TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts in the next print issue.
This month, David Garcia, MD, advises on the length of anticoagulation in a
patient with an idiopathic renal infarct.
Clinical
Dilemma:
I have a 32-year-old male patient with no cardiovascular risk factors who had what looks to be an idiopathic renal infarct. The radiologist feels that the
infarct was likely arterial in origin, but no source
of the clot has been found. Results from the CT
angiography of the entire aorta and embolic workup (including 48-hour Holter monitoring for atrial
fibrillation) have been negative to date – so have the
results from my APLA/PNH/MPN work-up.
In this instance, how long should anticoagulation last? I am unsure what duration to
recommend because the infarct was arterial and
idiopathic. Data for this circumstance seem to be
scarce, and I have read that the duration should
be anywhere from six to 12 months to indefinitely. While I am worried about recurrence – given
he had this thrombosis at such a young age – I
am also cognizant of the burden that lifelong
anticoagulation will bring.
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
David Garcia, MD
Professor of Medicine
Division of Hematology
University of Washington School of Medicine
Seattle, WA
However, if, after an exhaustive search, you are
unable to find any anatomic or “biochemical” reason
for this man’s thrombosis, I agree that you should
try to initiate antiplatelet therapy at some point.
Committing him to lifelong anticoagulation based on a
single event is difficult to justify. Of course, you should
counsel him about and document the issues you have
considered in making your recommendation.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
ASHClinicalNews.org
I perform T-cell receptor gene studies to
establish clonality, if abnormalities in
the T-cell population are detected. Do
I need to order both beta and gamma
analyses? I frequently order flow cytometry to establish clonality and to rule out
B-cell lymphoproliferative processes.
When do I need to order immunoglobulin
heavy chain (IgH) gene rearrangement by
fluorescent polymerase chain reaction?
How would you respond? Email us at
[email protected].
Experts Make the Call
The plan you proposed is entirely reasonable, and I
have very little to add to what you have already done
for this patient. I presume the patient has had a transesophageal echocardiogram; if not, I would—in an
abundance of caution—perform the test to exclude a
cardiac source of embolism.
Also, if you have not already done it, I would check
his serum homocysteine level. If these levels were very
elevated (e.g., >15 Mmol/L), the threshold to extend
anticoagulation (rather than switching to aspirin)
might be lowered.
Next Month’s Clinical Dilemma:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macgroglobulinemia
• Myeloproliferative Disorders
• Myelodysplastic Syndromes
• Thrombocytopenias
Assigned volunteer (“colleagues”) will
respond to inquiries within two business
days (eithe