow predominates the marrow until age 4 --> Yellow marrow begins to expand afterwards

- Stem cell --> Promyeloblast --> Basophilic normoblast --> Polychromatophilic normoblast --> Orthochromic normoblast --> Reticulocyte --> RBC

- Blast cells: Blue/basophilic cytoplasm

- Basophilic --> Orthochromic normoblasts: Color change due to change in cytoplasm composition from ribosomes and RNA to hemoglobin

- Reticulocytes: Methylene blue stain --> Stains left over RNA and ribosomes in the cytoplasm (reticulin)

- CD34: Stem cells

- CD33: Myeloid blast and promyelocytes

- CD13: Entire myeloid lineage

- CD11b: Myelocytes through mature myeloid cells

- CD14: Monocytes

- CD15: Myeloid lineage except mature myeloid cell

- CD16: Metamyelocyte and granulocytes

- CDw32: Myelocytes to granulocytes

- CD64: Monocytes

- Identifiable form is granular form

- Can become dysplastic and begin to look like promegakaryocyte (immature)

- DNA replicates but cell doesn't split

- Aged megakaryocytes are smaller than granular forms

- Erythrocyte Precursors: 14-30%

- Neutrophil precursors: 45-67%

- Eosinophils and precursors: 2-5% 

- Basophils and precursors: up to 0.5%

- Lymphocytes: 10-24%

- Monocytes: Up to 3%

- Plasma cells: Up to 3%

- Myeloid/Erythroid precursors= 3:1 --> RBCs last 120 days while WBCs only last 1-3 days

- Iron stain: Ringed cells is a sign of malignancy

- Reticulin stain: Shows the reticulin structure of blood vessels and sinusoids

- Cellularity

- M:E ratio --> Normal 3:1

- Erythroid and myeloid maturation

- Megakaryocytes

- Iron stores

- Reticulin deposition

- Granulomas, tumor, and other findings

- White pulp: Lymphoid tissue surrounding the central arteries --> Forms periarteriolar lymphoid sheath (PALS)

- Red pulp: Vascularized tissue with two compartments --> Sinuses and cords of Billroth

- Pathology: White pulp --> Hodgkin and Non-Hodgkin lymphomas and red pulp --> Leukemias, chronic myeloproliferative disorders, and storage diseases

- Dietary Iron: 1-2 mg absorbed daily --> Absorbed in duodenum

- Utilization: 300 mg in muscle, 1800 mg in circulating erythrocytes, 1000 mg in liver, and 600 mg in reticuloendothelial macrophages

- Iron loss: Sloughed mucosal cells, desquamation, menstruation, and other blood loss

- Fe3+ ingested in food --> Reduced to Fe2+

- Fe2+ stabilized and kept soluble by gastric acid --> Absorption reduced by PPIs and antacids

- Fe2+ is transported into duodenal enterocytes

- Ferroportin moves Fe2+ out of cells and into blood

- Hepcidin: Inhibits ferroportin and the movement of Fe2+ into blood --> Produced by liver during inflammation as an acute phase reactant

- Heme iron enters enterocyte through different transporter

1. Pica: Eating of non-food items

- Pagophagia: Ice eating --> Highly specific 

- Amylophagia: Paper and corn starch eating --> More common in African Americans

- Geophagia: Clay and dirt eating --> More common in Africa

2. Thinning and brittle hair

3. Fatigue

4. Restless legs --> Can occur even in the absence of anemia

5. Beeturia --> Red urine after beet consumption in 65% of iron deficient patients

6. Angular cheilosis

7. Plummer-Vinson Syndrome: Esophageal webs, glossitis, and anemia

1. Iron/Total Iron Binding Capacity (TIBC) --> TSAT

- TSAT should normally be >20%

- TSAT <20% --> Low iron quantity

2. Ferritin: Measures storage of iron

- Ferritin is an acute phase reactant --> >100 rules out classical iron deficiency

- Ferritin <40 indicates low iron stores

3. MCV and RDW: Determines average size and variation of size in RBCs --> Microcytosis and anisocytosis (cells of different sizes)

4. MCHC --> Low means severe, long-standing deficiency

5. Platelets: Thrombocytosis is common with iron deficiency

- Both have low MCV and high RDW

- RDW is higher and more severe in iron deficiency

- Iron Deficiency: Low MCV, low serum iron, TIBC high, low % saturation, and low ferritin

- Anemia of Chronic Disease: Normal to low MCV, low serum iron, low TIBC, low % saturation, and normal to increased ferritin --> Iron is stuck in stores, NOT in blood

- Thalassemia: Low MCV, normal to high serum iron, normal TIBC, normal or high % saturation, and normal or increased ferritin

1. Malabsorption --> Gastric bypass, sprue and meds

2. Menhorragia --> Menorrhea etc --> Most common in women

3. GI blood loss due to cancer, IBD, and vascular abnormalities --> Most common in the elderly

4. Dietary deficiency

5. Phlebotomy

6. Hematuria

- Impossible to accomplish simply by dietary modification

- Poor absorption of inorganic iron

- Ferrous sulfate 325 mg twice daily --> Causes severe constipation, nausea and epigastric distress --> Often not well tolerated

- Vitamin C improves Fe2+ absorption

- Absorption inhibited by milk, tea, high gastric pH, and rapid duodenal transit

- IV preparations have evolved --> Easier to replete than with oral supplementation

- Severe, acute hypersensitivity reactions --> Black box warning

- Indications: Failure of adequate trial of oral iron, desired prompt erythropoeitic response, refusal of blood transfusion, dialysis, and chronic kidney disease

- Patients on dialysis are always supplemented with iron

- Can give extremely high doses of iron quickly --> Quick effect

- Contraindications: Inability to tolerate multiple preparations, active bacterial or fungal infection, and iron overload

- Have reprocussions aside from anemia

- Impaired cognitive and athletic performance

- Fatigue syndrome

- Heart failure improves after IV iron

- Restless leg syndrome

- Causes insidious end-organ damage

- Target organs: Liver, pancreas, skin, and heart --> Bronze diabetes

- Diagnosis: Ferritin and transferrin levels, liver biopsy, and MRI

- Causes: Hereditary hemochromatosis, transfusional iron overload, and inappropriate iron avidity due to thallasemia

- HFE C282Y mutation --> Autosomal recessive

- 10% of caucasians are carriers --> Especially in Irish descent

- Screen with TSAT and confirm with genetic testing

- Treatment: Early diagnosis, phlebotomy, avoid excessive dietary iron, avoid alcohol, and avoid raw shellfish

- Treatment in iron overloaded patients: Chelation and hepcidin analogues

- Due to defective DNA synthesis

- Increasingly ineffective erythropoiesis with intramedullar cell death

- Fragility of cells with autohemolysis with severe anemia

- All dividing cells in the body are effected --> All become large with huge nuclei

- Causes: Vitamin B12 and folate deficiencies

1. Megaloblasts are larger at any stage than their normal counterparts

- Higher nuclear to cytoplasmic ratio

2. Increased intramedullary cell death --> Hyperplastic bone marrow but pancytopenia

3. Maturity of cytoplasm great than that of the nucleus --> Nuclear-cytoplasmic dissociation

4. Open chromatin present in orthochromatic normoblasts

5. Giant bands and horseshoe metamyelocytes

6. Polykaryocyte: Increased nuclei in the megakaryocytes

- Pancytopenia with reticulocytopenia

- Size and shape variation in erythrocytes

- MCV >110

- Macro-ovalocytes present

- Hypersegmentation of PMNs --> >5 lobes

- Severe anemia --> HCT <20 with teardrop cells and nucleated red cells

- Slowly developing anemia with pallor, fatigue, and shortness of breath

- Glossitis with megaloblastic features

- GI complaints

- Weight loss

- Neurological manifestations --> Only in B12 deficiency

- Pancytopenia

- High MCV >110

- Increased lactic acid dehydrogenase (LDH) levels

- Increased bilirubin due to hemolysis, etc

- High serum ion and transferrin is saturated

- Low plasma haptoglobin --> Bound by Hb that has been released from cells during hemolysis

1. Folate deficiency

- Folate is a methyl donor

- THF --> Vit B12/cobalamin --> Homocysteine --> Methionine

2. B12 deficiency

3. Antimetabolite and inhibitors of DNA synthesis --> Methotrexate

- Causes megaloblastic anemia

- Present in leafy green vegetables, fruits, mushroom, liver and yeast --> Folate destroyed by over cooking

- Minimal daily requirements --> 75 ug but storage is minimal

- Serum levels can drop in 2 weeks to cause deficiency symptoms

- Needs to be in polyglutamate form to be absorbed in the proximal jejunum

- Decreased folate intake 

- Increased requirement --> pregnancy, systemic disease, etc

- Inadequate diet --> Poverty, institutions, goat's milk, and special diets

- Malabsorption in small bowel --> Celiac disease, bacterial overgrowth, etc

- Drug induced --> Anti-convulsants

1. Diagnosis

- Serum folate level <3 ug/L --> Normal is >6 ug/L

- Low red cell folate levels (<100 ug/L) --> Normal is >160 ug/L

- Elevated serum homocysteine levels --> Cannot be methylated to form methionine so it builds up

2. Treatment

- 1 mg of oral folate to quickly correct deficiency

- Daily requirements <1 ug/day

- Parenteral preparations are also available but rarely needed

- Accepts methyl group from folate and transfers to homocysteine

- Also involved in conversion of methymalonic acid conversion to succinyl-CoA which enters into TCA/Kreb's Cycle

- Not synthesized de novo in humans --> Produced by bacteria and molds

- Diet is the only source --> Liver, eggs, cheese, milk, and mollusks

- Daily requirements: 0.1 ug/day

- Liver has large stores --> Deficiency takes years to develop

- Absorbed in the terminal ileum

- Less commonly caused by inadequate diet

- Veganism can cause vit B12 deficiency

- Malabsorption --> Pernicious anemia, gastrectomy, sprue, ileal resection, Crohn's disease, congenital specific malabsorption, fish tapeworm (dyphylobothrium latum) and drugs

- Most common cause is pernicious anemia --> Uniformly fatal if untreated --> Atrophic gastritis results

1. Megaloblastic anemia

- All cells become larger with larger nuclei and cytoplasm

- Hypersegmented polys

- Variable sized red cells

2. Neurologic manifestations: Demyelination of posterior and lateral columns of the spinal cord

- Loss of position and vibrational sense in the toes --> Positive Romberg test

- Symptoms can occur even in the absence of anemia

- Can progress to coma and death

- Loss of lateral corticospinal tract too --> Motor deficits

- Docs fear treating with folate because it might mask the other signs of B12 deficiency and lead to severe neuro complications

- Leads to deficiency in methionine --> Crucial for myelin formation --> Neuro consequences

- B12 binds R-binders in the mouth, esophagus, and stomach

- Pancreatic enzymes then cleave R-binders freeing B12

- Intrinsic factor (IF) binds Vit B12

- IF receptors bind complex in the terminal ileum --> Absorbed

1. Diagnosis

- Serum B12 level <200 pg/mL

- High methymalonic acid in serum

- High homocysteine in serum

- Antibodies for pernicious anemia --> Anti-intrinsic factor, anti-parietal cell antibody, and gastric achlorhydria

- Schillings test: Administer radioactive vit B12 and watch amount the enters urine --> Not performed routinely

2. Treatment

- 1000 ug of B12 infected daily for 7-10 days

- Injections then monthly for life

- 100 mg oral B12 also possible

- HbF (Fetal): a2g2

- HbA (Adult): a2b2

- HbA2: a2d2

- Hb at birth --> HbA 20% and HbF 80%

- Hb 6 months after birth --> HbA 96%, HbF <2%, and HbA2 2%

- Single point mutation causing HbS

- Autosomal recessive

- HbS homozygotes have severe disease

- Clinical features are heterogeneous --> Life is shortened

- Acute painful episodes

- Treatment: Stimulate HbF to reduce HbS levels in RBCs --> Imperfect treatment though

- Origin: Selective pressure due to P. falciparum caused the HbS gene to be passed --> Gene protects against malaria infection

- Diagnosis: Family studies, clinical symptoms, HPLC evaluation of Hb present in patient, and PCR

- Normal blood counts and normal blood film

- Heterozygotes for HbS gene

- 60% HbA and 40% HbS --> No sickling in RBCs

- Normal levels of HbA2 and HbF

- Normal lifespan

- Sickle crisis can result at high altitude, scuba diving, and during times of dehydration

- HbS homozytogte --> 1/600 African Americans

- HbSC: HbSC compound heterozygote (1/800)

- HbS-B Thalassemia: B+/Bo thalassemia compound heterozygotes (1/1600)

- HbSE: Compound heterozygotes

- Other less common and rare compound heterozygotes

- HbS polymerization --> Forms rods that poke holes in the membranes

- Polymerization can lead to autohemolysis

- Hemolysis of sickle cells --> Cells only last ~20 days 

- Intracellular adherence

- Reperfusion injury, NO scavenging, oxidant injury, and inflammation all result

- Sickle patients are deficient in NO --> Vasoconstriction and increased likelihood of occlusion and embolism

- Viscosity-Vaso-Occlusion subtype: Erythrocyte sickling

- Hemolysis-Endothelial Dysfunction subtype: Proliferative vasculopathy

- Hallmark of disease

- Result from membrane damage due to HbS polymerization

- HbS within the cell may not actually be polymerized though

- Membrane is said to be frozen

- Does NOT signify acute sickle cell crisis, etc

- These cells adhere more readily to endothelial cells --> Thromboembolic disease is much more common

- Very heterogeneous presentation

- Acute painful episodes --> Most patients and most frequent

- Acute chest syndrome --> Sometimes lethal --> Treatment is hyperbaric oxygen chamber

- Stroke --> 10% of children and neurocognitive damage

- Osteonecrosis --> Crippling and painful

- Leg ulcers --> Painful and destructive

- Proliferative retinopathy --> More common!!

- Splenomegaly

- Renal failure --> 2.4% of patients

- Pain: 0.4 episodes/patient/year

- Priapism: Less common

1. HbF-Inducing

- Hydroxyurea --> Increases HbF

- Decitibine

- Arginine butyrate

- HDAC inhibitors

2. Anti-adhesion, anti-inflammatory, and anti-oxidant

- Allopurinol --> Prevents resultant gout

- SOD

- NO

- Sulfasalazine

- Heparins

- L-4F

- Statins

3. Anti-RBC Dehydration

- Magnesium

- ICA 17043

- Arginine

- Reduction of pain

- 40% of reduction in mortality

- Less hemolysis

- Fewer hospitalizations

- Reduction in medical costs

- Improved physical capacity

- Acute painful episode --> Most frequent 

- Acute chest syndrome --> Often presents as acute pain or a new infiltrate on CXR --> Treat with heparin, antibiotics, fluids for dehydration, oxygen, and transufsion

- Osteonecrosis

- Leg ulcers --> Indolent and hard to heal

- Neuropathic --> Opioid induced for pain secondary to acute pain

- Most common compliation --> Some patients are always in pain while some rarely are

- Most pain can be managed at home

- Etiology is unclear --> Unrelated to sickling

- Physical findings are limited

- Increased frequency is a bad prognostic sign

- Directly related to PCV/indirectly related to HbF

- Diagnosis: History, hematological changes, and changes in RBC deformability and density

- Treatment: Short-acting parenteral opioids and long-acting opioids for chronic pain

- Complications: Acute chest syndrome, acute multiorgan failure, and sudden death

- Patients are commonly readmitted to the hospital after episodes

- Damage or dysfunction of the nervous system

- Dysesthesia and allodynia

- Burning, tingling, shooting and lancinating pain, and numbness

- Emotional distress

- Behavioral dysfunction

- Treatment: Antidepressants, anticonvulsants, and opioids

- Progressive tissue damage

- Inadequate treatment of pain with opioids

- Tolerance to opioids

- Hyperalgesia

- Changes at receptors causing decreased effect

- Maladaptive behavior

- Difficult patients: Acute upon chronic pain and have often alienate the entire health care team

- Know and believe the patient

- Work with the patient to develop a good treatment plan

- Educate the patient

- Necessary: Severe anemia, CVA prevention, pre-operatively, and acute chest syndrome

- Sometimes needed: Pregnancy and renal failure

- Contraindicated: Iron overload

- 4 copies of alpha gene are present on the 2 copies of Chromsome 16

- Disease results from gene copy deletions

- Cis mutations --> More common in Asia --> More severe anemia in the offspring --> High spontaneous abortion rate

- Trans mutations --> more common in Africa

- Silent carrier: 1 gene deletion --> Normal Hb levels

- Alpha-Thalassemia trait: 2 gene deletions --> Mild anemia results --> Can precipitate Hydrops fetalis in offspring

- Hb H disease: 3 gene deletions --> Moderate anemia with low MCV

- Hydrops fetalis/Hb Barts: 4 gene deletions --> Severe anemia and transfusion dependent --> Baby doesn't survive

- 1 copy of beta gene present on each chromosome 11

- Mutations due to deletion, splice mutations, and creation of stop codons

1. Beta-Thalassemia trait: Perfectly healthy --> Can pass gene along to cause B-thal. major in offspring

- Microcytosis, hypochromia, mild anemia possible, with elevated HbA2 levels

2. Beta-Thalassemia Intermedia: Multiple genotypes

- Microcytic anemia, may be transfusion dependent

- High HbF levels, bone disease,low MCV, iron loading, splenomegaly, and PH

3. Beta-Thalassemia Major: Bo/Bo genotype

- Transfusion-dependent microcytic anemia

- Very high HbF levels with low MCV

- Unbound a chains aggregate to form tetramers --> Occlusion

- Iron overload is possible due to repetitive transfusions

- Idea is the raise the HbF levels in the blood to compensate

- Hydroxyurea will raise HbF

- BCL11A gene activation leads to gamma globin transcription and HbF elevation

- Bone marrow transplant --> Replaces with cells that properly make alpha and beta globin chains

- Necessary for iron overloading due to repetitive transfusions

- Deferoxamine (Desferal)

- Deferasirox (Exjade)

- Deferiprone (Ferriprox)

- Carrier screening --> CBC, iron studies, and Hb analysis

- Genetic counseling --> Carrier testing on spouse and other family members

- Prenatal diagnosis --> Identify parental mutations and test fetal samples to see if gene has been transmitted

- Normal count: >150,000/mL

- No noticeable bleeding tendency: 50,000-150,000

- Increased nuisance bleeding: 20,000-50,000

- Risk of spontaneous bleeding; 10,000-20,000 --> Petechiae and ecchymoses can result

- Risk of severe hemorrhage: <10,000

- Pseudothrombocytopenia: Falsely reduced platelets in a test tube due to EDTA in the tube

- Medications

- Infections --> Viral or bacterial

- Sequestration in the spleen

- Cirrhosis --> Splenomegaly/portal hypertension and thrombopoietin secretion defect

- Platelet consumption --> ITP, HIT, TTP, and DIC

- Hypercoagulable state

- Heparin binds platelet factor IV

- Body creates an antibody to complex --> Platelet aggregation and degranulation

- Must terminate use of heparin!!

- Consequences: Deep vein thrombosis, pulmonary embolism, skin lesions at the injection site, acute limb ischemia, warfarin-associated venous limb gangrene, and acute thrombotic stroke or MI

- Treatment with argatroban significantly reduces new thrombosis formation

- Fatal if untreated and undiagnosed but curable if diagnosed

- Presentation: CNS abnormalities, renal pathology, fever, thrombocytopenia, and microangiopathic hemolytic anemia

- Platelet binding due to acquired deficiency of vWF proteinase --> Leads to inability to inactivate vWF

- Antibody is produced which binds to vWF proteinase and inactivates

- Thromboses normally form in the kidneys and the brain

- Peripheral blood: Schisitocytes form due to sheering force within the blood vessels --> Due to microangiopathic hemolytic anemia

- Plasma exchange procedure

- Specifically eliminates anti-ADAMTS13 antibodies and vWF multimers

- Repletes ADAMTS13 levels --> Active vWF proteinase

- Must be done multiple times a day

- Presents with isolated thrombocytopenia

- Common in younger patients, pregnant women and patients with other autoimmune problems

- Diagnosis of exclusion

- Strongly associated with infection (HCV and HIV) and lymphoma

- Evans Syndrome: ITP with autoimmune hemolytic anemia

- Antibody is produced to glycoprotein IIb/IIIa on the surface of platelets

- Macrophages in spleen then phagocytose the antibody covered platelets --> Depleting levels

- Presentation: Nose bleeds, petechiae, mouth blisters, and other signs of bleeding

- Reverse symptoms or raise platelet count >20,000

- Rescue therapy: Corticosteroids and IVIG

- Lots of corticosteroids needed to maintain levels --> Usually too high for chronic dosing

- Platelet transfusion doesn't help!! --> Doesn't actually deal with the problem

- Chronic: Long term steroids, splenectomy, rituximab (B-cell depletion), and thrombopoietin mimetics

- Thrombopoietin mimetics --> Stimulates marrow production of platelets

- Not first line treatment

- Try things beforehand

- Indications: Patients unresponsive to steroids or who have relapsed upon steroid cessation

- 2/3 of patients will have complete remission of disease at 5 years after splenectomy

- Most respond within 10 days --> Increased platelet counts

- Accessory spleens are present in 15% of patients --> Don't show complete remission

- Some patients don't respond --> Need further treatment

- Accelerated destruction or diminished lifespan of RBCs

- Bone marrow responds by increasing RBC production

- Reticulocytes are released into blood more frequently

- No anemia if hemolysis is appropriately compensated for by the marrow

- Hemolytic anemia: When erythropoiesis cannot keep up with the rate of hemolysis

- Hemolyzed RBCs release heme and LDH into circulation

- Heme --> Unconjugated bilirubin --> Jaundice if liver capacity is overwhelmed

- Reticulocytes --> Big bluish, immature cells --> Polychromasia

- Elevated unconjugated bilirubin

- Low Hb and HCT

- Low platelet count

- Decreased haptoglobin --> Severe hemolysis

- Elevated LDH

- Reticulocytosis/Polychromasia on blood smear

- Anemia --> Only in uncompensated hemolysis

1. Intrinsic Causes --> Most are inherited

- Hemoglobin dysfunction

- Membrane dysfunction

- Enzyme dysfunction

2. Extrinsic Causes --> Most are acquired

- Immune

- Non-immune --> Malarial infection --> Induces RBC changes --> RBC lysis

- Low Hb and HCT

- Low platelet count (<150,000)

- Abnormal coagulation studies

- Schistocytes seen on peripheral blood smear

- Schistocytes: RBC fragments damaged by shear stress in the microcirculation

- Often seen in DIC, TTP, mechanical heart valves, malignant hypertension and Scleroderma patients

1. Direct Coomb's Test

- Control antiserum added to a sample of the patient's RBCs

- If RBCs have receptors for antiserum --> Antiserum binds RBCs and they agglutinate and aggregate out of solution

- Spherocytes seen on peripheral smear

2. Indirect Coomb's Test

- Testing for antibodies in patient plasma/serum

- Used in type and screen test

- Positive Coombs test --> Detects antibodies on the surface of RBCs

- Causes: De novo, idiopathic, associated with other autoimmune diseases, and drug-induced

- Warm AIHA: IgG binds to RBCs at body temperature

- Cold AIHA: Complement C3 coats RBCs and IgM only binds complement and RBCs at temperatures below body temperature --> Most of the time not clinically significant

- Mother becomes sensitized by previous pregnancies and develops antibodies against them

- IgG antibodies can cross the placenta and bind to fetal RBCs --> Hemolysis

- Mild --> Hyperbilirubinemia due to hemolysis

- Severe --> Jaundice and anemia --> May require transfusion

- Most common membrane disorder --> Intrinsic cause of hemolysis

- Inheritance: Autosomal dominance

- Mutation in spectrin protein within RBCs --> Changes shapes

- Either quantitative loss of proteins or qualitative abnormality

- Pieces of abnormal membrane form microvesicles which are then plucked off

- Loss of membrane results in the inability for RBCs to change shape normally

- Presentation: Hemolytic anemia, reticulocytosis, jaundice, splenomegaly, and gallstones

1. Diagnosis

- Osmotic fragility test

- Spherocytes on peripheral smear

2. Treatment

- Splenectomy --> Allows for erythrocyte lifespan to normalize and improves anemia

- Laparoscopic splenectomy

- Splenectomy complications: Localized infection, bleeding, pancreatitis, and infection with encapsulated organisms

- G6PD --> NADPH generation --> Glutathione generation

- Glutathione is necessary to maintain Hb in the soluble state

- Heinz bodies: Insoluble Hb within RBCs

- Inheritance: X-linked recessive --> Variable inactivation

- Clinical variants: Acute intermittent hemolysis and chronic hemolysis

- Acute hemolytic variant: Hemolysis when individuals are exposed to oxidant drugs or stressful situations

- Oxidant drugs that precipitate hemolysis: Sulfa drugs, HIV meds, and fava beans

- Diagnosis: History and blood smear and enzyme activity measurement by rapid flourescent testing

- Bite cells seen on smear --> Macrophages in the spleen remove the Heinz bodies and take part of the membrane with it

- During acute hemolysis episode: Enzyme levels in reticulocytes become higher --> G6PD may become falsely elevated to normal range

- Treatment: Folate supplementation and transfusion

- Reticulin seen on smear

- Reticulin: Residual DNA and ribosomes

1. O pos: Anti-A and Anti-B antibodies --> 45%

- Compatible RBCs: O+/O-

- Compatible FFP: All

2. A pos: Anti-B antibodies --> 40%

- Compatible RBCs: A+/A- and O+/O-

- Compatible FFP: A+/AB+ and A-/AB-

3. B neg: Anti-A antibodies --> 10%

- Compatible RBCs: B-/O-

- Compatible FFP: B+/AB+ and B-/AB-

4. AB neg: No antibodies --> 5%

- Compatible RBCs: AB, A, B, O-

- Compatible FFP: AB-/AB+

- Universal donor for plasma --> No antibodies present

5. Rh+ (85%) and Rh- (15%) --> Rh patients can only get Rh- plasma

- Type and Screen: ABO typing, testing patient's plasma, and no transfusion planned

- Type and Cross: ABO typing and testing patient's plasma, and number of units ordered --> Transfusion planned

- ABO Typing: 10 min

- Crossmatching: >30 min

- Crossmatching ABO type specific with RBC alloantibody: >2 hours

- 450 mL of whole blood collected from donor

- Mixed with anticoagulant in blood bag

- Centrifuged to separate out RBCs and plasma

- Packed RBCs

- Second spin splits platelets from plasma

- Platelets --> Apheresis platelet

- Plasma by apheresis from AB donor

- Even RBC apheresis transfusions are possible

- 42- day shelf life

- 300 mL sample with HCT 55

- ABO and Rh compatibility determined

- Uncrossmatched group O blood in emergencies

- One unit of packed RBCs --> Raises HCT 2-3% and Hb 1 g/dL

- Stable non-bleeding patients don't need a transfusion until Hb <7 g/dL

1. Leukoreduced RBCs

- All samples are leukoreduced

- Reduces febrile transfusion reactions

- Blood is prefiltered in a blood center or at the bedside

2. Irradiated RBCs

- Used for patients on chemo and immuncompromised patients to prevent graft versus host disease

- By blood bank irradiator

3. Washed RBCs

- For patients with severe allergic reactions --> Must have more than one severe allergic reaction after transfusion

- Plasma is removed

- Only lasts for 24 hours after sample is made

- Used to restore clotting factors in bleeding patients

- Pt on warfarin with INR >2

- Must be ABO compatible

- 10 mL/kg --> Each unit is 250-300 mmL

- Need at least two units to really do anything

- Allergic reactions are fairly common --> Reaction between patients IgG antibodies and proteins in donor plasma

- No real bleeding risk unless platelets >10,000-15,000

- 1 bag --> Raises count by 20,000/uL

- 1 bag is pooled from 4-5 platelet concentrates --> Exposure to multiple different donors

- Half-life: 5 day storage at room temp

- Neonates need ABO compatible platelets

- Made from FFP

- Contains only Factor VIII, vWF, fibrinogen, and factor XIII

- 1 unit --> 8-10 units of cryo pooled together

- Only good for 4 hours once thawed

- Used in DIC to replace fibrinogen

- Bleeding when fibrinogen <100 mg/dL

- More common in patients with bacterial infections, HBV, HCV and HIV

- Symptoms: Fever, back pain, red/black urine, and hypotension

- Common cause: Clerical error and mislabeled samples

- Febrile Non-Hemolytic Transfusion Reaction --> 1:500

- Mild allergic reaction --> 1:735 (BMC 2012)

- Transfusion-related Acute Lung Injury --> 1:5,000

- Hemolytic Reaction: 1:6,000-33,000

- Transfusion-Associated Sepsis: 1:50,000

- Anaphylaxis --> 1:20,000

- Not uncommon

- Not always a transfusion reaction but can be the only sign of a transfusion reaction --> Must treat as such!!

- Stop transfusion if fever occurs

- Workup: Clerical check, visual inspection of plasma for hemoglobinemia, and direct Coomb's Test

- Febrile nonhemolytic reaction if NO immune cause found

- Hives or similar allergic reaction --> Frequent occurence

- Mediated by recipient IgE antibodies to donor plasma

- Most reactions don't recur

- Many times patients didn't even need plasma in the first place

- Pre-leukemia syndrome

- Marrow has trouble differentiating and producing mature cells

- Cells don't function normally and look funny

- Development of obliterative marrow fibrosis

- Identical to the spent phase of other myeloproliferative disorders

- JAK2 mutation in 50-60% of cases

- Fibrosis due to PDGF and TGF-B

- Teardrop-shaped RBCs seen on smear

- Extensive extramedullary hematopoiesis due to fibrosis of the entire marrow

- Usually occurs in people older than 60 years of age

- Labs: Moderate to severe normochromic normocytic anemia with leukoerythroblastosis, leukopenia, and thrombocytopenia

- Treatment: Harder to treat than PCV and ET

- Prognosis: Median survival of 3-5 years

- May transform to AML in extramedullary sites

- Increased marrow production of RBCs, granulocytes and platelets --> RBCs predominate

- Strongly associated with JAK2 mutations --> 97%

- Extramedullary hematopoiesis --> Splenomegaly

- Incidence: 1-3 per 100,000/year

- Presentation: Insidious onset in middle aged adults --> Headache, dizziness, hypertension, GI Symptoms, cyanosis, pain and redness

- Hyperviscosity syndrome

- Tends to evolve to spent phase --> Myelofibrosis

- 2% of patients transform to AML

- Treatment: Phlebotomy and chemo to suppress blood counts

- Elevated platelet counts

- Absence of polycythemia and marrow fibrosis

- JAK2 mutations 

- Marrow cellularity is only mildly increased

- Megakaryocytes are often markedly increased in number and in large abnormal forms --> Abnormally large platelets

- Delicate reticulin fibrils seen

- Spent phase and AML transformation is uncommon

- Incidence: 1-3 per 100,000/year --> Patients past the age of 60

- Presentation: Hypercoagulable state, hyperviscosity, and hemorrhage

- Median survival is 12-15 years

- Treatment: Gentle chemo to suppress thrombopoiesis

- Chimeric BCR-ABL gene (100%) --> t(9:22) translocation (Philadelphia Chromosome) --> Stimulates tyrosine kinases --> Proliferation!!

- Leukocytosis exceeding 100,000 cells/mm3 --> <30% blasts in the marrow and no blasts in peripheral smear

- Increased deposition of reticulin is typical

- Presentation: 50-60 year olds with high WBC and mild splenomegaly

- Symptoms: Mild/moderate anemia, hypermetabolism, fatigability, weakness, weight loss, and anorexia

- Slow progression --> 3 year median survival without treatment

- Stable phase --> Accelerated phase --> Blast crisis --> AML

- Blast crisis occurs within 5-7 years without treatment

- AML transformation because translocation makes other mutations much more common --> Mutations down the road make differentiation impossible

- Diagnosis: WBC count, symptoms, history, and Philadelphia Chromosome genetic testing

- Early diagnosis is crucial --> Prevents further mutations

- Treatment: Imatinib (BCR-ABL inhibitor) and stem cell transplant

- Imatinib may not actually be curative because it doesn't distinguish the CML stem cell

- Malignant lymphoid cells primarily confined to solid organs

- Classification: Pattern of growth, cell size, grade/mitotic rate, and cell lineage

- Non-Hodgkin's vs. Hodgkin's 

- Presence of malignant hematopoietic cells primarily in peripheral blood and bone marrow

- Malignancy of small round and regular lymphocytes

- Presentation: Generalized lymphadenopathy, hepatosplenomegaly (50-60%), and bone marrow always involved

- Naming depends on whether the malignancy is in peripheral blood or solid organs/lymph nodes

- Peripheral smear: Predominantly mature lymphocytes seen, no blasts, and smudge cells seen

- Splenomegaly --> Up to 250 g (usually ~25g)

- Low grade tumor

- Richter symdrome: Transformation into more aggressive large cell lymphoma

- Malignancy of germinal center cells (B-cells) with follicular growth pattern

- Grading depends on the number of centroblasts seen on biopsy --> <5% (Grade I), 5-15% (Grade II), and >15% (Grade III)

- Biopsy: Lots of mitosis and apoptosis seen with centroblasts present

- Centroblast: Large cells with euchromatic nucleus

- Spleen: Miliary involvement with expansion of white pulp

- Genetics: t(18;14) translocation (70%) --> Bcl-2 gene --> Anti-apoptotic effect but requires additional mutations to actually form FL

- May transform to a more aggressive large B-cell lymphoma

- Immunophenotype: slg+, CD19+, CD20+, CD79a+, bcl-2+, bcl-6+, CD10+, CD5-, and CD43- types

- Presentation: Elderly, almost everywhere in the body at diagnosis, and long median survival

- Malignancy of B-cells within the lymph node --> Diffuse pattern of growth that overruns capsule

- Most common form of Non-Hodgkin's Lymphoma (NHL)

- Biopsy: Extremely large cells with abundant cytoplasm and prominent nucleoli (B-cells) --> 4-5x normal

- Spleen: Mass seen --> Different from SLL/CLL and FL

- Staining: CD20+ 

- Molecular entities: Germinal center, activated B-cell and type 3 --> Best prognosis in germinal center type

- Endemic form: Africa and associated with EBV infection (100%)

- Sporadic and HIV forms: Most common in the US --> 15-20% are associated with EBV

- Intermediate sized cells --> Derived from small non-B-cells

- High mitotic rate and high grade --> Ki-67 >90%

- Most rapidly growing human tumor

- Biopsy: Starry sky appearance of nodes --> Presence of macrophages interspered with malignant cells

- Macrophage presence is a sign that cells are turning over quickly

- Genetics: t(8:14) translocation --> c-myc oncogene translocation

- Mostly present at extranodal sites --> Jaw/Mandible in Africa and abdominal cavity in the US

- Treatment: High dose chemo --> Highly aggressive therapy for highly agressive tumor

- Tumor lysis syndrome possible --> Very common complication from chemo --> Prophylactically treat with allopurinol

- Atrophic germinal center and small B-cells seen on biopsy

- Cells look similar to SLL and FL but are actually unique

- Genetics: Bcl-1/cyclin D1 --> t(11:14) translocation --> Cyclin D1 is involved in the cell cycle

- Cyclin D stain: Stains nuclei of malignant cells

- Appearance suggests low grade lymphoma but actually aggressive

- More aggressive than follicular lymphoma

- Equally incurable as follicular lymphoma

- Treatment: Chemo followed by stem cell transplant --> Reasonable remissions that last a long time

- LBL: Solid tumor presenting with malignant cells of intermediate size --> Blasts seen

- ALL: Peripheral blood tumor presenting with blasts (large cells with prominent nucleoli)

- TdT+ staining --> Pre-cursor lymphoma --> Lymphoma of blasts and precursor cells

1. Immunology

- Immunohistochemistry and flow cytometry --> Determining cell lineage (B or T)

- Detection of CDs --> CD34 (stem cells), CD19/CD20 (B-cells), and TdT+ (Stem cells --> Pre-B/T cells)

- Determination of B-cell monoclonality --> Kappa/lambda light chain restriction

2. Molecular Genetic Studies --> PCR and FISH procedures

- Determination of monoclonality of B-cells or T-cells by rearrangement of the IgG

- Detection of chromosomal translocations

- Addition of immunophenotypic and molecular genetic data to supplement morphology

- Accommodates additional subtypes of B-cell lymphomas --> Some lymphomas only recognized by molecular and genetic techniques

- Includes a much greater number of subtypes of T-cell lymphomas too

- 85% of lymphomas are B-cell lymphomas

1. Precursor B-cell neoplasms

- Precursor B lymphoblastic leukemia/lymphoma

2. Mature B-cell Neoplasms --> Most common type

- CLL/Small Lymphocytic Lymphoma (6.7%)

- Follicular lymphoma (22%)

- Mantle Cell Lymphoma (6%)

- Diffuse Large B-cell Lymphoma (30%)

- Burkitt Lymphoma/Leukemia (2.5%)

- Extranodal Marginal Zone B-cell Lymphoma (7.6%) --> MALT-oma

- Splenic Marginal Zone Lymphoma (<1%)

- TdT+ and CD34+ immunphenotypes

1. Precursor T-cell Neoplasms

- Precursor T-lymphoblastic leukemia/lymphoma

2. Mature T-cell Neoplasms --> Most common type

- Mycosis Fungoides/Sezary Syndrome

- Peripheral T-cell Lymphoma

- T-cell Prolymphocytic Leukemia

- Enteropathy-type T-cell Lymphoma

- Hepatosplenic T-cell Lymphoma

- Adult T-cell Leukemia/Lymphoma

- Angioimmunoblastic T-cell Lymphoma

- Lymphoid malignancy composed of large atypical cells --> Reed-Sternberg (RS) cells

- Associated with mixed inflammatory background

- RS cells generally only compromise <5% of cellular makeup of lymphoma

- Bulk of cellularity composed of non-malignant inflammatory cells --> Small lymphocytes, histiocytes, plasma cells, eosinophils, neutrophils

- Mass can present with or without fibrosis

- Biopsy: RS cells are large with two nuclei --> Look like owl eyes --> CD15+/CD30+ cells

- Prognosis of HD depends on the # of RS cells within mass

- Classical vs. Non-classical --> Classical have RS cells

- Antigen gene rearrangement precedes transformation

- Malignant cells shar antigen gene receptor gene sequence and synthesize identical antigen receptor proteins

- Reactive reaction --> Polyclonal

- Malignancy --> Monoclonal

- Demonstrated by light chain restriction in B-cells, serum electrophoresis in plasma cells, and molecular techniques/PCR in T-cells

- Non-random translocations are present in the majority of white cell neoplasms

- Dysregulated expression of oncogenes brought under the control of normal Ig enhancers --> usually due to translocations

- Specific rearrangements are associated with particular lymphomas

- Follicular lymphoma --> t(14:18) --> Bcl-2 oncogene

- Burkitt's Lymphoma --> t(8:14) --> c-myc oncogene

- Antibody antigenic rearrangement --> dsDNA breaks are common

- Frequent dsDNA breaks leads to the increased likelihood of other mutations, especially translocations, occuring

- Lymphoid neoplasms are often associated with immune abnormalities

- Loss of protective immunity --> Susceptibility to infection

- Breakdown of tolerance --> Autoimmunity

- Age

- Viral infections --> EBV, CMV, etc

- Chronic immune stimulation by infection --> H. pylori and gastric MALTomas

- Immune deficiency --> HIV, SCID, and iatrogenic causes

- Toxin exposure --> Benzene and hair dye

- Family history

- Human T-cell Leukemia Virus (HTLV-1) --> Adult T-cell Lymphocytic Leukemia --> Retrovirus endemic in the Carribbean and Japan --> Almost always fatal

- Epstein-Barr Virus (EBV) --> Burkitt, Hodgkin's lymphoma, NK-T-cell lymphoma

- Kaposi Sarcoma Herpes Virus/Human Herpes Virus-8 (KSHV/HHV-8) --> Primary Effusion lymphoma --> Almost exclusively in advanced HIV patients

- Treatment mirrors disease: Aggressive chemo for aggressive lymphomas

- Aggressive lymphomas treated with curative intent

- Dose intensity is crucial for cure

- Treat through complications if goal is the cure

- Prompt and aggressive treatment of infections

- 43 different types --> ~80% is DLBCL or FL

- Only 3 treatment paradigms

- Indolent Lymphomas: Untreated survival measured in years --> Follicular lymphoma

- Aggressive Lymphomas: Untreated survival measured in months --> Diffuse Large B-Cell Lymphoma

- Highly Aggressive Lymphomas: Untreated survival measured in weeks --> Burkitt Lymphoma

1. B-Cell Lymphomas

- B-cell CLL/SLL

- Lymphoplasmacytic

- Plasma cell myeloma

- Hairy cell leukemia

- Follicular lymphoma --> Grades I and II

- Marginal zone lymphoma

- Mantle Cell lymphoma

2. T-cell Lymphomas

- T-cell LGL leukemia

- Mycosis Fungoides

- T-cell PLL

3. Natural Killer cell

- NK LGL leukemia

- Diffuse Large B-cell Lymphoma

- Follicular lymphoma (Grade III)

- Peripheral T-cell lymphoma

- Anaplastic large cell lymphoma

- Burkitt lymphoma

- Precursor B lymphoblastic lymphoma

- Precursor T lymphoblastic leukemia/lymphoma

- Adult T-cell lymphoma/leukemia

- Natural toxins which damage DNA or interfere with cell division

- Preferentially affect dividing cells

- Non-cancerous proliferating tissues damaged along with cancer cells --> Hair, hematopoiesis and GI tract effects

- Every drug has a dose limiting toxicity

- Side effects: Mucositis (very painful) and neutropenia (myelosuppression)

- Chemo dosage and treatment frequency limited by how quickly marrow regrows after cessation

- Chemo usually given every 3 weeks but can be given every 2 weeks if growth factors are given to stimualte growth

1. ABVD Therapy --> Hodgkin Lymphoma

- Adriamycin: Myelosuppression and cardiotoxicity

- Bleomycin: Pulmonary toxicity

- Vinblastine: Neurotoxicity

- Dacarbazine: Myelosuppression

2. R-CHOP --> Non-Hodgkin Lymphoma

- Patients become VERY vulnerable to infections --> Simple infections

- Affect GI tract --> Disrupts mucosal structure and barrier between patient and patient's intestinal mucosa

- Causes febrile neutropenia

- Aggressive cancer so aggressive chemo is necessary

- CHOP: Cyclophosphamide, doxorubicin, vincristine, and prednisone

- Stage I/II Disease: Abbreviated course of chemo with immunotherapy followed by radiation or full course of chemo

- Surgery or radiation is NOT enough for cure --> Patients always relapse after surgery or radiation

- Advanced Disease: Chemoimmunotherapy, rituximab, and CHOP --> 6-8 cycles

- Anti-CD20 antibody --> Depletes B-cells

- Better prognosis with combination therapy of rituximab and CHOP

1. Mechanisms of Action

- Antibodies bind CD20, fix complement and induce cell lysis

- Lymphocytes recognize antibody binding --> Cell induced apoptosis

- Direct cytotoxicity of rituximab binding CD20 --> Apoptosis

- Gentle chemo --> Long median survival so treatment related mortality is not acceptable

- Treatment related side effects are less acceptable since the disease is so indolent

- Watch and wait first!!

- Indications for Chemo: Constitutional symptoms, anatomic obstruction, organ dysfunction (marrow involvement), cosmetic considerations, painful lymph nodes, and cytopenias

- Not curable with conventional therapy 

- Therapy: Rituximab based --> Goal is not curative, goal is to reduce symptoms

- Relapse is common but acceptable because relapses are successfully treated with treatment

- History --> Painless lymphadenopathy, night sweats, weight loss, and fevers

- Excision or core biopsy necessary to determine subtype

- Staging with PET/CT scan --> Also used to follow treatment

- Arise in mucosal-associated lymphoid tissue (MALT)

- Very low grade B-cell lymphoma

- Caused by the chronic inflammation caused by H. pylori infection

- Treatment: Antibiotics for H.pylori --> 50% regression

- Later stage MALTomas will not regress after antibiotic treatment

- Aggressive lymphoma/leukemia

- Frequently present in extranodal or cutaneous sites

- Hypercalcemia common

- Poorly responsive to treatment

- Malignant cells are CD4+ and secrete IL-2

- Caused by HTLV-I virus --> Endemic in Japan, Carribean, and southern US

- Causes tropical spastic paraparesis

- Some patients transform to ATL up to 40 years later

- Increasing problem today with the increased survival time in people with AIDS

- High grade B-cell NHL and Hodgkin's Disease

- Advanced --> Extranodal and CNS involvement

- Poorly responsive and poorly tolerant to therapy

- Treatment: Anti-retroviral therapy (HIV), chemotherapy, and growth factor support (myelosuppression)

- Occurs in severely immunocompromised patients

- Post-transplant for solid organs and bone marrow transplants

- Uniformly associated with EBV

- Polyclonal phase --> Aggressive monoclonal high grade B-cell lymphoma

- Disease may regress if immunocompromised state can be reversed

- Malignancy of CD4+ helper T-cells

- AKA Mycosis fungoides

- Presents with infiltrative skin plaques --> Erythema, eczema, then plaques

- Sezary Syndrome: Circulating leukemic phase

- Treatment: Topical nitrogen mustard, phototherapy, electron beam and IL2-diptheria toxin for phase III disease

- Associated with t(2:5) --> Nucleophosmin-anaplastic lymphoma kinase (NPM-ALK) fusion protein

- Presents in younger patients

- Frequently presents in skin and visceral organs

- Rarely involves the marrow

- Lymphadenopathy in 2/3 of patients (70%)

- B symptoms --> Fever (>38%), drenching night sweats, and weight loss of >10% in 6 months

- Extranodal involvement --> GI tract, skin and bone

- Rare involvement in the kidney, bladder, adrenal gland, heart, lungs, breasts, testes, and thyroid

- Pruritis --> Often first symptom in young women

- Pain in nodes with alcohol (uncommon)

- Hypercalcemia

1. Excisional biopsy --> Best because the entire node is removed

- Supraclavicular > Cervical or axillary > Inguinal nodes

2. Core needle biopsy --> Core of node but not whole node so harder to diagnosis pathologically

3. Fine Needle Aspiration biopsy

- Send samples for pathology, immunohistochemistry and flow cytometry

- History

- Physical Exam

- Staging studies --> PET/CT scan and bone marrow biopsy

- Labs: CBC with differential, ESR, albumin, LFTs, Ca levels, and HIV test

- Tests to Prep for Chemo: Echocardiogram and PFTs

- Ann Arbor Staging

- Stage I: 1 nodal site above diaphragm

- Stage II: >1 nodal site above diaphragm

- Stage III: Nodal sites involved on both sides of the diaphragm

- Stage IV: Extranodal involvement --> Bone marrow, liver, and lung

- A: No B symptoms

- B: B symptoms present --> Fever, night sweats, or weight loss

- 30% of all lymphomas

- Slight male predominance

- 3x risk with prior mono infection --> EBV

- Median age is 26 years

1. Classical: RS Cells present

- Nodular Sclerosis --> Large, fibrous, sclerotic nodes/bands

- Mixed cellularity --> Often associated with HIV infections

- Lymphocyte-rich classical

- Lymphocyte depleted

2. Non-classical: No RS cells

- Nodular lymphocyte predominant

- Predictable progression --> Different from NHL

- Mediastinal/cervical nodes --> Spleen --> Liver --> Marrow --> Extranodal sites

- Almost never isolated disease with involvement below the diaphragm --> Begins before the diaphragm

- B symptoms correlate with stage --> Later stages come with B symptoms

- ABVD therapy: 2 cycles followed by radiation for early disease and 6 cycles for advanced disease

- Complications: Pulmonary toxicity (bleomycin), cardiac toxicity (doxorubicin), and secondary malignancies

- Pulmonary toxicity with mediastinal radiation

- Cardiac toxicity with mediastinal radiation as well

- ABVD is very low risk for fertility side effects

- Overtreating --> Maximizes chance of cure but comes along with side effects and possible mortality due to chemo

- Undertreating --> Minimizes the risk of secondary malignancy, fertility issues, and treatment related mortality --> Accepts high risk of relapse and most patients can be salvaged at relapse

1. Autologous transplant: From yourself --> Used to reconstitute bone marrow after high dose chemo

- Not a curative treatment --> Rescue therapy

- Allows for higher cure rates when used after high dose chemo

2. Allogeneic transplant: From someone else --> HLA matched donor

- Curative treatment

- Melphalan and cytoxan

- Dose response curve for their affect on alkylating and inhibiting DNA replication

- Dose limiting toxicity --> Myelosuppression

- Autologous transplant needed after high dose treatment

1. Arteriolar vasoconstriction via thromboxane A2

2. Tissue factor in subendothelial ECM exposed to blood and platelets --> Binds Factor VII and activates extrinsic pathway

- Results in platelet aggregation and primary hemostatic plug

- vWF also present in subendothelial ECM --> Huge stores

3. von Willebrand Factor released via endothelial cell damage and platelet degranulation

- vWF helps platelets adhere together and adhere to endothelial cells at site of damage --> Via glycoprotein Ib on platelet membranes

4. Aggregating platelets begin to express glycoproteins IIb/IIIa --> Binds fibrinogen which bridges between platelets to stabilize

- Endothelial cells normally produce NO, prostacyclin, heparin-like molecules, and thrombomodulin --> anti-thrombotic

- Thrombomodulin: Converts thrombin from the active thrombotic form to the anti-thrombotic form

- Protein C and Protein S --> Cleave Factor VIII and V to inhibit clot formation

- Anti-thrombin III: Inhibits the function of thrombin and other serine proteases

- Tissue Factor Pathway Inhibitor: Cell surface protein that directly inhibits tissue factor-Factor VIIa complex formation and factor Xa activity

- Tissue plasminogen activator (t-PA): Protease forming plasmin --> Cleaves fibrin and degrades thrombi

1. Factor VII binds phosphotydyl serine --> Unique to activated platelets

- Ensures localized activation of extrinsic pathway by localizing to activated platelets and exposed tissue factor

- Phosphotydyl serine binds vitamin K dependent coag. factors (Factors 2,7,9, and 10) --> Brings together primary clot

2. Factor VIII (extrinsic) carried to clot by vWF and factor V is carried by platelets --> Ensures activation only at site of present clot formation

- Subendothelial collagen also has factor VIII --> Biggest store --> Also ensures factor VIII presence only at site of active clot formation

3. Thrombin is the regulator of the entire cascade --> Need enough thrombin to overcome the effect of anti-thrombin III to form clot

- Thrombin activates Factors V and VIII --> Necessary co-factors for clotting

- Normal: 10-12 seconds

- Measures functionality of the extrinsic pathway and common pathway --> Factor VII and common pathway

- Full thromboplastin added with tissue factor

- International standardized test to normalize worldwide --> INR

- High PT with normal aPTT --> Vit. K deficiency or warfarin use --> Best test for warfarin therapy evaluation

1. Common Pathway

- X --> V --> II --> I

- Factor II: Prothrombin --> Thrombin

- Factor I: Fibrinogen --> Fibrin

- Activated form represented with a (ex. Va)

2. Extrinsic Pathway

- Factor VII --> Bound by tissue factor in subendothelial ECM

3. Intrinsic Pathway

- XII --> XI --> IX --> VIII

- Factors II, VII, IX and X are all vitamin K dependent

- Normal: 30-50 seconds --> Takes 20-25 seconds to form enough of the co-factors to begin cascade

- Measures functionality of intrinsic pathway and common pathway

- Thromboplastin added without tissue factor --> Isolates extrinsic pathway

- aPTT test is used to monitor heparin use NOT PT/INR

- Factor XII is actually more involved in inflammation than clotting --> Not necessary to activate in aPTT test

- High aPTT with normal PT --> Heparin use and lupus anti-phospholipid syndrome (anti-coagulant and anti-cardiolipin antibodies)

- Blocks the vitamin K dependent clotting factors (2,7,9, and 10)

- Must be monitored using the INR

- Pharmacologically induces mild hemophilia in patients

- Drops factor counts to 10-20%

- Increases the activity of antithrombin III

- Heparin will have NO therapeutic effect in patients with antithrombin III deficiency --> aPTT remains normal with therapy

- Monitored using aPTT times

- Determines if elevated PTT time is due to a factor deficiency or the presence of an inhibitor (antibody, etc)

- Mix patients plasma with normal plasma with normal levels of clotting factors

1. If PTT normalizes --> Pt has factor deficiency

- Factor Deficiencies: VIII > IX > XI > XII

2. PTT remains elevated --> No factor deficiency but inhibitor/antibody must be present

- PTT usually partially corrects --> Antibody diluted

- Add phospholipid --> Overwhelmes antibody and PTT normalizes --> Confirmatory test for antibody/inhibitor presence

- Factor VIII deficiency --> Specifically factor VIII coagulation factor deficiency

- Familial or spontaneous (30%) mutations!! --> X-linked recessive

- Treatment: Recombinant Factor VIII injections

- Mild disease: 6-50% factor VIII

- Moderate disease: 2-5% of factor VIII

- Severe disease: <1% of factor VIII

- Patients may develop antibodies to factor VIII (15%) because they have so little in their body naturally that body detects it as foreign --> No response to treatment

- Autoimmune disease against Factor VIII --> Severe hemophilia but not true hemophilia because not a disease caused by mutation

- Perform antibody test to differentiate between true hemophilia and auto-immune condition

- Presentation: Easy bruising, delayed bleeding, deep tissue bleeding, and NO petechiae or epistaxis, etc

- Labs: Prolonged PTT and normal PT

- Factor IX Deficiency

- Less common than hemophila A

- Clinically indistinguishable from hemophilia A

- X-linked recessive trait with variable clinical severity

- 15% of patients have Factor IX but it is non-functional 

- PTT is prolonged but PT is normal

- Most common inherited bleeding disorder

- Defect in vWF --> Affects platelet aggregation and stability of factor VIII

- Type 1: Autosomal dominant --> Mild to moderate deficiency of vWF --> 70% of cases --> Mild disease

- Type 2: Autosomal dominant --> Non-functional vWF circulating but normal amounts --> Mild to moderate disease

- Type 3: Autosomal recessive --> Severe reduction in functional vWF --> Severe disease

- Reduced circulating vWF affects the stability of Factor VIII --> Bleeding characteristics of Hemophilia

- Presentation: Characteristics of hemophilia bleeding along with characteristic bleeding with platelet deficiencies --> Epistaxis, petechiae, ecchymoses and immediate bleeding

- Primarily performed by plasmin

- Plasminogen --> Plasmin via Factor XII-dependent pathway or plasminogen activators (PAs)

- t-PA is the most common PA in the body --> Used therapeutically too

- Inactivated by a2-plasmin inhibitor in plasma

- Plasmin cleaves fibrin into D-dimers

- D-dimer test is highly sensitive for the detection of the presence of fibrin clot within the body

- Endothelial cell injury

- Stasis or turbulent blood flow

- Hypercoagulable state

- Surgery/trauma

- Immobility

- Obesity

- Oral contraceptive drugs

- Pregnancy

- Malignancy

- Smoking

- Infection/inflammation

- Post anti-coagulation therapy cessation --> ~50% for 5 years

1. Antithrombin III deficiency: Reduces the ability of the body to inactivate thrombin --> Determined when PTT doesn't become prolonged with heparin therapy

- Thrombotic threshold is easily overwhelmed

- Presents early in life

2. Protein C and S Deficiencies: Inability to inactivate factor V and VIII

- Presents later on in life

3. Factor V Leiden: Factor V resistant to protein C and protein S inactivation

- Antiphospholipid antibody syndrome --> Lupus

- Disseminated intravascular coagulation

- Heparin-induced thrombocytopenia and thrombosis syndrome

- Inflammatory bowel disease

- Myeloproliferative disorder: ET and PCV

- Nephrotic syndrome: Loss of protein C and other thrombotic inactivators

- Paroxysmal nocturnal hemoglobinuria (PNH)

1. Venous thrombosis: Based on blood stasis

- Can break off and travel to the right heart and lungs

2. Arterial thrombosis: Based on turbulent state of blood --> Atherosclerosis

- Can break off and lodge in small arteries/arterioles in heart, visceral organs, brain, etc

- Present in acute leukemias --> Malignancy of immature WBCs circulating in blood

- Large cells

- High nuclear:cytoplasmic ratio

- Immature chromatin --> Lacey and nucleoli

- Presence is an alarm finding --> Essentially never seen in normal peripheral blood

- Environmental toxins: Radiation and benzene

- Inherited disorders: Down's syndrome and Fanconi's anemia

- Therapy Related: Topoisomerase II inhibitors, anthracyclines, and radiation

- Arises from an antecedent hematologic disorder --> Myelodysplasia or myeloproliferative disorder

- ALL most common in 10-24 year olds

- AML is most common in 50-60 year olds

- Patients presenting with bruising, bleeding, and infections

- CBC abnormal

- Evidence on peripheral smear --> Peripheral blasts

- Bone marrow biopsy and aspirate evidence

- Flow cytometry --> Gives CD values

- Cytogenetic/Molecular studies --> PCR and FISH studies

- Only acute leukemia that presents with gum/mucosal involvement

- Red, beefy and bleeding gums present

- Arises in older individuals

- Presentation: Bleeding, bruising, infection and fatigue

- CBC: Elevated or decreased WBC counts

- Causes cessation of normal hematopoiesis

- Patients become susceptible to bleeding, infection, and anemia

- Hyperviscosity syndromes at high circulating blast counts --> Cells are very sticky and get stuck

- Hyperviscosity can lead to respiratory and neuro. dysfunction --> Confusion and dyspnea

- Coagulation abnormalities --> DIC (esp. in APML)

- Myeloblastic without maturation --> 15-20%

- Myeloblastic with maturation --> 20-25%

- Promyelocytic --> 8-15%

- Myelomonocytic --> 20-25%

- Myelomonocytic with abnormal eosinophils --> 5%

- Monocytic --> 10%

- Erythroleukemia --> 3-5%

- Megakaryocytic --> 1-2%

- Depends highly on the karyotype of patient

- Karytotype matters but also DNA methylation, microRNA expression, and microarray gene signatures matter

1. Favorable: t(15:17) --> APML

2. Unfavorable: 5 or 5q deletion and 7 or 7q deletion

- Begins with myelodysplastic syndrome --> Advanced

- Complex or monosomal karytotype

- Very poor overall survival --> Very hard to get these patients into remission

3. Intermediate: Normal and t(9:11) translocation

- ~25% of patients with APML will die before diagnosis or within the first week of treatment

- Death due to DIC and bleeding in CNS, lung, or GI tract

- Therapy: All trans-retinoic acid therapy --> Resolve coagulopathy and initiated induction therapy with arsenic trioxide

- These patients do not usually need chemotherapy

- ATRA should be started at the earliest suspicion of APML diagnosis --> Before bone marrow biopsy

- Leukopenia

- DIC very common

- Circulating promyelocytes with abundant azurophilic granules --> All cells frozen at the promyelocyte stage

- Multiple Auer rods in cytoplasm

- Flow characteristics: Blasts are CD34- and HLA-DR-

- More common in Hispanics and less common in African American patients

- Blast cells seen on peripheral smear

- Blasts may or may not have Auer rods in cytoplasm --> Not multiple though

- Immunophenotype: CD13+, CD33+, and MPO+

- 1st mutation: Impairs differentiation --> Myelodysplastic syndrome

- 2nd mutation: Proliferative advantage --> Malignancy

- Treatment: Chemo and bone marrow transplantation

- Associated conditions: Ionizing radiation (5x), Down's Syndrome (20x), siblings (2-4x), tumor suppression mutations (Neurofibromatosis, etc), and impaired DNA repair (Bloom Syndrome and Fanconi's Anemia)

- Most common in patients 1-7 years old --> Pediatric oncology --> Best prognosis when diagnosed in younger kids

- Blasts seen in peripheral smear --> No Auer rods

- Immunophenotype: CD10+ and TdT+

- Low Risk Cytogenetics (70%): Hyperdiploidy (50-67 chromosomes) and t(12:21) TEL/AML1 rearragements --> Precursor B-cell ALL

- High Risk Cytogenetics (30%): Hypodiploidy (<45 chromosomes) and t(9:22) Philadelphia chromsome --> Poor prognostic factor in children and adults

1. Presentation --> Remission --> Allogeneic bone marrow transplant --> Cure

- Allogeneic bone marrow transplant --> Unfavorable cytogenetics --> Cure rate also ~50%

2. Presentation --> Remission --> Consolidation chemotherapy (high dose) --> Cure

- High dose chemo --> 3-4 cycles with favorable cytogenetics --> ~50% cure rate

- Infection due to neutropenia

- Bacterial infections: Translocation of gut flora, gram negative sepsis, and early use of broad spectrum antibiotics

- Fungal infection: Invasive pulmonary aspergillus and disseminated candidiasis --> Early recognition and aggressive treatment with antifungals

- Expanding blast population in bone --> Bone and joint pain

- Pallor and fatigue --> From anemia

- Bruising, petechiae, and bleeding --> Thrombocytopenia

- Fever due to infection and cytokines from leukemic cells

- Adenopathy, hepatomegaly, and splenomegaly --> Extramedullary hematopoiesis

- Leukocytosis --> High WBC count

- Combination chemo therapy with CNS prophylaxis with methotrexate --> Crosses BBB

- Radiation and chemo treatment --> ~90% cure rates

- Induction chemo --> Bone marrow remission

- Post-induction intensive therapy

- Longer periods of less intensive therapy follows

- Outpatient therapy

- Duration: 2.5 years for girls and 3.5 years for boys

- Bone marrow transplants: Almost never warranted for these patients --> Risks too high

- BMT only in very high risk patients and in relapses

- Multi-agent, risk-directed chemo

- Better use of chemotherapy agents in this patient population

- More effective treatment of sub-clinical CNS leukemia

- Better supportive care --> 3rd generation cephalosporins with better anti-fungals

- Seen in ALL, Burkitt lymphoma, AML and high tumor burden DLBCL

- Usually treatment induced but sometimes spontaneous

- Release of intracellular uric acid, potassium, and phosphate into plasma

- Treatment: Hydration, electrolyte management, allopurinol/rasburicase, and phosphate binders

- CNS impairment

- Decrease in growth --> Chemo halts bown epiphysis growth --> Stunted growth in children

- Cardiotoxicity

- Infertility: Most patients become infertile and are unable to have children later in life

- Increased incidence of secondary cancers

- AKA pre-leukemia syndrome

- Abnormal leukocytes circulate in the blood and are present in the peripheral smear

- Cytopenias result

- Patients are often transfusion dependent

- Treatment is very difficult --> No BMTs possible

- More common in the elderly

- Commonly transforms to AML

- Uncontrolled proliferation of plasma cells

- Malignant plasma cells make an excess amount of monoclonal Ig --> Either k or l light chains

- Most common IgG and kappa based

- Light chains can be detected in urine (Bence-Jones Proteins)

- Prevalence: 4/100,000 patients and most common in patients >40 years old

- 2x more common in African-Americans

- Marrow Aspirate: Almost complete replacement of marrow with plasma cells

- MGUS

- Smoldering myeloma

- Indolent myeloma

- POEMS

- Solitary osseus plasmacytoma

- Extramedullary plasmacytoma

- Multiple myeloma

- Direct consequences of tumor mass effects

- Mediated by cytokines --> Hypercalcemia, fatigue, and anemia

- Symptoms due  to protein deposition --> Amyloidosis

1. WHO Criteria

- Major Criteria: Plasmacytoma, BM plasmacytosis >30%, or monoclonal IgG >3.5 g/dL, IgA >2.0 g/dL or >1.0 g/dL of BJP

- Minor Criteria: BM plasmacytosis 10-30%, M protein spike, lytic bone lesions, and reciprocal suppression of other Ig values 

- Diagnosis: 1 major + 1 minor criteria or 3 minor criteria

2. Hematology Criteria

- Bone marrow biopsy signs

- M protein spike --> Monoclonal

- CRAB findings --> Calcium >10.5 mg/L, Renal (serum Cr>2 mg/dL), Anemia (Hb <10g/dL), and Bone lesions (lytic or osteoporotic)

- Low albumin

- High b2 microglobulin

- High c-reactive protein

- Multi-nucleated plasma cell morphology

- Deletions of chromosome 13 or other abnormalities

- Increased angiogenesis

1. Hypercalcemia --> Mediated by OAF, IL-6, TNF-b, and IL-1b

2. Hematologic: Rouleaux formation due to M protein binding, anemia (fatigue), thrombocytopenia, and platelet dysfunction due to M binding protein

3. Effects of paraprotein: Expansion of plasma volume, decreased anion gap, pseudohyponatremia and pseudohypoglycemia --> Displaced by M protein in blood

4. Renal insufficiency: renal tubular dysfunction, myeloma cast nephropathy, amyloid kidney (nephrotic syndrome), UTI, and pyelonephritis

- Avoid ionizing contrast --> Contrast nephropathy possible

- Avoid nephrotoxic antibiotics

5. Immunodeficiency: Impaired humoral and cell mediated immunity --> Secondary to TGF-b

- Susceptible to G+ encapsulated organisms

- Effective hypogammaglobulinemia manifesting a poor antibody response

- Reversal of CD4 to CD8 ratios --> Imparied cell mediated immunity

6. Skeletal Events: Punched out osteolytic bone lesions (50-70%), pathologic fractures, and negative bone scans

7. Neurological: Cord compression and neuropathy

- Incurable malignancy

- No treatment for patients who are asymptomatic and without CRAB findings

- Goal of treatment is to palliate symptoms and achieve a plateau phase --> NOT cure

1. Radiation therapy: Plasma cells very susceptible --> Given in patients with cord compression, bone pain, or potential for fracture

2. Chemotherapy

- Melphalan and prednisone (DNA alkylators) --> 40-70% remission rate

- VAD: Higher overall RR, faster response, and less nephrotoxic

- High dose dexamethasone: Infectious complications and indicated in marrow failure

3. Supportive care: Antibiotics, maintain hydration, transfusion, vaccination for encapsulated organisms, erythropoietin for anemia, and bisphosphonates for bone lesions and hypercalcemia

4. Maintenance Therapy: Continuing therapy --> Prolongs duration of plateau --> No improvement of overall survival

5. Autologous stem cell transplantation: Treatment of choice for younger patients

6. Allogeneic Bone Marrow Transplantation: HLA matched donor --> 30-40% treatment mortality

- Combination of high dose chemo and stem cell transplants --> Better median survival times

- Came out in 1999

- Inhibits IL-6, TNF-a, and IL-1b

- Induces IL-2 and IFN-g

- Stroma and microenvironment around plasma cells are problematic

- Makes microenvironment more hostile --> Not good for malignant plasma cell survival

- Better results when combined with conventional chemotherapy or other treatment

- Generally well tolerated

- Constipation

- Teratogenicity

- Fatigue/sedation

- Skin toxicity/rash

- Peripheral neuropathy

- DVT

- Generally manageable with dose reduction or interruption of therapy

- Indications: Multiple myeloma and AML

- New agent similar to thalidomide

- Potent analogue of thalidomide

- Promising in relapsed or refractory MM

- Fewer non-hematologic toxicities -> Peripheral neuropathy, constipation and sedation

- Side effects: Neutropenia and thrombocytopenia

- Asymptomatic myelomas --> Do not require treatment

1. Smoldering myeloma: Pre-malignant condition

- M protein > 3 g/dL

- No bone lesions, anemia or renal insufficiency (CRAB)

- BM plasmacytosis 10-30%

2. Indolent myeloma

- M protein > 3 g/dL

- No bone lesions, anemia or renal insufficiency (CRAB)

- BM plasmacytosis >30%

3. MGUS: Benign

- M protein

- BM plasmacytosis <10%

- Asymptomatic

- 1% risk of progresison to more severe disease

4. POEMS: Polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes

5. Plasmacytoma

- Solitary osseous plasmacytoma: Higher incidence of MM progression

- Extramedullary plasmacytoma: Better survival

- IgG migrates in gamma band --> M spike presents there

- IgA migrates in beta region --> M spike presents there

- Elevated gamma globulin is normal as long as it is polyclonal instead of monoclonal

- More sensitive than SPEP in detecting discrete clonality

- Quantitative immunoglobulins cannot distinguish between M-paraprotein and polyclonal Ig

- Tells you kappa vs. lambda antibody differentiation and Ig subtype

- Light chain --> Bence Jones protein --> Monoclonal component in gamma globulin region

- Urine dipstick only detects albumin --> Doesn't give + dipstick

- Sensitivity depends on sample, background proteinuria, and renal function

- Polyclonal gamma globulin level >3 g/dL

- None developed myeloma or any other clonal plasma cell dyscrasia

- Common in HIV, HCV, and HBV patients

- Unexpected presence of intact immunoglobulin monoclonal protein

- Patients do NOT have evidence of myeloma, amyloidosis, Waldenstrom's macroglobulinemia, lymphoproliferative disorders, plasmacytoma or other related conditions

- No evidence of other serious plasma cell dysplasia

- M-spike on SPEP --> Typed by SIFE --> 69% IgG and 62% kappa chains

- Low plasma cell burden --> M spike <3 g/dL and BM plasma cells <10%

- Risk factors: Abnormal serum free light chain ratio, non-IgG MGUS (less commonly IgA or IgM), and M spke >1.5 g/dL

- 58% progression over 20 years in high risk and 5% progression over 20 years in low risk

- History and exam

- Hb concentration

- Serum Ca and Cr --> Rules out CRAB findings

- Protein studies: SPEP, UPEP, SIFE, and UIFE

- Bone marrow examination: Only if M >1.5 g/dL

- Skeletal Survey: Only if M >1.5 g/dL

- No formal guidelines

- Re-evaluate annually --> Measure total protein by SPEP, UPEP, Hb, serum Cr, and serum Ca (CRAB)

- Goal is to detect myeloma before end organ damage --> Renal failure and bone lesions

- Low-risk MGUS (40%) --> May not even need follow up by hematologist --> PCP follow up necessary

- Malignancy of mature lymphocytes

- Most common form of leukemia --> Most commonly B-cell derived

- Disease of the elderly --> Median age of 70

- Prognostic factors: Karyotyping, ZAP-70, Ig heavy chain composition, and amount of smudge cells on smear

- Presentation: High WBC count

- Diagnosis: Smudge cells and prolymphocytes seen on smear

- Immunophenotype: CD5+, CD19+, CD23+, and CD10-

- CLL is a B-cell derived disease --> Express CD5+ abberantly --> CD5 is a T-cell marker

- Treatment: Often none but combination chemo or BMT may be necessary

- Cure rate: Chronic course --> Hard to cure but able to control well

- No single molecular defect known

- Malignant cells derived from previously stimulated B-cells

- Stimulated by common antigenic stimuli

- Malignant cells do not signal like normal B-cells --> Abnormal signaling properties

- p53 mutations --> Malignant cells not responsive to any normal DNA alkylating agents --> Poor prognosis

- ZAP-70 mutation: Unmutated VH genes --> Poorer prognosis and shorter treatment-free period

- Lymphocytosis --> Small, mature lymphocytes >5,000/uL

- >30% lymphocytes in bone marrow

- <55% atypical/immature lymphoid cells

- Cloncal expansion of abnormal B lymphocytes

- Low density of surface Ig --> IgM or IgD

- CD19+, CD20+, CD23+, and CD5+

- Widely variable --> Median survival months to decades

- Early treatment doesn't improve survival --> In indolent disease

- Prognosis allows for proper selection of watchful waiting, single agent, combination chemotherapy, and stem cell transplant therapy

- Better prognosis:13q14 deletion in 50-60%

- Worse prognosis: 17p deletion (5-10%), 11q deletion (15-20%), and trisomy 12 (15-20%)

- 17p deletion --> p53 mutation

- Mutated VH regions also possible --> Better prognosis

- Rai staging

- Stage 0: Lymphocytes in peripheral blood and bone marrow --> Low

- Stage 1: Lymphocytosis and lymphadenopathy --> Low

- Stage 2: Lymphocytosis, hepatosplenomegaly, with or without lymphadenopathy --> Intermediate risk

- Stage 3: Lymphocytosis, anemia (Hb <11g/dL), with or without hepatosplenomegaly or lymphadenopathy

- Stage 4: Lymphocytosis, thrombocytopenia (Plt <100,000), with or without anemia, hepatosplenomegaly or lymphadenopathy

- Lymphocytosis --> Lymphadenopathy --> Hepatosplenomegaly --> Anemia --> Thrombocytopenia

1. Infections --> Leading cause of death

- Bacterial RTIs --> Pneumonia, bronchitis, and sinusitis

- Hypogammaglobulinemia --> 70% of CLL patients

- Prophylactic IVIG --> Patients with frequent bacterial infections

- Campath (Anti-CD52) meds --> Changed spectrum of infections seen in patients --> Opportunistic infections such as CMV

2. Autoimmune Disease: Increased incidence of autoimmune disease --> AIHA, ITP, pure red cell aplasia, paraneoplastic pemphigus, and acquired angioedema

- CLL is most common cause of autoimmune hemolytic anemia (AIHA) --> Warm-type IgG antibodies

- Produced by IgG from non-malignant causes

- Treatment: Prednisone with or without rituximab, IVIG inducing quicker remissions, and spelenctomy

1. Adenosine analogs: Highly toxic to T-cells --> Contributes to immunodeficiency --> Serious infections possible

2. Antibody therapy: Rituximab (Anti-CD20) and alemtuzemab (Anti-CD52) --> Effective against p53 mutated cells

3. Alkylators: Cyclosphosphamide, chlorambucil, and bendamustine

4. Lenalidomide: Active against CLL --> Target cereblon --> Critical for the activity of other drugs

- CLL and B-cell lymphoid malignancies

- Oral medication

- Side effects: Diarrhea

- Target: BCR signalosome --> Syk, BTK, and PI3K

- Highly active in CLL trials

- Class effect -> Shrinkage of lymph nodes (lymphadenopathy and splenomegaly) but marked increase of WBC counts

- Acts on p53 mutated cell lines

- Work as cofactors to increase the activity of antithrombin III

- Compounds: Unfractionated heparin (UFH), Low-Molecular Weight Heparins (LMWH), and fondaparinux

- Have little anticoagulant effect on their own --> Need the presence of ATIII

- Results in the inhibition of Factors Xa and IIa/Thrombin

- Large molecule of sulfated mucopolysaccharides --> Large chain --> More side effects

- Pentasaccharide chain binds ATIII --> Inhibits factors V, VIII, and XI

- Larger chain --> Loops around to bind to thrombin as well as Factor Xa

- Administration: Continuous infusion or subcutaneous

- Clearance: Binding to endothelial cells receptors and macrophages

- Non-linear clearance --> t 1/2 depends on the duration and intensity/dosage of medication

- Monitoring: aPTT values every 4-6 hours

- Indications: Inpatient prophylaxis for DVT, PE, MI and CVA

- Formed by chemical or enzymatic depolymerization of UFH

- Maintains the pentasaccharide sequence that binds ATIII

- Shorter polysaccharide chain --> Less binding to thrombin --> More specific for Factor Xa than thrombin

- Enoxaparin --> Subcutaneous administration

- Decreased bleeding risk than with UFH

- Monitoring: Anti-Xa levels --> Not done routinely

- Half-life: 4-8 hours

- Side effects: Hemorrhage and HIT --> Limted reversal options for HIT

- Advantages: Lower risk of bleeding and HIT and decreased osteoporosis risk

- Disadvantages: Dose response is not as predictable and shorter t 1/2 

- Just the pentasaccharide moiety that binds to ATIII --> No effect on thrombin

- No effect on platelet function or bleeding times

- Administration: Flat subcutaneous dosing based on weight range

- Elimination: Depends on renal elimination --> Poor elimination in patients with renal insufficiency

- Indication: Potential role for management of HIT, DVT and PE prophylaxis in heparin allergies

- IV administration --> Argatroban and bivalrudin

- Oral administration --> Dabigatran

- Binds directly to the active site of thrombin --> Inhibits its ability to cleave fibrinogen to fibrin

1. Argatroban

- Indications: HIT

- Elimination: Hepatobiliary and renal

- Not dialyzable

- Half-life: 40-60 minutes

- Low thrombin binding affinity

2. Bivalrudin

- Indications: Percutaneous interventions only

- Elimination: Proteolytic cleavage and renal

- Dialyzable medication

- Half-life: 25 minutes

- Intermediate thrombin-binding affinity

- Only oral direct thrombin inhibitor available

- Indication: Atrial fibrillation only

- No monitoring is required

- Metabolism: Conjugation by P450 system in the liver

- Elimination: 80% renal clearance --> Must monitor renal function for patients on this medication

- Dosage: 150 mg BID and 75 mg BID with renal insufficiency

- Side effects: Bleeding risk in elderly and CKD patients and dyspepsea and reflux due to tartric acid capsule

- Not actually used in clinics --> Risk data for bleeding not available for renal insufficiency

- Interferes with the conversion of vitamin K epoxide --> Decreases g-carboxylation on vitamin K dependent factors

- Causes hepatic production of less effective Factors II, VII, IX, and X, and proteins C and S

- Warfarin/coumadin

- S enantiomer is 3x more potent

- Drug interactions: CYP2C9 (S) and CYP1A2/CYP3A4 (R)

- Genetic factors: 2C19*2 and 2C9*3 mutations

- Monitoring: PT/INR --> Goal is an INR of 2-3 or 2.5-3.5 for mechanical valves

- Administration: Oral but slow onset and immediate pro-thrombotic effect --> Overlap with parenteral agent initially

- Dosing Considerations: Heart failure, alcohol consumption, age, diet, and drug interactions

- Toxicity: Bleeding and infarction (early in therapy)

- Contraindications: Pregnancy

- Reversal: Stop warfarin, give vitamin K, fresh frozen plasma, and prothrombin complex concentrate

- Rivaroxaban and apixaban --> Couple others in phase III trials

- No routine monitoring --> Not accurate for oral inhibitors

- Bioavailability: Rivaroxaban (60-80%) and apixaban (80%)

- Half-life: 7-11 hours for rivaroxaban and 12 hours for apixaban

- Clearance: 60% renal for rivaroxaban and 25% renal for apixaban

- Dosing: 20 mg daily for rivaroxaban and 5 mg BID for apixiban

- Bleeding risk: Increases in patients with renal insufficiency and elderly patients

- Increased GI bleeding in rivaroxaban compared to warfarin

- Tenectplase>>Alteplase>>Reteplase

- Indications: Ischemic strokes, PE and MI

- Risks: Intracranial hemorrhage

- Mechanism: Cleaves fibrin into fibrin split products

- Binds the lysine bindings sites on plasminogen and plasmin

- Blocks binding of plasmin to the binding sites on fibrin

- Indications: Mucosal bleeding and hemophiliacs

- Aminocarproic acid and tranexamic acid

- Used increasingly in trauma patients to stop bleeding

- Inhibits thromboxane A2 (TXA2)

- Low doses --> Inhibit COX1 --> Anti-platelet function

- High doses --> Inhibit COX2 --> Anti-inflammatory function

- Irreversible inhibition of COX1 and COX2 inhibitors --> ~7 day duration

- Clopidogrel, prasugrel, and ticagrelor

- Inhibits the effect of ADP that has degranulated from activated platelets

- Requires a loading dose along with a maintenance dose

- Time to peak inhibition: 1-2 hours

- Indications: TIA, percutaneous coronary interventions, peripheral artery disease, etc --> Primarily in cardio intervention

- 1.1% of BM cells are CD34+ stem cells --> Only 0.1% able to provide long term HSC reconstitution

- Harvested while patient is under anesthesia

- No drop in peripheral counts does not occur

- BM is highly vascular --> Substantial blood loss possible

- 1.35% serious complication rate

- Blood remaining in the UCB and placenta at the time of delivery

- Very good source of SCs

- Used more commonly in children than in adults

- 0.06% of circulating cells in blood are CD34+ stem cells

- G-CSF administration at 10-16 mg/kg per day for 3-5 days --> Mobilizes the stem cells in the peripheral blood

- G-CSF stimulation results in tons of stem cells

- Plerixafor: Synergistic effect with G-CSF

- Desirable: CD34+ >2 x 10^6/kg --> Autologous SCT

- Optimal: CD34+ >5 x 10^6/kg

- Infusion dose has an impact on engraftment time --> Higher dosage the quicker the engraftment time

- Recovery significantly worse when CD34+ <1.2 x 10^6/kg

- Allogeneic SCT: BM > 3 x 10^6/kg and PBSC > 6 x 10^6/kg

1. Related donors: Complete HLA matched --> 10/10 is the best --> 1st choice 

2. Unrelated donors: Donor marrow registries --> 3-4 months of search time usually required

- Very low risk of graft failure but can be fatal if it occurs

- Better HLA matching --> Reduced risk of graft vs. host disease

3. Cord Blood: Usually only takes ~ 13.5 days to harvest and prepare but only 1/3 of patients find an unrelated match

- Harvested from placenta and umbilical cord --> Cryopreserved

- Less risk of GVHD due to T-cells being naive in newborn sample

- Rate of engraftment is longer --> Higher risk of infection

4. Haploidentical-Related Donors

- Shares only 1 haplotype with recipient --> Parents, etc

- Still investigational

- High rates of GVHD and delayed immune reconstitution

- Prevent rejection of incoming donor cells by the host immune cells

- Not required in autologous or syngeneic HSCT (monozygotic twins)

- Increased immunosuppression for less HLA matched donors

- Risk of injection increases with the recipient has been pre-sensitized against minor antibodies --> Multiple transfusions

- Myeloablative conditioning: Causes irreversible pancytopenia and myeloablation within 1-3 weeks --> SC support is mandatory for survival

- Non-Myeloablative conditioning: Minimal cytopenia, little early toxicity, and doesn't require SC support --> High risk of GVHD

- Reduced Intensity Conditioning: Cytopenia of variable duration and should be given with SC support

- Advantages: Access to sanctuary sites --> CNS and gonads

- Necessary for ALL --> Often affects CNS and gonads

- Long-term toxicities: Pulmonary function alterations, cataracts, sicca syndrome, hypothyroidism, and thyroiditis

- Acute toxicities: Salivary gland enlargement, nausea and vomiting

- Limitations: Cost and toxicity

- Classified by the severity of neutropenia

- Moderate: Absolute neutrophil count (ANC) is 500-1,000/uL

- Severe: ANC 200-500/uL

- Very severe: ANC <200/uL

- Marrow is empty in patients with SAA --> Conditioning only for immunosuppression

- Rejection still remains a concern

- Genetic disorder affecting normal DNA repair mechanisms

- Results in progressive BM failure and increased risk of leukemia and other cancers

- Treatment: HSCT

1. Auto-HSCT: Most commonly performed --> Can cure many patients with aggressive lymphomas

- Significantly prolonges the duration of response in patients with myeloma

2. Allo-HSCT: Considered in patients with relapsing NHL and HD, high risk of relapse in NHL and HD< and high risk MM in young patients

- Interval between HSCTs ranges between 3-6 months

- Proteasome inhibitors in conditioning in MM possible

- Well established for metastatic renal cell carcinoma, thymoma, breast, and neuroblastoma

- Investigational in all other solid tumor cancers

- Useful in germ cells disease --> Relapsing disease that is easily treated

- MAC with TBI follow by allo-HSCT --> Standard for adults with ALL

- RIC regimens produce similar outcomes

- Allo-HSCT recommended for remission #2

- Imatinib therapy before or after allogeneic HSCT --> Adult ALL with Philadelphia chromosome

- Helpful in patients with AML <55 years old with high risk cytogenetics (monosomal)

- No survival advantage for patients with AML >55 years old with low risk cytogenetics --> Hyperdiploid

- Remission #2 --> Allo-HSCT or auto-SCT if allo not available

- Otherwise AML is treated with chemo

- Mucositis: Most common before engraftment has occured

- Cytopenias

- Veno-occlusive disease of the liver --> Sinusoidal obstruction syndrome

- Graft versus host disease

- Acute lung injury --> Not common --> Bacterial, PCP, fungal infections, and viral infections

- Infections --> Most common

- Sterility

- Secondary malignancies

- TMA

- 

1. Acute GVHD

- Immune cells in the donor graft react against donor cells

- Presentation: Skin involvement, nausea, vomitting, anorexia, and cholestatic hyperbilirubinemia

- 1 body skin site affeted --> Shows immune system is working and that graft is engrafting

- Prevention: Cyclosporine and methotrexate

- Treatment: Corticosteroids and Anti-TNF-a inhibitor

2. Chronic GVHD

- ~50% of long-term survivors are affected

- Lethal in 20-40%

- Presentation: Loss of appetite, unable to eat well, skin thickening, leg ulcers, etc

- Treatment: Corticosteroids, cyclosporine, rituximab, infliximab, and supportive care

- Supportive care: Antiboitics, IVIG, prophylaxis for infections, and revaccination