what is hyperviscosity syndrome

2014 Jun 3. Serious cardiovascular events contribute to the increased mortality rate among patients with PV. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. What are the diagnostic considerations for hyperviscosity syndrome (HVS)? [QxMD MEDLINE Link]. Please enable scripts and reload this page. 8600 Rockville Pike A strong linear relationship has been described in the absence of deficient erythropoiesis. What is the role of maintenance chemotherapy in the treatment of Waldenstrom macroglobulinemia (WM)? Accessibility 2017 Dec. 31 (6):927-940. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Nothing to disclose. Although it is commonly accepted that sustained hyperviscosity can decrease perfusion and increase blood pressure, it should be noted that increased blood viscosity has two effects in the cardiovascular system: it may act to increase shear stress on the endothelium and increase NO release, promoting vasodilation as . Renal vein thrombosis may also cause renal tubular damage, proteinuria, or both. Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center 2022 Mar 7;34(1):10. doi: 10.1186/s43046-022-00107-6. [QxMD MEDLINE Link]. How does blood viscosity affect blood pressure? Medscape Education, Lymphoma Clinic: Approaches to the Management of Relapsed/Refractory Follicular Lymphoma and Relapsed/Refractory Diffuse Large B-Cell Lymphoma, 20022004902-overviewDiseases & Conditions, 20021219134-overviewDiseases & Conditions, Waldenstrom Macroglobulinemia Treatment Protocols, encoded search term (Waldenstrom Macroglobulinemia Treatment Protocols) and Waldenstrom Macroglobulinemia Treatment Protocols, Fast Five Quiz: Non-Hodgkin Lymphoma (NHL): TP53 in Mantle Cell Lymphoma, Fast Five Quiz: Test Your Knowledge on Key Aspects of Non-Hodgkin Lymphoma, CAR T-Cell Therapy for B-Cell Acute Lymphoblastic Leukemia, The Past, Present, and Future of Bendamustine in Mantle Cell Lymphoma, Cutaneous Clues to Diagnosing Metastatic Cancer. o [ pediatric abdominal pain ] Nonetheless, no prospective studies have defined an optimal regimen in any patient with WM/LPL, including high-risk patients. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM MD. Clipboard, Search History, and several other advanced features are temporarily unavailable. [QxMD MEDLINE Link]. Plasma hyperviscosity is a rare complication of both monoclonal and polyclonal disorders associated with elevation of immunoglobulins. [QxMD MEDLINE Link]. 2017 Jan 26. Seeing through thick and through thin: Retinal manifestations of thrombophilic and hyperviscosity syndromes. Acute Respiratory Failure Secondary to Hyperviscosity Syndrome - CHEST [27], Allogeneic SCT has resulted in some very durable remissions, with the largest study reporting a 5-year PFS of 46% in heavily pretreated patients. Hyperviscosity Syndrome - Healthline Secondary erythrocytosis occurs in cyanotic heart disease as a physiological response to chronic hypoxia, and this leads to hyperviscosity and various complications of the same. Hyperviscosity syndrome (HVS) is a pathological condition in which blood is thicker than normal and as a result flow is decreased. Hypoxia from long standing (chronic) lung disease and smoking are common causes of polycythemia. Overview What is hyperviscosity syndrome? Mayo Clin Proc. This accounts for 1-2% of hematological cancers. Cancer. Kastritis E, Gavriatopoulou M, Kyrtsonis MC, et al. [Full Text]. What bone marrow conditions cause hyperviscosity syndrome (HVS)? Symptoms include lack of energy (fatigue) or weakness, headaches, dizziness, shortness of breath, visual disturbances, nose bleeds, bleeding gums, heavy menstrual periods, and bruising. THE HYPERVISCOSITY SYNDROME IN MULTIPLE MYELOMA. Kwaan HC. Correction of hyperviscosity by apheresis. 2008 Feb;31(2):469-72. Treon SP, Tripsas CK, Meid K, et al. [1] However, this advantageous effect is offset by the increased serum viscosity that ultimately reduces blood flow and tissue perfusion. How is asymptomatic/smoldering Waldenstrom macroglobulinemia (WM) treated? Hyperviscosity syndrome is clinically manifested by oronasal bleeding, retinal hemorrhages, and variable neurological symptoms. AGGREGATION OF IGG GLOBULIN IN VIVO. Asymptomatic infants should be treated with IV hydration (see treatment of dehydration in children Treatment Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Thorne SA. Extreme increases in concentrations of mature and immature white blood cells can also produce hyperviscosity. Crit Care Clin. Mehta J and Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Two to three exchanges are required to reduce the IgM levels by 30%-60%. Acute hemodynamic effects of red cell volume reduction in polycythemia of, 14. On the other hand, cerebral venous thromboses have not been identified in older patients with CCHD whether or not the erythrocytosis is accompanied by iron deficiency.[8]. Hyperviscosity syndrome (HVS) refers to the clinical sequelae of increased blood viscosity. With further clinical improvement, he was discharged home on day seven. Your message has been successfully sent to your colleague. Clin Cancer Res. All rights reserved. Blood. Lancet Haematol. Which lab studies can confirm a diagnosis of hyperviscosity syndrome (HVS)? Another type is characterized by polycythemia . The degree to which laboratory markers of coagulation activation are elevated are substantially lower in secondary erythrocytosis than in PV, and there is no clear clinical evidence that secondary erythrocytosis poses an elevated thrombosis risk. Diagnosis and management of Waldenstrm macroglobulinemia: Mayo stratification of macroglobulinemia and risk-adapted therapy (mSMART) guidelines. [14] : 106 treatment-naive and previously treated patients; ORR 93%, CRR 0%, Laszlo et al [7] : 72 treatment-naive patients; Bortezomib1.3 mg/m2 IV days 1, 4, 8, 11 during cycle 1 followed by 1.6 mg/m2 on days 1, 7, 15, and 22 for cycles 2-5, Dexamethasone 40 mg IV weekly starting day 1 of cycle 2, Rituximab 375 mg/m2IV weekly starting day 1 of cycle 2, 5 cycles total; 21 days for cycle 1; 35 days for cycles 2-5. Symptoms of high blood viscosity include spontaneous bleeding from mucous membranes, visual disturbances due to retinopathy, and neurologic symptoms ranging from headache and vertigo to seizures and coma . 2021 Dec;15(12):1259-1274. doi: 10.1111/crj.13438. [3] Risk Factors Waldenstrom macroglobulinemia has an incidence of 3 per million people per year. 8 (4):40. What should I eat if my blood is too thick? On the other hand, more serious consequence of uncontrolled erythrocytosis is thrombotic event, including cerebrovascular accident (CVA) and transient ischemic attacks (TIA), which usually present as hemiparesis and/or hemisensory defects, cortical blindness, aphasia, dysarthria, dysphagia ataxia, or drop attacks distinguishing thrombotic event from hyperviscosity. [19], The role of maintenance therapy in patients with WM/LPL remains controversial, as there are no prospective trials demonstrating a benefit. However, similar association is not established in uncorrected CCHD in an adult with secondary erythrocytosis. Polycythemia and hyperviscosity in the newborn. Mukherjee S, Sharma M, Devgan A, Jatana SK. An official website of the United States government. [QxMD MEDLINE Link]. This can lead to an increase in blood pressure. Links to PubMed are also available for Selected References. [Full Text]. Asymptomatic patients with an elevation in the serum viscosity do not require plasma exchange, and the majority will have other indications for therapeutic intervention. Allogeneic Transplantation for Relapsed Waldenstrm Macroglobulinemia and Lymphoplasmacytic Lymphoma. We present a series of four patients with uncorrected cyanotic congenital heart disease who presented with a spectrum of features of hyperviscosity and discuss pathophysiology, clinical features, and management of hyperviscosity in detail. Blood. 2009 Jan 10. Polycythemia refers to an increase in more than one (generally all) of the formed elements in blood (from the Greek polys, many), which is more appropriately related to primary polycythemia or PV. What other lab testing is done to diagnose hyperviscosity syndrome (HVS)? [18], Urgent plasmapheresis followed by initiation of systemic chemotherapy (see Table 1, above) is an accepted treatment approach for symptomatic hyperviscosity. Hyperviscosity presents as headache, dizziness, vertigo, blurring of vision or shortness of breath in early stages. Zarkovic M, Kwaan HC. Oral iron supplementation was started simultaneously. [15] : 29 treatment-naive and previously treated patients; ORR 90%, CRR 24%, Peinert et al Surgical treatment was not considered in view of poor ventricular function. 1999; 36(1):9-13. HHS Vulnerability Disclosure, Help American Society for Blood and Marrow Transplantation, Hemostasis and Thrombosis Research Society, American Association for Cancer Education, American College of Clinical Pharmacology. Sarkar PK, Doty P. The optical rotatory properties of the beta-configuration in polypeptides and proteins. Symptoms of high blood viscosity include spontaneous bleeding from mucous membranes, visual disturbances due to retinopathy, and neurologic symptoms ranging from headache and vertigo to seizures and coma. Leukocytapheresis and urgent therapy with . Why is there Hyperviscosity in multiple myeloma? Keyword Highlighting Prospective Clinical Trial of Ixazomib, Dexamethasone, and Rituximab as Primary Therapy in Waldenstrm Macroglobulinemia. These patients have almost no symptoms or mild symptoms of hyperviscosity. Hyperviscosity Syndrome Questions & Answers - Medscape The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Carfilzomib, rituximab, and dexamethasone (CaRD) treatment offers a neuropathy-sparing approach for treating Waldenstrm's macroglobulinemia. Polycythemia is also more common when the mother resides at a high altitude. Why is there Hyperviscosity in multiple myeloma? - TimesMojo Four major factors interact to affect blood pressure: cardiac output, blood volume, peripheral resistance, and viscosity. Lele AV, Mirski MA, Stevens RD. 2021 Dec;12:100275. doi: 10.1016/j.rineng.2021.100275. [QxMD MEDLINE Link]. High concentrations of vasopressin can also cause your blood vessels to constrict. SMITH E, KOCHWA S, WASSERMAN LR. Protein Pur had an increased molecular radius (58.2 A) and was asymmetrical (intrinsic viscosity 10.2 cc/g, frictional ratio 1.63). In general, the guidelines for people with PV are the same as for everyone else: eat a low-fat diet in sensible portions with fruits, vegetables, grains and legumes. On admission, she was found to have polycythemia (HCT 72%) and red cell indices suggestive of iron deficiency state. Preterm infants Preterm Infants An infant born before 37 weeks gestation is considered preterm. Three patients with IgG myeloma and the clinical hyperviscosity syndrome were investigated, none of whom had IgG polymers in the serum by analytical ultracentrifugation. [QxMD MEDLINE Link]. A case of myelomatosis with normal colloid osmotic pressure in spite of extremely high serum protein concentration. [QxMD MEDLINE Link]. As a library, NLM provides access to scientific literature. What should I eat if I have polycythemia? The role of chronic hyperviscosity in vascular disease. Hyperviscosity syndrome may present as spontaneous bleeding and neurologic deficits, and is usually associated with Waldenstrm macroglobulinemia. Biol Blood Marrow Transplant. Your doctor may recommend a treatment approach called phlebotomy, where they insert an intravenous (IV) line into a vein to remove a certain amount of blood. Herein, we present a series of four patients with complications of secondary erythrocytosis and hyperviscosity. How is nonbulky symptomatic Waldenstrom macroglobulinemia treated? [QxMD MEDLINE Link]. Platelet larceny: spurious hypoxaemia due to extreme thrombocytosis. Hyperviscosity syndrome is a group of symptoms triggered by an increase in the viscosity of the blood. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree read more causing relative hemoconcentration and an elevated hematocrit mimics polycythemia, but red blood cell mass is not increased. Which imaging studies are indicated in the workup of hyperviscosity syndrome (HVS)? Clin Lymphoma Myeloma Leuk. Thalidomide and rituximab in Waldenstrom macroglobulinemia. Hyperviscosity syndrome - Cancer Therapy Advisor did not report an increased incidence of cerebral infarction in adult patients who suffered from CCHD and secondary erythrocytosis. [QxMD MEDLINE Link]. Learn more about the MSD Manuals and our commitment to. Arterial blood pressure is maintained within normal ranges by changes in cardiac output and peripheral resistance. Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University Why Do Cross Country Runners Have Skinny Legs? Polyclonal hyperviscosity syndrome in IgG4-related disease and associated conditions. MeSH Protein measurement with the Folin phenol reagent. Can hyperviscosity be cured? Elevated blood viscosity is the result of either red blood cell shape deformity or a pathological increase in serum proteins, red blood cells (RBC), white blood cells (WBC), or platelets. [12] Secondary erythrocytosis in a background of limited body iron store leads to a state of functional iron deficiency where microcytic red cells are produced. [12] : 63 previously treated patients; ORR 90.5%, Rituximab 375 mg/m2IV once weekly during weeks 1-4 and weeks 17-20, Dimopoulos et al Chronic hypoxaemia and decompensated erythrocytosis in, 9. Pearson TC and Messinezy M. The diagnostic criteria of polycythaemia rubra vera. What is the most common cause of polycythemia? The role of protein concentration and molecular shape. He was started on intravenous heparin infusion. Hyperviscosity Syndrome Treatment & Management - Medscape Full text is available as a scanned copy of the original print version. Treatment focuses on reducing your risk of complications. These complications can include: stroke. Rarely, can present as hyperviscosity syndrome, a spectrum of sign and symptoms as a result of impaired blood flow in the microvasculature due to increased plasma proteins. Hyperviscosity syndrome can also occur in multiple myeloma patients. Hyperviscosity syndrome (HVS) refers to the clinical sequelae of increased blood viscosity. [16] : 27 treatment-naive and previously treated patients; ORR 90%, CRR 3%, Tedeschi et al What other symptoms are associated with hyperviscosity syndrome (HVS)? 55 (1):75-83. She was discharged on beta blocker and angiotensin-converting enzyme-inhibitor. monoclonal protein called "immunoglobulin M" (IgM), which can result in a thickening of the blood known as "hyperviscosity." This monoclonal IgM protein may lead to many symptoms, including fatigue, unexplained weight loss, enlarged lymph nodes or spleen, weakness and unexplained bleeding. Int J Rheum Dis. When these factors increase, blood pressure also increases. Acute hyperviscosity: syndromes and management - ScienceDirect Before Does dehydration cause high blood pressure? Please enable it to take advantage of the complete set of features! Kastritis et al MILLER F, METZGER H. CHARACTERIZATION OF A HUMAN MACROGLOBULIN. A 12-lead electrocardiogram showed marked ST-segment depression in the left precordial leads and some ST/T changes in anterior and inferior leads [Figure 1]. Hyperviscosity syndrome in IgA multiple myeloma - Oxford Academic Bookshelf Blood-thinning foods, drinks, and supplements, 2022 - 2023 Times Mojo - All Rights Reserved When blood is viscous, in addition to a high blood pressure required for the blood circulation, blood vessel walls are also easy to be damaged. Role of plasmapheresis in Waldenstrm's macroglobulinemia. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNzgwMjU4LXF1ZXN0aW9ucy1hbmQtYW5zd2Vycw==. and transmitted securely. Unable to load your collection due to an error, Unable to load your delegates due to an error. Treatment with plasma exchange is required when the clinical syndrome is symptomatic. 61 (2):236-47. Hyperviscosity Syndrome - PubMed 124 (4):503-10. [QxMD MEDLINE Link]. Drink plenty of fluids. One type is due to serum hyperviscosity and is characterized by spontaneous bleeding with neurologic and ocular disorders. How is Hyperviscosity syndrome diagnosed? [QxMD MEDLINE Link]. EQUILIBRIUM ULTRACENTRIFUGATION OF DILUTE SOLUTIONS. 2012 Mar 8. Kopp WL, Beirne GJ, Burns RO. How is Hyperviscosity syndrome diagnosed? The https:// ensures that you are connecting to the We had one patient with myocardial ischemia possible coronary artery occlusion by thrombus due to HVS, and another patient with lower limb swelling and pain due to venous thrombosis However, overall chances of arterial and venous thrombosis are lesser in secondary erythrocytosis than primary or PV. This beneficial effect is offset by increased blood viscosity which impairs microvascular circulation and tissue perfusion leading to symptoms of hyperviscosity and microvascular thrombosis. Overview of Congenital Cardiovascular Anomalies, Overview of Congenital Adrenal Hyperplasia, Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. The total serum proteins ranged from 14 to 19 g/100 ml of which 10 to 17 g/100 ml was IgG globulin. Thomas J Hemingway, MD, FACEP is a member of the following medical societies: American College of Emergency PhysiciansDisclosure: Nothing to disclose. 2018 ACC/AHA guideline for the management of adults with congenital heart disease: A report of the American College of Cardiology/ American Heart Association Task Force on clinical practice guidelines Circulation. Ibrutinib Monotherapy in Symptomatic, Treatment-Nave Patients With Waldenstrm Macroglobulinemia. https://medical-dictionary.thefreedictionary.com/hyperviscosity. Spurious hypoxemia. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. [11] : 30 treatment-naive patients; ORR 100%, CRR 0%, Treon et al [17] : 43 treatment-naive and previously treated patients; ORR 79%, CRR 11.6%. Thomas J Hemingway, MD, FACEP Attending Physician, Department of Emergency Medicine, Wilcox Memorial Hospital Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. When should a hematologist be consulted in the treatment of hyperviscosity syndrome (HVS)? IgM-mediated manifestations include the following Risk of stroke in adults with. Click on the image to see a larger version. What is the standard of care for chemotherapy to treat Waldenstrom macroglobulinemia (WM)? Its most commonly caused by a mutation in the bone marrow cells, which produce your red blood cells. Abstract Symptomatic hyperviscosity is a common clinical manifestation in patients with Waldenstrm macroglobulinaemia (WM) and high serum IgM levels. I. Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of PhysiciansDisclosure: Nothing to disclose. You may be trying to access this site from a secured browser on the server. Blood. 381 (9873):1203-10. Blood Cancer J. Microvascular stasis due to hyperviscosity results in symptoms including headache, fatigue, paraesthesia, and loss of vision. On admission, the right lower limb was markedly cold and edematous with bluish discoloration, and the right pedal pulse was not palpable. 2018 May 1. How is hyperviscosity treated? 2008 Dec 1. A 35-year-old female with unrepaired cyanotic heart disease with single-ventricle physiology (common atrium, large VSD amounting to single ventricle, and pulmonary stenosis) had presented with headache, dizziness, and tingling, numbness with swelling of lower limbs of a few months' duration. Search for Similar Articles [2], It has been reported that in patients with CCHD the hemoglobin level can be predicted from oxygen saturation in the absence of associated iron, Vitamin B12, and folate deficiency. Hyperviscosity syndrome - Wikipedia PV is not only associated with increased hematocrit level and RBC mass but also associated with thrombocytosis, leukocytosis, and endothelial cell adhesiveness along with higher number of activated platelets leading to an enhanced risk of thrombosis. Prompt intervention is required to prevent catastrophic events, such as retinal or central nervous system bleeding. Some error has occurred while processing your request. It occurs when resistance to flow of blood increases sharply, resulting in impaired transit through the microcirculatory system. I. 1990 Sep-Oct;8(5):567-9. The viscosity of blood can also be increased by deformity of the shape of red blood cells (RBCs) that causes RBC aggregation and reduced blood flow. Elevated blood viscosity is the result of either red blood cell shape deformity or a pathological increase in serum proteins, red blood cells (RBC), white blood cells (WBC), or platelets. Kastritis et al Elsewhere blood viscosity might be increased by pathological . Doppler ultrasound of the limb was suggestive of deep vein thrombosis of the right leg veins. Polycythemia is an abnormal increase in red blood cell mass, defined in neonates as a venous hematocrit 65%; this increase can lead to hyperviscosity with sludging of blood within vessels and sometimes thrombosis. official website and that any information you provide is encrypted Emerg Med Clin North Am. Annals of Pediatric Cardiology15(3):284-290, May-Jun 2022. HHS Vulnerability Disclosure, Help Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery SVISC - Overview: Viscosity, Serum - Mayo Clinic Laboratories Asymptomatic patients with an elevation in the serum viscosity do not require plasma exchange, and the majority will have other indications for therapeutic intervention. [12] : 63 previously treated patients; ORR 90.5%, Dimopoulos et al After the procedure, the patient should be asked to drink lots of fluids and avoid strenuous activities for one or two days. Another cause is an imbalance in the blood clotting system. Sloop G, Holsworth RE Jr, Weidman JJ, St Cyr JA. [24, 25]. Leuk Lymphoma. LOWRY OH, ROSEBROUGH NJ, FARR AL, RANDALL RJ. Please confirm that you would like to log out of Medscape. The most common cause of hyperviscosity is increased concentrations of gamma globulins, either monoclonal in malignant disease or polyclonal, usually seen with rheumatic disorders. In PV, erythropoiesis is not dependent on erythropoietin, and erythroid progenitors proliferate despite normal or even low serum erythropoietin level. Consequently, iron-deficient erythropoiesis leads to production of microcytic RBCs which are less deformable and paradoxically increase blood viscosity and impairs tissue oxygenation, thus leads to increased risk of stroke. HVS classically presents with mucosal bleeding, visual and neurological abnormalities. Treatment recommendations from the Eighth International Workshop on Waldenstrm's Macroglobulinemia. Theres no cure for polycythemia vera. Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of SciencesDisclosure: Nothing to disclose. Common regimens used to treat bulky symptomatic Waldenstrom macroglobulinemia (Open Table in a new window), Rummel et al Leleu X, Soumerai J, Roccaro A, et al. The .gov means its official. [QxMD MEDLINE Link]. Polycythemia and hyperviscosity often happen together. 28 (13):2227-32. FOIA [9], Perloff et al. Hyperviscosity Syndrome: Causes, Symptoms, and Diagnosis - Healthline The main symptoms and signs of neonatal polycythemia are nonspecific and . On the other hand, some patients with decompensated erythrocytosis, iron deficiency states, those might have recurrent symptoms of hyperviscosity.[8]. You may search for similar articles that contain these same keywords or you may In response, when youre dehydrated, your kidneys reabsorb water as opposed to passing it in urine. The hyperviscosity syndrome is an uncommon complication in IgG myeloma. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Cerebrovascular events in adult patients with, 13. Bone Marrow Transplant. How should a patient be educated about hyperviscosity syndrome (HVS)? Hyperviscosity Syndrome - an overview | ScienceDirect Topics Many recommendations are guided by response rates; however, some responses are more durable than others and may not predict outcome. Garnier A, Robin M, Larosa F, et al. Hyperviscosity syndrome is a group of symptoms triggered by an increase in the viscosity of the blood. Careers, Unable to load your collection due to an error. Evaluation of hyperviscosity in monoclonal gammopathies. Wolters Kluwer Health Unauthorized use of these marks is strictly prohibited. Peinert S, Tam CS, Prince HM, et al. Results Eng. Dehydration and iron deficiency may precipitate or aggravate symptomatic hyperviscosity and thrombotic event and have to be managed before phlebotomy in patients with CCHD with HCT level of >65%. Ghobrial IM, Fonseca R, Greipp PR, et al. Semin Thromb Hemost. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Treon SP, Tripsas CK, Meid K, et al. [QxMD MEDLINE Link]. the contents by NLM or the National Institutes of Health. 2017 Jul. J Clin Oncol. 2011 Aug. 154 (3):357-62. Guidelines also warn against the risks of adverse transfusion events in these patients, including iron overload, hemolysis.

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