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Acquired aplastic anaemia is a rare, serious, immunologically mediated bone marrow failure syndrome, characterised by marrow hypoplasia of varying severity and significant pancytopenia. Careful attention and investigation, including molecular testing, is required to confirm the diagnosis and exclude other mimicking conditions, such as inherited bone marrow failure syndromes. In a proportion of patients, the disease evolves to myelodysplasia or acute myeloid leukaemia and in some there is an association with paroxysmal nocturnal haemoglobinuria. The disease has a major impact on patient quality of life. Haemopoietic stem/progenitor cell transplantation for eligible patients with an available donor is the only current curative therapy. Other patients may receive immunosuppression, most commonly with anti-thymocyte globulin and cyclosporin. An initial response to immunosuppression is often encouraging, but relapse is common. Supportive care, including management of transfusion requirements and infections, is central to management. Promising new diagnostic tools and emerging therapies will likely transform approaches to this important, chronic and life-threatening condition.

BACKGROUND: Transfusion of platelets is common in cardiac surgery, and while there are guidelines for their use, there are concerns about potential risks. We aimed to assess the impact of platelet transfusion on mortality, thrombosis, and infection in this patient group. STUDY DESIGN AND METHODS: A retrospective cohort study of all patients at St Vincent's Hospital Melbourne who underwent a first cardiac surgery procedure from June 2001 to June 2014 was conducted. A propensity-weighted analysis was performed to examine the association between intraoperative platelet transfusion and outcomes. RESULTS: A total of 5233 patients met inclusion criteria, and 531 (10.15%) received intraoperative platelet transfusion (median two platelet doses, interquartile range, 1-17). Patients receiving platelets were older, had higher body mass index, lower rates of diabetes and dyslipidemia, higher rates of infective endocarditis, recent myocardial infarction and unstable angina, and exposure to aspirin or clopidogrel. On univariable analysis, platelet transfusion was associated with increased 30-day mortality (2.4% vs. 10.55%, p

In recent years, the anti-CD38 monoclonal antibody daratumumab (Darzalex; Janssen-Cilag Pty Ltd) has been shown to be highly efficacious in relapsed and refractory multiple myeloma, with the final results of treatment in newly diagnosed patients awaited. Despite awareness of the potential interference of daratumumab in pre-transfusion immunohaematology testing during phase I and II clinical studies, there was a degree of unpreparedness in the community upon the introduction of this drug into the clinics, particularly the impact that it has on the operational processes in hospital transfusion laboratories and timely issue of red blood cells (RBCs). Anti-CD38 interference in pre-transfusion immunohaematology tests is a particular problem in patients being treated with daratumumab for multiple myeloma as many will require RBC transfusions during their disease treatment. Panagglutination caused by anti-CD38 monoclonal antibody during the indirect antiglobulin test may mask the presence of a clinically significant RBC alloantibody in the patient's plasma during the antibody screen and identification process, which may be overlooked, particularly in urgent situations, subsequently resulting in a delayed or acute haemolytic transfusion reaction. Here, we summarise daratumumab's effects on pre-transfusion immunohaematology testing and its impact on clinical practice and make practical recommendations based on a consensus from medical and scientific transfusion experts and myeloma specialists on behalf of the Australian and New Zealand Society of Blood Transfusion and Myeloma Scientific Advisory Group to Myeloma Australia, respectively.

In patients with anemia, transfusion of red blood cells (RBCs) can save lives and improve quality of life. The choice to transfuse should be cautiously made owing to risks of transfusion, economic costs, and limitations on the blood supply. Until the 1980s, the decision for RBC transfusion was guided by Hb threshold, with the aim of maintaining the patient's blood Hb level over 100 grams per liter. Since then, multiple randomized controlled trials and key systematic reviews have provided evidence-based guidelines as to appropriate transfusion thresholds in a number of clinical settings. Here, we aimed to address the outcome of defining different anemia criteria in specific clinical populations exclusively on the basis of the need for RBC transfusion based on Hb concentration. We focused on the patient populations, where there were the most available data on differing transfusion thresholds, which looked at transfusing to a higher or liberal transfusion threshold in comparison with a lower or restrictive transfusion threshold. These included patients in intensive care with or without septic shock, hip fracture surgery, cardiovascular surgery, and upper gastrointestinal bleeding, the pediatric population, and also those with malaria, by reviewing key randomized controlled trials and systematic reviews. Twenty-four randomized controlled studies and 12 systematic reviews have been included, and these are discussed below.

Background There continues to be uncertainty about the optimal approach to documenting bleeding data in platelet transfusion trials, with a desire to apply a common assessment tool across all trials. With this in mind, a consensus bleeding assessment tool (BAT) has been developed by the Biomedical Excellence for Safer Transfusion (BEST) collaborative, based on review of data collection forms used in published randomized trials and following content validation with a range of healthcare professionals at seven haematology centres through BEST members. This study aimed to evaluate reliability and reproducibility of the consensus BAT. Methods Replicated clinical assessments of bleeding were undertaken by participants with haematological malignancies recruited at four haematology centres in an international, multicentred, observational study. Concordance of repeat assessments was calculated for agreement in site and grade of bleeding observed. Results Forty patients consented to participate, and 13 trained bleeding assessors collected these data. Bleeding assessments were carried out on 113 separate days. Of all 225 bleeding assessments, 204 were compared for grade concordance, and 160 were compared for site concordance. There was very good grade concordance (83%, 95% confidence interval 74–93%) and good bleeding site concordance (69%, 95% confidence interval 57–79%) in observations of bleeding. Discordance was primarily in relation to assessing skin bleeding. Conclusions Alongside a structured training programme, levels of concordance for a consensus BAT were high. Researchers using assessment tools for bleeding need to balance comprehensive data collection against potential loss of accuracy for some types of bleeding, such as skin findings.

Objective To assess whether introduction of universal leukodepletion (ULD) of red blood cells (RBCs) for transfusion was associated with improvements in cardiac surgery patient outcomes. Methods Retrospective study (2005-2010) conducted at 6 institutions. Associations between leukodepletion and outcomes of mortality, infection, and acute kidney injury (AKI) were modeled by logistic regression, and intensive care unit length of stay (LOS) in survivors was explored using linear regression. To examine trends over time, odds ratios (ORs) for outcomes of transfused were compared with nontransfused patients, including a comparison with nontransfused patients who were selected based on propensity score for RBC transfusion. Results We studied 14,980 patients, of whom 8857 (59%) had surgery pre-ULD. Transfusions of RBCs were made in 3799 (43%) pre-ULD, and 2525 (41%) post-ULD. Administration of exclusively leukodepleted, versus exclusively nonleukodepleted, RBCs was associated with lower incidence of AKI (adjusted OR 0.80, 95% confidence interval [CI] 0.65-0.98, P = .035), but no difference in mortality or infection. For post-ULD patients, no difference was found in mortality (OR 0.96, 95% CI 0.76-1.22, P = .76) or infection (OR 0.91, 95% CI 0.79-1.03, P = .161); however, AKI was reduced (OR 0.79 95% CI 0.68-0.92, P = .003). However, ORs for post-ULD outcomes were not significantly different in nontransfused, versus transfused, patients. Furthermore, those who received exclusively nonleukodepleted RBCs were more likely to have surgery post-ULD. Conclusions Universal leukodepletion was not associated with reduced mortality or infection in transfused cardiac surgery patients. An association was found between ULD and reduced AKI; however, this reduction was not significantly different from that seen in nontransfused patients, and other changes in care most likely explain such changes in renal outcomes.

Blood transfusion is not without risk. Although the risks of HIV and hepatitis transmission have diminished, haemovigilance programs highlight that other significant transfusion hazards remain. Sepsis from bacterial contamination is the most common residual infectious hazard in developed countries, and events due to clerical error are problematic. Unnecessary transfusions should be avoided. New national guidelines on patient blood management (PBM) emphasise holistic approaches, including strategies to reduce transfusion requirements. Perioperative PBM should incorporate preoperative haemoglobin and medication optimisation, intraoperative blood conservation, and consideration of restrictive postoperative transfusion and cell-salvage techniques. When massive transfusion is required, hospitals should implement massive transfusion protocols. These protocols reduce mortality, improve communication and facilitate adequate provision of blood products. They should include multidisciplinary team involvement and guidelines for use of blood components and adjunctive agents. Although fresh frozen plasma to red blood cell and platelet to red blood cell ratios of ≥ 1 : 2 appear to reduce mortality in trauma patients who receive massive transfusion, there is insufficient evidence to recommend specific ratios. Systematic reviews have found no significant benefit of recombinant activated factor VII in critical bleeding, and an increase in thromboembolic events; specialist haematology advice is therefore recommended when considering use of this agent. The National Safety and Quality Health Service Standards address use of blood and blood products, and provide important transfusion principles for adoption by all clinicians. Storage of red cells in additive solution results in changes, known as the "storage lesion", and studies to determine the clinical effect of the age of blood at transfusion are ongoing.

The BTK (Bruton's tyrosine kinase) inhibitor ibrutinib is associated with an increased risk of bleeding. A previous study reported defects in collagen- and adenosine diphosphate (ADP)-dependent platelet responses when ibrutinib was added ex vivo to patient samples. Whereas the collagen defect is expected given the central role of BTK in glycoprotein VI signaling, the ADP defect lacks a mechanistic explanation. In order to determine the real-life consequences of BTK platelet blockade, we performed light transmission aggregometry in 23 patients receiving ibrutinib treatment. All patients had reductions in collagen-mediated platelet aggregation, with a significant association between the degree of inhibition and the occurrence of clinical bleeding or bruising (P=0.044). This collagen defect was reversible on drug cessation. In contrast to the previous ex vivo report, we found no in vivo ADP defects in subjects receiving standard doses of ibrutinib. These results establish platelet light transmission aggregometry as a method for gauging, at least qualitatively, the severity of platelet impairment in patients receiving ibrutinib treatment.

Current literature suggests that contact with specialist palliative care for patients diagnosed with hematological malignancy is infrequent. As part of an investigation into patterns of care, the symptom profile of this patient group required elucidation.The purpose of this study was to determine the patterns of symptoms and level of distress in patients diagnosed with a hematological malignancy.One hundred eighty patients diagnosed with a hematological malignancy attending a tertiary referral hospital completed the Memorial Symptom Assessment Scale-Short Form. Comparisons were made to published symptom prevalence studies of those with nonhematological malignancies.Patients with hematological malignancy had a considerable physical and psychological symptom burden, with an overall mean of 8.8 (± 5.9) symptoms. The mean number of symptoms was significantly greater in those on treatment (P0.05), those with poorer performance status (P0.001), inpatients (P0.01), and those with a more advanced disease stage (P0.001) than their respective counterparts. Symptom prevalence ranged from 69% for fatigue to 9% for vomiting. Global, physical, and psychological distress scores were high and varied significantly according to disease stage, Eastern Cooperative Oncology Group status, and patient location. The mean number of symptoms and level of distress were comparable to those patients with metastatic nonhematological malignancy.Patients with hematological malignancy are likely to have symptom control needs similar to those with metastatic cancer. Because such symptom burden appears to affect those at all phases of illness, comprehensive symptom assessment is suggested throughout. The introduction of palliative care services during times of increased symptom burden may assist hematologists and other carers in the management of their patients' distress and quality of life.

A 38-year-old man was admitted to hospital with several days of malaise and dyspnoea. He was on no prescribed medications, and had previously been well apart from an episode of gangrenous cholecystitis due to mixed gallstones three years previously. Full blood examination showed haemoglobin 110 g/l, white cell count 12AE9 · 10/l with neutrophil count 9AE2 · 10/l, and platelet count 266 · 10/l. The blood film (left) demonstrated marked polychromasia with features of oxidative haemolysis and hyposplenism. Supravital staining with methyl-violet demonstrated numerous Heinz bodies (top right). Other indicators of haemolysis included a reticulocytosis of 241 · 10/l, lactate dehydrogenase 374 IU/l, bilirubin 54 lmol/l with undetectable haptoglobin and a negative direct antiglobulin test. On further enquiry, the patient denied fava bean ingestion but disclosed heavy recreational use of inhalational amyl nitrite. Avoidance of further nitrite exposure resulted in resolution of haemolysis, and the patient was provided with counselling on drug use. Laboratory testing in the convalescent phase did not detect evidence of glucose-6-phosphate dehydrogenase deficiency or an underlying haemoglobinopathy. Nitrite inhalants, such as amyl nitrite, are highly volatile yellow liquids that cause rapid vasodilation and hence were once used as anti-anginals. Nitrites efficiently oxidize haemoglobin to methaemoglobin and may also increase the proteolytic susceptibility of haemoglobin leading to globin chain denaturation and Heinz body formation. The recreational use of alkyl nitrites, colloquially known as ‘poppers’ (bottom right), should be considered in apparently idiopathic episodes of oxidative haemolysis. Significant complications may occur even in patients with intact red cell reduction pathways.

A 30-year-old man was admitted to hospital following an explosion at the metal foundry where he worked. He had sustained sulphuric acid exposure to 80% of his body, including full thickness skin destruction over 20% of his body surface area. Full blood examination on admission showed haemoglobin 151 g/l, white cell count 24AE3 · 10/l with neutrophil count 20AE4 · 10/l, and platelet count 357 · 10/l. The blood film (illustrated) demonstrated numerous spherocytes and microspherocytes, a number of crenated red cells, occasional red cell fragments and toxic neutrophil granulation. The direct antiglobulin test was negative, and a blood film performed 2 years prior to this presentation had shown no morphological abnormalities. Microspherocytes are a characteristic finding following thermal injury to red cells, such as that resulting from physical burns, but have not to our knowledge been described in association with chemical injury. The mechanism underlying this morphological change is thought to be a decrease in red cell membrane deformability caused by thermal damage to membrane proteins and phospholipids. This may also lead to fragmentation and cell destruction. Microspherocytes and fragments have been implicated in the pathogenesis of renal impairment in the setting of severe burns, through deposition in renal tubules, and may also interfere with automated cell counts. Sulphuric acid (H2SO4), once called oil of vitriol, is a highly corrosive mineral acid. Its destructive properties are enhanced by its exothermic reaction with water, which forms hydronium and sulphate while releasing substantial heat. The chemical injury associated with exposure to sulphuric acid may therefore result in greater damage than that from other acids of similar strength, as local heat and dehydration increase tissue destruction. In this case, it is likely that this secondary thermal damage contributed to the observed morphological changes. This patient was treated with surgical debridement and supportive measures, and made a full recovery. His blood counts and red cell morphology normalized within seven days, with complete resolution of the microspherocytosis.

Objectives Evidence is accumulating of adverse outcomes associated with transfusion of blood components. If there are differences in perioperative transfusion rates in cardiac surgery, and what hospital factors may contribute, requires further investigation. Methods Analysis of 42,743 adult patients who underwent 43,482 procedures from 2005 to 2011 at 25 Australian hospitals, according to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database. Multiple logistic regression examined associations of patient and hospital characteristics with transfusion of ≥1 red blood cell (RBC) unit; platelet (PLT), fresh frozen plasma (FFP), and cryoprecipitate (CRYO) doses; and ≥5 RBC units, from surgery until hospital discharge. Results Procedures included 24,222 (55%) isolated coronary artery bypass grafts, 7299 (17%) isolated valve, 4714 (11%) coronary artery bypass graft and valve, and 7247 (17%) other procedures. After adjustment for various patient and procedure characteristics, transfusion rates varied across hospitals for ≥1 RBC unit from 22% to 67%, ≥5 RBC units from 5% to 25%, ≥1 PLT dose from 11% to 39%, ≥1 FFP dose from 11% to 48% and ≥1 CRYO dose from 1% to 20%. Hospital characteristics, including state or territory, private versus public, and teaching versus nonteaching, were not associated with variation in transfusion rates. Conclusions Variation in transfusion of all components and large volume RBC was identified, even after adjustment for patient and procedural factors known to influence transfusion, and this was not explained by hospital characteristics.

Background and Aim Studies have reported association between red cell (RBC) transfusion (tx) and increased mortality and morbidity in cardiac surgery (CS). Conflicting data exist on whether universal RBC leucodepletion (ULD) reduces mortality and morbidity, particularly infection and intensive care unit (ICU) length of stay (LOS), in CS patients. RBC tx has also been independently associated with renal failure (RF) in CS, however mechanisms for this effect are unclear. An inflammatory basis has been postulated. No large studies have explored the potential benefit of ULD in reducing RF. We investigated whether introduction of ULD in Australia (July 2008) was associated with reduced in-hospital mortality, infection, new RF (NRF) and ICU LOS in a large cohort of CS patients. Methods All consecutive CS patients 18y and older at 6 hospitals between 2005 and 2010 were included. Clinical and outcome data were obtained from the Australian and New Zealand Society for Cardiac and Thoracic Surgeons Cardiac Surgery Database, which prospectively collects data on all CS patients. Laboratory results (pre-operative hemoglobin, platelet, coagulation profile and creatinine) and transfusion data were obtained from hospital laboratory information systems (LIS). Statistical analysis Tx was defined as ≥ 1 RBC within 48h of CS. Patients were categorized as having surgery pre- or post-ULD and as having received either exclusively LD, non-LD or mixed RBC. Logistic regression modeled the association between LD and mortality, infection and NRF. The association with LD was analyzed in two ways: whether surgery occurred pre- or post-ULD, and whether patients received LD or non-LD RBCs. To examine for trends over time, an equal number of non-tx patients were selected as ‘controls’, based on a propensity score for RBC tx. The relationship between LD and ICU LOS among survivors was explored using linear regression. Results 16,253 patients underwent CS in the study period. LIS data were available for 14,980 (92%), and of these, 8857 (59%) had surgery pre-ULD. RBC tx was given in 3799 (43%) pre-ULD, and 2525 (41%) post-ULD. Of the 6324 patients who were tx, 2794 (44%) received LD RBC, 2702 (43%) non-LD RBC and 828 (13%) received mixed LD and non-LD RBCs. In tx patients, there was no significant difference in mortality (136 [5.4%] vs. 240 [6.3%], p=0.125) or infection (310 [11.9%] vs. 510 [13.4%], p=0.080) post-ULD compared with pre-ULD, however there was a significant reduction in NRF (215 [8.5%] vs. 398 [10.5%], p=0.010). After adjusting for hospital, age, sex, co-morbidities, ejection fraction, pre-operative laboratory parameters, surgical history, type and urgency of procedure, pre-operative shock, medications, perfusion time, drain output in first 4 hours and number of RBC, there was no difference in mortality (OR 0.92, 95% CI 0.71-1.20, p=0.534) or infection (OR 0.96, 95% CI 0.81-1.15, p=0.671), however there was a difference in NRF post-ULD compared with pre-ULD (OR 0.77, 95% CI 0.64-0.94, p=0.011). When the analysis was repeated comparing those who received LD vs. non-LD RBC the results were similar, with no difference in mortality or infection, but a reduction in NRF (OR 0.80, 95% CI 0.65-0.98, p=0.035). In the non-tx controls, there was no significant difference in mortality (30 [1.2%] vs. 39 [1.0%], p=0.546), infection (139 [5.5%] vs. 231 [6.1%], p=0.338) or NRF (110 (4.4%] vs. 181 [4.8%], p=0.445) post-ULD compared with pre-ULD. After adjusting as above, there was no significant difference in mortality (OR 1.18, 95% CI 0.72-1.9, p=0.512), infection (OR 0.82, 95% CI 0.66-1.03, p=0.094) or NRF (OR 0.83, 95%CI 0.64-1.07, p=0.148) post-ULD compared with pre-ULD in non-tx pts. In the unadjusted linear regression, post-LD was associated with a small reduction in ICU LOS in transfused (41 vs. 44 h, p=0.034) and with a small increase in non-transfused (29 vs. 31 h, p Conclusions Introduction of ULD was associated with a reduction in NRF but not mortality, infection or ICU LOS in transfused CS pts. These findings support the potential role of inflammation as a contributor to acute RF in tx CS pts. ULD may be worth exploring prospectively as a possible strategy to reduce the incidence of NRF in CS, given its substantial morbidity and mortality. Disclosures: Phillips: CSL Behring: Research Funding. Wood:CSL Behring: Research Funding.

Abstract 4384 The management of musculoskeletal tumors has evolved markedly over the past 30 years, with improvements in surgical techniques, staging and chemotherapeutic advances delivering improved survival and functional outcomes, both in the setting of primary malignant bone tumors and in the palliation of tumors metastatic to bone. Advances in surgical technique as well as pre-operative chemotherapy has meant that most patients are now able to undergo limb-sparing surgery. Whilst clearly desirable to improve functional outcome, limb-sparing surgery is however more technically challenging and is associated with greater blood loss than amputation. There is a paucity of data concerning blood utilization in the setting of major musculoskeletal tumor surgery. We retrospectively analyzed a database containing 1322 consecutive surgeries in 1222 patients over a 14 year timeframe, performed at a quaternary referral center in Melbourne, Australia. The following factors were significantly associated with high blood utilization: Chordomas, sacral and pelvic tumors, lower starting haemoglobin, tumors >5cm in size and high American Society of Anesthesiologists (ASA) score. The ASA score also clearly correlated with 30 day mortality. Pre-operative planning in these patients is critical to ensure adequate blood supply, minimize wastage and optimize the patient's general health prior to surgery. As such, based on modeling from our data, we propose a maximum surgical blood order schedule based on the presence or absence of the above factors. Allogeneic blood transfusion, while a potentially life-saving intervention, is associated with major complications, including transmission of infectious agents and immunological complications. Longer-term, transfusion has been reported to result in immunomodulation and potentially a higher risk of tumor recurrence. Clearly, minimization of blood loss and avoidance of un-necessary transfusion is desirable. There is also a lack of data surrounding interventions designed to minimize blood loss in musculoskeletal tumor surgery, especially when compared to similar studies performed in major orthopedic surgery for benign conditions. These would be ideal targets for future randomized studies in the high-risk groups we have identified. Disclosures: No relevant conflicts of interest to declare.

Abstract 4385 The multiply alloimmunized patient poses a difficult predicament for clinicians, the hospital blood bank and duty hematologist. Whilst parallels may be drawn between patient blood management strategies used in the setting of blood refusal, others are unique to alloimmunization. There is limited literature guiding the management of the multiply alloimmunized patient requiring transfusion. We describe a 54-year-old lady who presented with symptomatic anaemia due to a delayed haemolytic transfusion reaction from an unidentifiable antibody. She had been transfused 2 units of red cells 13 days earlier in the setting of gastrointestinal bleeding. At this time she was found to have an anti- Fya antibody and was transfused with Rh matched, K negative, Fy(a-) and indirect anti-globulin test (IAT) cross-match compatible red cells. Her history included previous transfusions in the setting of bleeding, but no pregnancies. On admission hemoglobin (Hb) was 69 g/L [115 – 165], reticulocyte count 237× 109/L [20 – 100], bilirubin 33 μmol/L [T, encoding Gln581Leu and a silent 1671C>T, not affecting Ser557. These mutations are 2 out of the 3 mutations describing the LU- 13 genotype1. Our patient lacks the third mutation 1340C>T previously described. The patient's Hb dropped to 42 g/L and her treatment included bed-rest, intravenous iron, intramuscular vitamin B12, oral folate and erythropoietin. Whilst she had no active gastrointestinal bleeding she was given pantoprazole infusions and had a capsule endoscopy. She had a history of menorrhagia so was started on norethisterone and tranexamic acid to suppress menstrual loss. No first degree relatives were available for directed donation. She was transfused with 1 unit of IAT cross match compatible red cells together with 100mg prednisolone orally daily and 1g/kg intravenous immunoglobulin in an attempt to suppress immune haemolysis. She tolerated the transfusion well; however there was no increment in her Hb. Avoidance of unnecessary blood testing and pediatric collection tubes were used to reduce phlebotomy related loss. Over the next 10 days her Hb incremented without further transfusion to 78 g/L and had normalized by 4 weeks. Due to the need for future gastrointestinal surgery, on recovery of her Hb she had 5 autologous units of blood collected and frozen. Patient blood management strategies in the patient where the risk of potentially significant haemolytic reactions to transfusion is high must focus on minimizing blood loss, maximizing tissue oxygenation, promoting erythropoiesis and reducing metabolic needs. Approaches to lessen blood loss include early radiologic or surgical intervention to stop active bleeding, cessation or reversal of anticoagulants or aspirin and avoidance of medications or supplements associated with increased bleeding risk. Reducing phlebotomy-based blood loss includes minimizing the number of blood tests, using pediatric collection tubes and point of care devices. In our patient we investigated for ongoing bleeding sources, utilised proton pump inhibitors and used hormonal control for cessation of menstruation. Erythropoiesis was stimulated by the delivery of iron, folate, vitamin B12 and erythropoietin. Early investigation for associated coagulopathy or thrombocytopenia and early treatment with vitamin K, fresh frozen plasma and cryoprecipitate ensures that red cell volume is optimised. In a patient with multiple alloantibodies, the hospital blood bank should screen their inventory of donated red cells and consult with local and regional blood authorities. The blood typing of family members may allow for identification of potential donors. In the acute setting with an unstable haemorrhaging patient, the decision to transfuse the least incompatible blood may need to be considered. Long-term management plans may include autologous unit collection and identification of alloantibodies at a molecular level. Disclosures: No relevant conflicts of interest to declare.

Abstract 3311 Background Hemorrhage from disease processes or their therapy commonly complicates the course of patients with malignancies. Recombinant activated factor VII (rFVIIa) was developed for prevention or treatment of bleeding in hemophilia patients who have factor inhibitors, but may also have a role in enhancing coagulation and augmenting conventional therapies in refractory bleeding. However, outcomes are not defined for this indication, and randomized studies are challenging. We explored the safety and efficacy of rFVIIa in the treatment of hemorrhage associated with malignancy or stem cell transplantation (SCT) using prospective clinical registry data. Methods The Australia and New Zealand Haemostasis Registry (ANZHR) documented all rFVIIa use in non-hemophilia patients in both countries. More than 90 institutions participated in its operation from 2000 to 2009, capturing an estimated 85% of use in these countries. Participating institutions obtained approval from local institutional review boards to provide de-identified data. They were required to report all usage to limit bias and registry data were audited regularly. We identified episodes of rFVIIa use where the primary diagnosis at the time of hemorrhage was a malignancy or SCT. Response to rFVIIa reported by the treating clinician, transfusion requirements, adverse events and 28 day survival were analyzed. Logistic regression and multiple linear regression models were used to identify factors associated with response. Results Of 3446 episodes reported to ANZHR, 362 eligible episodes were identified in 325 patients (10.5% the total). Median patient age was 56 years (IQR 39–67); 205 (63%) were male. Episodes were reported from 51 institutions (57% of participating), median 5 (IQR 3–8) per institution. Primary diagnosis was hematological in 173 cases (48%); non-hematological malignancy in 189 (52%). 321 (88.6%) were receiving disease-directed therapy (initial therapy in 200 [55% of the total], 19 [5%] supportive care, unreported in 22 [6%]). Intent of care was curative in 218 (60%), palliative in 122 (34%), 22 (6%) unreported. 33 (9.1%) were undergoing allogeneic SCT and 5 (1.4%) autologous SCT. Primary sites of bleeding were gastrointestinal in 165 (46%), pulmonary 47 (13%), intracranial 36 (10%), genitourinary 34 (9%), hepatic 28 (8%), others 52 (14%). Causes of bleeding were 116 (34%) surgical (including resection of tumor or metastases), disease-induced coagulopathy 48 (14%), disease invasion 62 (18%), mucositis (including graft-versus-host disease) 53 (15%), others 65 (19%); 6 (2%) received rFVIIa prophylactically prior to procedures. In 255 episodes (70%) a single dose of rFVIIa only was administered. Median dose was 90μg/kg (IQR 77–100). Prior to administration median (IQR) hemoglobin was 82 g/L (69–93); platelet count 82 × 109/L (43–127), fibrinogen 2.1 g/L (1.4–3.1), INR 1.4 (1.2–1.8), pH 7.3 (7.2–7.4), temperature 36.7°C (36.0–37.1), and patients had received 5 (2–12) units red cells, 2 (0–4) platelet doses, 4 (0–8) plasma units, and 0 (0–8) cryoprecipitate doses. Bleeding stopped or decreased in 175 (60%) of cases where response was reported (prophylactic cases were excluded from response assessment). Transfusion requirements fell to 2 (0–4) red cells, 0 (0–2) platelets, 0 (0–3) plasma, and 0 (0–8) cryoprecipitate following the first dose. Response decreased with low pH in univariate analysis (p=0.014). In multivariate analysis, low pH and hematological malignancy were independent predictors of poor response (p=0.001). 18 patients (5.5%) had thromboembolic events reported within 28 days of administration. 202 patients (57%) survived to 28 days. Survival was significantly higher in rFVIIa responders (71% vs 38% p Conclusions This is the first comprehensive exploration of rFVIIa in hemorrhage associated with malignancy. Usage in this setting was higher than anticipated. Reported efficacy and safety were promising in this heterogeneous group with severe refractory bleeding and elevated baseline risk of thrombosis. Clinician-reported bleeding response was supported by reduced transfusion requirements and survival benefit. Response was associated with pH and type of malignancy, suggesting that these factors may assist in patient selection. Use of rFVIIa may be an effective adjunct to conventional therapies in carefully selected cancer patients with refractory hemorrhage. Disclosures: Off Label Use: Recombinant Activated Factor VII, for bleeding associated with malignancy.

Abstract 3158 Poster Board III-95 Background Previous studies have demonstrated significant variation in red cell transfusion in cardiac surgery. Allogeneic red cell transfusion has been reported as associated with adverse post-operative outcomes in this setting, whilst there is conflicting evidence on potential adverse effects of platelets. We investigated the variation in transfusion practice (including red cell, platelets and plasma transfusion) across six large cardiac surgery centres and whether peri-operative transfusion was independently associated with clinical outcomes. Methods Data were prospectively collected on 9363 cardiac surgery patients at six major Australian hospitals from January 2005 to December 2008 through the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) Cardiac Surgery Database. The independent association of transfusion (including red cells, platelets and plasma) with clinical outcomes was determined by stepwise logistic regression analysis. Patient factors (including co-morbidities and medication use such as anticoagulants and anti-platelet agents) and surgical factors (including type of procedure, previous cardiothoracic intervention, urgency of surgery, cardiopulmonary bypass time, cross-clamp time, return to theatre and other peri-operative complications) were included in the analysis. Results Procedure types were: coronary artery bypass graft (CABG) surgery in 60%, valve surgery in 14%, CABG and valve in 10% and other procedure in 16%. There was significant variation in transfusion of all blood components between the six hospitals, which was not accounted for by patient or surgery related factors. The adjusted odds ratio (OR) for the risk of receiving a transfusion of red cells varied between the hospitals from 0.22 to 1.98, for platelets from 0.39 to 3.3 and for plasma from 0.27 to 2.0. Transfusion of red cells, platelets and plasma were each associated with all outcome measures. In multiple logistic regression analysis, red cell transfusion was independently associated with multi-system failure (OR, 2.97; 95% confidence interval [CI], 1.41 - 6.28; p = 0.004), peri-operative myocardial infarction (OR, 2.63; 95% CI, 1.45 - 4.77; p = 0.001), stroke (OR, 1.76; 95% CI, 1.13 - 2.72; p = 0.012), prolonged ventilation (OR, 2.6; 95% CI, 2.19 - 3.06; p < 0.001), pulmonary embolism (OR, 4.29; 95% CI, 1.4 - 13.16; p = 0.011), pneumonia (OR, 2.12; 95% CI, 1.8 - 2.72, p < 0.001) and septicaemia (OR, 2.29; 95% CI, 1.31 - 4.0; p = 0.004). Platelet transfusion was independently associated with multi-system failure (OR, 2.17; 95% CI, 1.3 - 3.63; p = 0.003) and pneumonia (OR, 1.25; 95% CI, 1.02 - 1.52; p = 0.03). Plasma transfusion was independently associated with in-hospital (OR, 2.46; 95% CI, 1.82 - 3.32; p < 0.001) and 30 day mortality (OR, 2.2; 95% CI, 1.61 - 2.99; p < 0.001), multi-system failure (OR, 1.97; 95% CI, 1.18-3.31; p = 0.010), prolonged ventilation (OR, 1.81; 95% CI, 1.55 - 2.13; p < 0.001) and septicaemia (OR, 1.83; 95% CI, 1.17 -2.85; p = 0.008). Conclusion There was significant variation in transfusion practice for red cells, platelets and plasma across these six major hospitals that was not accounted for by patient or surgery related factors. Peri-operative transfusions of red cells, platelets and plasma, after adjusting for established clinical risk factors, were each independently associated with an increased risk of adverse events. These findings from a large cohort of patients are in keeping with previous reports of adverse events associated with red cell transfusion in cardiac surgery and support the need for further research into the effects of transfusion on patient outcomes. An improved understanding of factors contributing to the significant variation in transfusion practice is also required as this may have important implications for patient outcomes. Disclosures No relevant conflicts of interest to declare.

Treatment of various haematological malignancies such as chronic lymphocytic leukaemia (CLL) with alkylating drugs (e.g. chlorambucil, CLB) fails to extinguish the leukaemic clone and often results in chemo-resistance. A possible mechanism of drug resistance in CLL B cells is p53 inactivation. The resistance of cells to standard chemotherapy may be ameliorated by agents that alter the chromatin remodelling processes, DNA methylation and histone acetylation (e.g. sodium butyrate, NaBu). We used the HL-60 cell line (which carries a non-functional p53 protein) as a cell model for resistant CLL B cells and determined the sensitivity of HL-60 cells to a range of concentrations of CLB (5μM,10μM and 20μM) and NaBu (0.5mM, 1mM and 2mM) by tetrazolium salt-based proliferation assays of cells incubated with the drugs over 4 days (days 0, 1, 2 and 3). Cells were resistant to 5μM CLB until day 3 where 56% of cells were killed. 10μM and 20μM CLB had very similar effects (p>0.05) with both treatments killing 83.2% and 87.3% respectively of cells by the end of the incubation. The cell death induced by NaBu was both time- and dose-dependent, with 2mM NaBu being the most effective treatment, while 0.5mM NaBu did not result in significant cell death (p>0.05). To investigate if the treatment of HL-60 cells with both drugs would enhance or have an additive killing effect on the cells, we tested combined treatment involving a series of lower drug concentrations of each of the two drugs (5μM/10μM CLB ± 0.2mM/0.5mM/1mM). All combined treatments using 5μM CLB were more effective in cell killing than when the cells were treated singly with CLB or NaBu (p0.05). In conclusion, combined treatment involving NaBu increased the cytotoxic effect of low concentrations of CLB in p53-inactivated cells, implying the potential benefit of chromatin modifying agents in cytotoxic therapy. Further studies including the use of a wider range of concentrations of CLB with NaBu or other chromatin modifying agents are underway to investigate possible synergism in the killing of HL-60 cells by these agents.

Optimal management of intercurrent hematological malignancy in patients with HIV, in particular the feasibility of allogeneic peripheral blood stem cell transplantation (PSCT), remains to be defined. We present our experience with allogeneic transplantation in a series of three patients with HIV. The first patient is a 38 yo man with secondary myelodysplasia in transformation to acute myeloid leukemia. He had had no AIDS-defining illnesses, and was maintained on second-line anti-retroviral therapy of Stavudine, Lamivudine and Tenofovir with an undetectable HIV viral load and CD4 count 58 cells/μL. He received a HLA-identical PSCT, conditioned with cyclophosphamide 60 mg/m2 and total body irradiation (TBI) 13.2 Gy in 6 fractions with standard graft-versus host disease (GVHD) and infective prophylaxis. Transplantation was complicated by severe BK-virus associated hemorrhagic cystitis and prolonged neutropenia with sepsis necessitating temporary withdrawal of anti-retrovirals. Engraftment occurred at day 48, and bone marrow aspirate (BMA) confirmed remission. Anti-retroviral therapy was re-introduced 12 months post-transplantation in response to a rising HIV viral load. He subsequently developed progressive renal impairment due to post-transplant glomerulopathy, but had no late infective complications and is otherwise well and in remission 21 months post-transplantation with HIV viral load 150 copies/mL and CD4 count 181 cells/μL. The second patient was a 41 yo man with multiply-relapsed acute myeloid leukemia in third complete remission. He had no AIDS-defining illnesses and was maintained on fifth-line anti-retroviral regimen of Emtricitabine, Tenofovir, and Fosamprenavir with an undetectable viral load and CD4 count 275 cells/μL. He received an HLA-Identical sibling PSCT, conditioned as above, with additional anti-microbial prophylaxis with Entecavir for HBV; Azithromycin for MAC and Ciprofloxacin for a previous Rhodococcal pulmonary infection. Transplantation was complicated by neutropenic sepsis, pericarditis, and grade 2 cutaneous GVHD. Engraftment occurred day 21; BMA confirmed remission. He remained well with no further infective complications until day 67, when he presented with drug resistant Pseudomonal sepsis, multi-organ failure and succumbed day 78. The third patient was a 24 yo man with multiply-relapsed T-cell acute lymphoblastic leukaemia in second complete remission without prior AIDS-defining illnesses, maintained on second-line anti-retroviral regimen of Tenofovir, Ritonavir, and Fosamprenavir, with an undetectable HIV viral load and CD4 count 204 cells/μL. He received an HLA-identical sibling PSCT conditioned with etoposide 60 mg/m2 and TBI 13.2 Gy in 6 fractions, with extended anti-microbial prophylaxis. This was complicated by neutropenic dental infection and grade 2 cutaneous GVHD, treated with steroid therapy. Engraftment occurred day 25; BMA confirmed remission. There were no late complications and he maintained an undetectable HIV viral load and CD4 counts >200 copies/mL. At day 101 he relapsed, was treated with palliative intent, and died day 105. This series illustrates that allogeneic transplantation is a feasible therapeutic modality for high-grade hematological malignancies in carefully selected patients. Careful optimization of HIV control, and preventive management of infective complications and drug toxicity are critical to successful outcomes.

Passenger lymphocyte syndrome (PLS) is rare following solid organ transplantation. We describe 3 transplant recipients who developed severe hemolysis after receiving organs from a single donor with multiple red cell (RC) alloantibodies. The donor was a 54 y.o. male, blood group O Rh(D) negative (rr) with a positive antibody screen due to anti-D, anti-C and anti-k. His Cellano negative and RC alloantibody status was well characterized antemortem, given that he was a rare RC phenotype donor for the Australian Red Cross Blood Service (ARCBS). The lungs and the liver were offered for organ donation. The right single lung recipient was a 61 y.o. male with emphysema (blood group O Rh(D) positive [R2r]). From post transplant day (PTD) 0 to 10 his hemoglobin (Hb) fell from 126g/L to 69g/L without bleeding and with elevated hemolytic markers. A positive direct antiglobulin test (DAT) due to IgG was noted and anti-D eluted. Management included increased immunosuppression and transfusion of 2 RC units (rr, k positive). Ongoing hemolysis required a second transfusion at PTD 24. To facilitate tapering of corticosteroids, intravenous immunoglobulin (IVIG; 2g/kg in divided doses) was administered. The patient subsequently stabilized and 3 months post-transplant has mild compensated hemolysis with persisting anti-D. The left single lung recipient was a 59 y.o. female with emphysema (blood group O Rh(D) positive [R1r]). From PTD 0 to 10, Hb fell from 91g/L to 73g/L with elevated hemolytic markers. The antibody screen and elution demonstrated anti-D, and she was transfused with 2 RC units (rr, k positive). Three months post transplant she has ongoing evidence of mild compensated hemolysis with persisting anti-D. The liver recipient was a 45 y.o. male with Hepatitis B (blood group B Rh(D) positive [R1R1]). From PTD 0 to 13 Hb fell from 102g/L to 64g/L without bleeding. The DAT was positive (IgG) at day 4. Anti-D+B+C were detected in the plasma and anti-C+D+k+B were found in eluates. He was managed with increased immunosuppression and transfusion of 2 RC units (rr, k negative). Fresh Cellano negative units were accessed through the ARCBS rare RC register. The patient has subsequently also stabilized, despite ongoing seropositivity for anti-D (but not anti-k). These cases highlight the potential for severe hemolysis due to PLS following solid organ transplant. This is the first apparent description of PLS where anti-k has been implicated, with significant hemolysis in all recipients of organs from the same donor. We conclude that the identification of donor RC alloantibodies at the time of transplant should prompt close surveillance for development of PLS. Consideration of strategies to ameliorate hemolysis, such as early use of IVIG, is suggested. Where an antibody to a high incidence antigen (such as Cellano) is detected, early notification of central blood bank services may facilitate call up of phenotyped donors and provision of rare units.

Chronic Lymphocytic Leukaemia (CLL) is a lymphoproliferative disorder in which leukaemic B cells are arrested in the G0/G1 phase of the cell cycle, resulting in their prolonged lifespan. The clinical course of CLL is highly variable with survival ranging from a few months to decades. Thus, a good prognostic tool is needed to help predict the course of the disease. The pathogenesis of CLL is unknown but it has been associated with the “escape” of B cells from apoptosis, possibly due to overexpression of anti-apoptotic genes and downregulation of pro-apoptotic genes. The expression of these genes is influenced by alterations in chromatin structure through a change in DNA methylation (chromatin remodelling) mediated by multi-protein complexes. The Vitamin D receptor (VDR), which forms part of one such chromatin remodelling complex, has been shown to be linked to the susceptibility to and outcome of other malignancies (e.g. prostate cancer). We hypothesised that VDR polymorphisms (FokI, TaqI, BsmI and ApaI) may be linked to CLL pathogenesis and/or might be a marker of CLL progression, given the immunomodulatory actions of Vitamin D. The genotypes of 34 patients with CLL were determined by either allele-specific PCR (FokI) or PCR/restriction digestion analysis (TaqI, BsmI and ApaI). Clinical data including disease stage (Rai), other prognostic markers (e.g. lymphocyte doubling time) and therapy status were recorded. Statistical analysis including Wilcoxon, Chi-square and Spearman correlation tests were performed. Initial analysis-to-date has not shown significant difference in allelic distribution between CLL patients and a healthy control population. There was no statistically significant association between the 4 VDR polymorphisms and the clinical parameters of CLL (all p>0.05). A larger cohort of CLL patients is currently under study to determine any such potential correlation.

Although essential in the management of AML, there is little information quantitating transfusion requirements for these patients. We evaluated 111 consecutive adults treated for AML, showing that approximately 150 blood donors are required to adequately cater for a single patient's complete therapy with little variation for age, prognostic group or intensity of treatment.

Alloimmune hemolysis is a recognized but infrequent complication of solid organ transplantation, particularly where there is incompatibility within the ABO blood group system. We describe severe hemolysis due to passenger lymphocyte syndrome (PLS) in all three recipients of organs from a single donor with multiple red cell (RC) alloantibodies. The first patient, a liver transplant recipient, required augmentation of immunosuppression to treat immune hemolysis due to anti-B, -D, -C and -Cellano (k). This is the first description of PLS caused by alloantibody to the high incidence RC antigen, k. The two single lung transplant recipients developed hemolysis due to anti-D. Both required escalation of immunosuppression and early transfusion support. Three months posttransplant, all three patients have ongoing evidence of compensated hemolysis. This series highlights the potential for severe non-ABO-mediated immune hemolysis following solid organ transplantation. A positive donor RC antibody screen should prompt careful monitoring of organ recipients for hemolysis.