Maureen Okam Achebe

Background: Iron deficiency is the most common micronutrient deficiency and, when untreated, progresses to anemia. Existing guidance on the diagnostic criteria for iron deficiency is limited and not evidence based. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the diagnosis of iron deficiency, taking a global perspective in all settings. Methods: ASH established a multidisciplinary guideline panel that included 1 patient representative and was balanced to minimize potential bias from conflicts of interest. The University of Kansas Health System supported the guideline-development process, including performing systematic evidence reviews on the prevalence of iron deficiency across populations and studies to inform diagnostic thresholds up to July 2025. The panel prioritized clinical questions according to clinical impact and high-risk populations. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently open for public comment. Results: The panel agreed on 5 recommendations. Conclusions: Key recommendations of these guidelines include serum ferritin thresholds for specific populations, with the goal to prioritize the diagnosis of iron deficiency, irrespective of the presence of anemia, remarks for considerations of other diagnostic thresholds, and guidance on the diagnosis of iron deficiency in persons with inflammation. Gaps in the literature and research priorities were also identified.

Problem: Approximately 100,000 individuals in the United States have sickle cell disease (SCD). These individuals face multiple barriers to equitable care. At Brigham and Women’s Hospital, existing health inequities for these patients were compounded by admitting, rounding, and team structures that assigned patients with SCD to multiple medicine teams with a hematologist attending, leading to delays in patient care and gaps in residents’ hematology knowledge. Approach: A hematology–general medicine hybrid team was created in September 2021 to enhance trainee knowledge, skill, and confidence in managing hematology conditions and improve the quality of care delivered to individuals with SCD. This allowed for regionalization of patients with classical hematology conditions to specific hospital floors under the care of one team with a hematologist as the attending of record. Outcomes: From October 1, 2021, to January 11, 2022, the majority (745/824, 90%) of in-hospital days for patients with a primary hematology diagnosis were under the care of the hematology–general medicine hybrid team. Regionalization to the home floor of the hybrid team was achieved on 331 (40%) of these 824 hospital days, consistent with regionalization rates for other teams. From October 1, 2021, to September 30, 2022, there were 128 unique patients with SCD admitted over 511 encounters and cared for by approximately 78 residents and 12 medical students. Feedback from residents reported improved knowledge in the management of hematology conditions, especially SCD. Next Steps: The authors are working on a comprehensive analysis of the hybrid team’s impact on trainee skill and confidence in managing SCD. The authors believe that this model can be replicated at other institutions to optimize trainee education, consolidate care, and address implicit bias against patients with SCD, even with the hematology attending as a consultant instead of as the attending of record.

This study establishes a Duffy null phenotype–specific absolute neutrophil count reference range to optimize care and improve health equity.

Background: End stage renal disease (ESRD) is a common complication of sickle cell disease (SCD), contributing to 14% mortality. Most patients with ESRD are managed with dialysis. The relative risk of mortality in hemodialysis (HD) versus peritoneal dialysis (PD) may be influenced by the primary cause of ESRD (Vonesh et al, 2004). The purpose of this study is to compare patients with ESRD primarily caused by SCD (SCD-ESRD) to non-SCD-ESRD controls and to evaluate the association of dialysis type with mortality and hospitalization in SCD-ESRD patients. Methods: This was a retrospective study of SCD-ESRD patients newly initiated on dialysis in the United States Renal Data System between January 1, 2006 and December 31, 2013. SCD-ESRD patients were identified by ICD-9 codes. A sample of 5% of African Americans with incident ESRD caused by conditions other than SCD (non-SCD-ESRD cohort) initiated within the same timeframe were randomly selected as controls. Patient demographics, comorbidities, and dialysis type were compared between SCD and controls. Patient demographics, clinical characteristics, and outcomes were compared between HD and PD patients in the SCD-ESRD cohort. Chi-square, t-test, and Wilcoxon rank sum tests were used for comparative analysis. Survival times were estimated by Kaplan Meier curve and compared using log rank test. Results: 768 SCD-ESRD and 12,402 non-SCD-ESRD patients were included in analysis. SCD-ESRD patients started dialysis at a younger age (44±12.9 vs 58.6±15.4 years; p<0.001), were more likely to be unemployed (44% vs 29.7%; p<0.001) and have Medicaid insurance (55% vs 33%; p<0.001). Most common comorbidities in SCD-ESRD patients were hypertension (71%) and congestive heart failure (26%) and in controls were hypertension (89.3%) and diabetes (61.3%). SCD-ESRD patients had twice the odds of being initiated on PD compared to controls (11.3% vs 5.7%, OR 2.11, p<0.001). Demographics, comorbidities, laboratory values, access to nephrology care prior to dialysis initiation, survival, hospitalization, and kidney transplantation of HD and PD patients in the SCD-ESRD cohort are shown in Table 1. Kaplan Meier survival plot is shown in Figure 1. PD patients were more likely to be female, have full time employment and employer insurance, be students, have lower glomerular filtration rate, and have congestive heart failure as a comorbidity. They were also 1.6 and 1.9 times more likely to have been seen by a nephrologist and received erythropoietin prior to dialysis initiation respectively (p<0.001). PD patients had significantly better survival rates at year 1 (88.5% vs 75.9%, p=0.01). Survival rates were still higher in PD patients at years 3 and 5 although not statistically significant. HD and PD patients were hospitalized equally within a year of dialysis initiation however, HD patients had more intensive care unit (ICU) stays (p=0.003) and ~1.5 times the number of hospitalizations per person. More PD patients had been informed about (90.8% vs 80.47%, p=0.019) and listed for (42.5% vs 19.1%, p<0.001) transplant although no patients in this study had undergone a kidney transplant within the 5 year follow up. Discussion: SCD-ESRD patients in this study were more likely to be started on PD compared to non-SCD-ESRD patients. This could be explained by the younger age of SCD-ESRD patients as younger individuals are more likely to be started on PD in the general ESRD literature. SCD-ESRD patients started on PD had better survival and hospitalization outcomes particularly within the first year of dialysis initiation when mortality and morbidity is known to be high in ESRD. These results suggest a survival benefit of PD over HD in SCD-ESRD patients. This could perhaps be explained by decreased likelihood of vaso-occlusive events due to less fluid shifts and thus hematocrit fluctuations in the PD group (Boyle et al, 2016). A limitation of our study is that we do not have data on the possibility of individuals switching dialysis modalities (crossovers) over the course of follow up that could bias survival rates in either direction. A next step would be to look at the same outcomes in individuals who switch. Moreover, a prospective observational study or randomized control trial could further evaluate differential survival rates in HD versus PD initiation in SCD and inform guidelines in SCD-ESRD care. Acknowledgement: Support was provided to MKS by the Minority Resident Hematology Award Program. Figure 1 Figure 1. Disclosures: Achebe: Pharmacosmos: Membership on an entity's Board of Directors or advisory committees; Fulcrum Therapeutics: Consultancy; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

The 30-day readmission rate after hospitalization for a sickle cell crisis (SCC) is extremely high. Accurate information on readmission diagnoses, total readmission costs and factors associated with readmission is required to effectively plan resource allocation and to plan interventions to reduce readmission rates. The present study aimed to examine readmission diagnoses and factors associated with all-cause 30-day readmission after hospitalization for SCC. We analyzed 2016 nationwide readmission database (NRD) to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for SCC. We estimated the percentage and most common readmission diagnoses for 30-day and 7-day readmissions after discharge. We studied the relationship between risk factors and readmission and the impact of readmission on patient outcomes and resulting financial burden on health care in dollars. In 2016, of 67,887 discharges after index hospitalizations, 18099 (26.9%) were readmitted within 30-days. Of all readmissions, 5166 (7.6%) were readmitted within 7 days. The spectrum of readmission diagnoses was largely similar in both 30-day and 7-day readmission with more than 80% patients in both time periods readmitted with diagnoses related to SCC. The mean length of stay for readmitted patients was significantly longer than the index hospitalization (5.3 days (5.1–5.5) vs 4.9 days (CI 4.8–5.1, p < 0.01). Also, the mean cost of hospitalization in readmitted patients $8485 was significantly higher than the index hospitalization $8064 p < 0.01. In 2016, readmission among patients with SCC incurred an additional 95,445 hospitalization days resulting a total charge of $609 million and a total cost of $152 million in the US. On Multivariate analysis, age group 18–30 years, discharge against medical advice, higher Charlson comorbidity index, low socioeconomic status and admission at high volume centers were associated with a higher likelihood of 30-day readmission. Among patients hospitalized for SCC, 30-day readmissions were frequent throughout the month post hospitalization and resulted in an enormous financial burden on the United States healthcare system.