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Since 1986, the American Society for Apheresis (ASFA) has published practice guidelines on the use of therapeutic apheresis in the Journal of Clinical Apheresis (JCA) Special Issue. Since 2007, updated guidelines have been published every 3 years to reflect current evidence based apheresis practice with the most recent edition (8th) published in 2019. With each edition, the guidelines are reviewed and updated based on any newly published literature since the last review. The PEXIVAS study, an international, randomized controlled trial comparing therapeutic plasma exchange (TPE) vs no TPE and standard vs reduced dose steroid regimen on the primary composite outcome of end stage renal disease or death in patients with ANCA-associated vasculitis (AAV), was published in February 2020. This study represents the largest study on the role of therapeutic apheresis in AAV published to date and prompted the JCA Special Issue Writing Committee to reassess the current AAV fact sheet for updates based on this newly available evidence. This interim fact sheet summarizes current ASFA recommendations for the evidence-based use of therapeutic apheresis in AAV and supersedes the recommendations published in the 2019 guidelines.

Dabigatran etexilate is an oral direct thrombin (Factor IIa) inhibitor approved for patients with atrial fibrillation and for management of risk of deep vein thrombosis and pulmonary embolism. Dabigatran offers advantages over treatment with warfarin, including limited laboratory monitoring. It is equivalent in prevention of stroke and deep vein thrombosis with essentially equivalent complication rates. In contrast to warfarin, reversal of the anticoagulation is less well established. Idarucizumab is available for reversal, however supporting research is mixed; the agent also happens to be quite expensive making availability difficult. Hemodialysis has been proposed as a method of reversal, but this is difficult in patients with life threatening hemorrhage, and is not available at many hospitals. Intravenous fat emulsion (IFE) has been used for treatment of overdose of lipophilic drugs. Most toxicologists only recommend IFE for patients in extremis after ingestion of a lipid soluble substance. Dabigatran is lipid soluble, although the pro-drug more so than the active metabolite. The authors sought to see if dabigatran-induced coagulopathy of human in vitro blood samples could be reversed with IFE. Blood samples were spiked with dabigatran or dabigatran plus IFE. Values for Ecarin clot time (ECT-primary outcome), PT/INR, and aPTT, were compared across both study arms. A total of 18 healthy volunteers were included in our study. There were no significant differences in the ECT, PT/INR, and aPTT between the dabigatran arm and the dabigatran plus IFE arm. Based on these methods, IFE does not reverse dabigatran-induced coagulopathy.

Sinusoidal obstructive syndrome, also known as hepatic veno-occlusive disease, is a potentially life-threatening complication that occurs in children undergoing haemopoietic stem-cell transplantation (HSCT). Differences in the incidence of genetic predisposition and clinical presentation of sinusoidal obstructive syndrome between children and adults have rendered the historical Baltimore and Seattle diagnostic criteria insufficient for children. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) proposed the first paediatric diagnostic and severity grading guidelines for sinusoidal obstructive syndrome, intended for implementation across European centres. However, universally accepted paediatric criteria are needed to ensure prompt diagnosis, definitive treatment, and improved outcomes for children, adolescents, and young adults with sinusoidal obstructive syndrome, and to facilitate international clinical research collaboration. We convened an international panel of multidisciplinary experts including physicians with expertise in HSCT, paediatric intensive care, nephrology, hepatology, radiology, pathology, and transfusion medicine; HSCT advanced-practice providers and medical trainees; pharmacists; and translational and basic science researchers from the Pediatric Acute Lung Injury and Sepsis Investigators Network, the EBMT, the Pediatric Blood and Marrow Transplant Consortia, and several other institutions with extensive experience in sinusoidal obstructive syndrome. Panellists convened at The University of Texas, MD Anderson Cancer Center (Houston, TX, USA) in February, 2019, to evaluate the available evidence. In this expert position statement paper, we provide consensus recommendations for the international implementation of guidelines for the diagnosis, severity grading, and treatment of sinusoidal obstructive syndrome among children, adolescents, and young adults. We endorse universal adoption of paediatric diagnostic guidelines for sinusoidal obstruction syndrome as proposed by the EBMT, and provide implementation guidance for standardisation across centres; we have further proposed adjunctive use of age-appropriate organ-specific toxicity criteria for severity grading and provided prophylaxis and treatment considerations among children and adolescent and young adult patients. Key recommendations include: (1) liver biopsy, portal venous wedge pressure, and reversal of portal venous flow on Doppler ultrasonography should not be used for the routine diagnosis of sinusoidal obstructive syndrome in children, adolescents, and young adults; (2) platelet refractoriness can be defined as a corrected count increment of less than 5000-7500 following at least two sequential ABO-compatible fresh platelet transfusions; (3) hepatomegaly is best defined as an absolute increase of at least 1 cm in liver length at the midclavicular line; and if a baseline measurement is not available, hepatomegaly can be defined as greater than 2 SDs above normal for age; and (4) the presence and volume of ascites can be categorised as mild (minimal fluid by liver, spleen, or pelvis), moderate (1 cm fluid), or severe (fluid in all three regions with1 cm fluid in at least two regions).

OBJECTIVES To summarize current bleeding scales and their validation to assess applicability to bleeding in critically ill children. DATA SOURCES We conducted electronic searches of Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and Web of Science Core Collection databases from database inception to 2017. STUDY SELECTION Included studies contained a bleeding score, bleeding measurement tool, or clinical measurement of hemorrhage. DATA EXTRACTION We identified 2,097 unique citations; 20 full-text articles were included in the final review. DATA SYNTHESIS Of the 18 studies that included subjects (two others were expert consensus definitions), seven (39%) were pediatric-only, seven (39%) were adult-only, and four (22%) included both adults and children. Nine (50%) occurred with inpatients (two studies in critical care units), seven (39%) involved outpatients and two (11%) included both inpatients and outpatients. Thirty-nine percent of the scales were developed for those with idiopathic thrombocytopenic purpura and only two (12%) described critically ill patients. The majority (80%) included need for treatment (either RBC transfusion or surgical intervention). The majority (65%) did not report measures of reliability or validation to clinical outcomes. CONCLUSIONS There is a lack of validated bleeding scales to adequately assess bleeding and outcomes in critically ill children. Validated scales of bleeding are necessary and urgently needed.

Background Immunomodulatory strategies in heparin-induced thrombocytopenia (HIT) include the use of intravenous immune globulin (IVIG) and therapeutic plasma exchange (TPE). The optimal application of these therapies is unknown and outcomes data are limited. We investigated treatment categories and laboratory and clinical outcomes of IVIG and/or TPE in HIT with a systematic literature review. Study design and methods We searched MEDLINE, Embase, and Web of Science through December 2019 for studies combining controlled vocabulary and keywords related to thrombocytopenia, heparin, TPE, and IVIG. The primary outcome was treatment indication. Secondary outcomes were platelet recovery, HIT laboratory parameters, heparin re-exposure, and post-treatment course. Case-level data were analyzed by qualitative synthesis. Results After 4241 references were screened, we identified 60 studies with four main categories of IVIG and/or TPE use as follows: (a) treatment of refractory HIT (n = 35; 31%); (b) initial therapy (n = 45; 40%); (c) cardiopulmonary bypass surgery (CPB; n = 30; 27%); and (d) other (n = 2; 2%). IVIG was most commonly used for the treatment of refractory HIT while TPE was primarily used to facilitate heparin exposure during CPB. Both IVIG and TPE were equally used as initial therapy. Heparin re-exposure occurred without thrombotic event in 29 TPE-treated patients and three IVIG-treated patients. Conclusion In patients with HIT, both TPE and IVIG are used for initial therapy or treatment of refractory HIT. However, TPE is more commonly used in patients undergoing CPB. Prospective studies may help clarify which treatment is indicated in HIT population subsets.

OBJECTIVES: To present the recommendations and supporting evidence for RBC transfusions in critically ill children with hematologic and oncologic disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.DESIGN: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.METHODS: The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The hematologic/oncologic subgroup included seven experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.RESULTS: The hematologic/oncologic subgroup developed 14 recommendations (seven clinical, seven research); all achieved greater than 80% agreement. In patients with sickle cell disease, Transfusion and Anemia Expertise Initiative recommends: 1) RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL rather than hemoglobin of less than 30% prior to surgical procedures requiring general anesthesia and 2) exchange transfusion over simple (nonexchange) transfusion if the child's condition is deteriorating (based on clinical judgment), otherwise a simple, nonexchange RBC transfusion is recommended. There is insufficient evidence to make recommendations on transfusion thresholds for patients with sickle cell disease prior to minor procedures, with acute stroke or with pulmonary hypertension. For patients with oncologic disease or undergoing hematopoietic stem cell transplant, a hemoglobin concentration of 7-8 g/dL is recommended. Due to lack of evidence, research is needed to clarify the appropriate transfusion thresholds in these patients.CONCLUSIONS: Transfusion and Anemia Expertise Initiative developed specific pediatric recommendations regarding RBC transfusion management in critically ill children with sickle cell disease, oncologic disease, and hematopoietic stem cell transplant and recommendations to help guide future research priorities.

BACKGROUND Four similar transfusion reactions involving infants were reported in less than 1 year. After transfusion of red blood cells (RBCs) via syringe in the operating room, each patient experienced discolored urine, laboratory evidence of hemolysis, and acute kidney injury. Clerical and serologic investigations were unremarkable. Mechanical hemolysis was considered. STUDY DESIGN AND METHODS Simulated syringe transfusions were performed. Measurements included hematocrit (Hct), free hemoglobin, and visual hemolysis index. Washed and unwashed RBCs were tested with or without a recently introduced one-way valve, using a 24- or 16-gauge intravenous catheter. Constant manual pressure (1.43 ± 0.49 mL/sec) or syringe pump (2 mL/min) was used and a subset was timed. RESULTS The valve increased hemolysis during manual transfusion using both catheters with washed and unwashed RBCs. With the 24-gauge catheter, the change in Hct was -3.53 ± 0.69% with the valve and 0.22 ± 0.13% without (p

BACKGROUND Drug-induced immune hemolytic anemia (DIIHA) is rare, but potentially life-threatening. A high index of clinical suspicion is required for diagnosis, since the number of medications known to induce DIIHA continues to expand. Additionally, in vitro antibody reactivity against reagent additives has been reported, which may complicate test interpretation. CASE REPORT A 61-year-old group A, D+ woman with a history of negative antibody detection tests developed hemolytic anemia on Postoperative Day 7 after repeat incision and drainage of a chronically infected right knee prosthesis. She was treated with multiple antibiotics in the postoperative period, including three cephalosporins and vancomycin intravenously as well as vancomycin and gentamicin-containing intraarticular cement spacers. STUDY DESIGN AND METHODS A workup for possible DIIHA was performed. Testing was performed using vancomycin and cephalosporin antibiotics. Initially, gentamicin injection solution was used for testing, followed by testing with its component ingredients. RESULTS A vancomycin antibody was detected and anemia resolved after vancomycin was discontinued. Reactivity was seen when gentamicin injection solution was used for testing, raising the possibility of a gentamicin antibody as well. However, testing with purified gentamicin as well as methylparaben and propylparaben demonstrated a paraben antibody that reacted with the paraben-containing gentamicin solution. The patient also demonstrated an anti-N. Neither the paraben antibody nor the anti-N appeared to cause in vivo hemolysis. CONCLUSION This is the second reported case of DIIHA associated with anti-vancomycin. It is the fourth report describing a paraben antibody.

INTRODUCTION: Anti-heparin/platelet factor 4 antibody immune complexes resulting from heparin-induced thrombocytopenia (HIT) are removed by therapeutic plasma exchange (TPE). We sought to define TPE in HIT practice patterns using an international survey. METHODS: A 31-item online survey was disseminated through the American Society for Apheresis. After institutional duplicate responses were eliminated, a descriptive analysis was performed. RESULTS: The survey was completed by 94 respondents from 78 institutions in 18 countries. Twenty-nine institutions (37%) used TPE for HIT (YES Cohort) and 49 (63%) did not (NO Cohort). Most NO respondents (65%) cited “no requests received” as the most common reason for not using TPE. Of the 29 YES respondents, 10 (34%) gave incomplete information and were excluded from the final analysis, leaving 19 responses. Of these, 18 (95%) treated ≤ 10 HIT patients over a 2-year period. The most common indications were cardiovascular surgery (CS; 63%) and HIT-associated thrombosis (HT; 26%). The typical plasma volume processed was 1.0 (63% CS and 58% HT). For CS, the typical replacement fluid was plasma (42%) and for HT, it was determined on an individual basis (32%). For CS, patients were treated with a set number of TPE procedures (37%) or laboratory/clinical response (37%). For HT, the number of TPE procedures typically depended on laboratory/clinical response (42%). CONCLUSION: In a minority of responding institutions, TPE is most commonly used in HIT to prophylactically treat patients who will undergo heparin re-exposure during cardiovascular surgery. Prospective studies are needed to more clearly define the role of TPE in HIT.

Acquired von Willebrand syndrome (AVWS) is a rare, potentially fatal bleeding disorder caused by low activity of von Willebrand factor (VWF) in patients without congenital deficiency. The majority of adult cases are associated with hematological malignancy, including lymphoproliferative (48%) or myeloproliferative (15%) disorders (Federici et al., 2000). Both qualitative and quantitative defects occur, due to antibody-mediated clearance or functional interference, increased proteolysis, absorption to malignant cells or platelets, or increased shear stress due to valvular defects or mechanical vascular devices (Tiede et al., 2011). The predominant mechanism for decreased or absent VWF in malignancy is autoantibodies that are inhibitory to VWF function or shorten VWF survival (Kumar et al., 2002 [3]). Antibody-mediated clearance occurs through inactivating antibody directed towards VWF, antibody binding the non-active sites of VWF, and nonspecific antibodies that form circulating immune complexes with VWF, enhancing clearance by the reticuloendothelial system (Mannucci et al., 1984). Bleeding may be very difficult to treat due to reduced half-life of VWF-concentrates.

Background: The balance of hemostasis and anticoagulation is a concern for patients dependent upon ventricular assist devices (VADs). Bleeding is a common complication with both short- and long-term use of these devices. A better understanding of the risk factors and etiologies of bleeding associated with these devices is needed and could improve the overall results. We sought to determine the relationship of mechanical circulatory assist device use with acquired von Willebrand disease (avWD) in children. Methods: Data were analyzed retrospectively via review of the medical record of 19 consecutive patients who were supported with the Berlin EXCOR VAD for greater than 24 hours. Laboratory testing for avWD was performed at the discretion of the clinical team, often in association with clinical bleeding. Results: Of 19 pediatric patients, 10 (52.6%) had laboratory testing consistent with avWD. Median time to detection of avWD was 35 days postimplantation of device (range 0-310 days). Both minor mucosal bleeding and bleeding requiring intervention were highly prevalent in patients in whom avWD was identified (10/10 [100%] and 7/10 [70%]). The mean age of all patients was 3.3 years, but patients found to have avWD tended to be older (mean 5.3 years) and supported with larger volume VADs. Conclusions: This experience demonstrates a high prevalence of avWD following EXCOR implantation. Bleeding, older age, and larger VAD size may be associated with avWD. These results should stimulate critical evaluation of individualized anticoagulation regimens in pediatric VAD patients.

SummaryIn 2010–2012, the North American Specialized Coagulation Laboratory Association (NASCOLA) distributed 12 proficiency testing challenges to evaluate laboratory testing for protein S (PS). Results were analysed to assess the performance of PS activity, PS free antigen, and PS total antigen testing. Statistical analysis was performed on the numeric results and qualitative classification submitted for each method. There were 2,106 total results: 716 results from PS activity assays, 833 results from PS free antigen assays, and 557 results from PS total antigen assays. The three assay types performed well in the classification of five normal samples and nine abnormal samples, although certain PS activity methods were more likely to classify normal samples as abnormal and one PS total antigen assay was more likely to classify abnormal samples as normal. PS activity methods were affected by interfering substances such as heterozygous or homozygous factor V Leiden mutation (underestimation) and the anticoagulant drug rivaroxaban (overestimation). In conclusion, NASCOLA laboratories using a variety of PS assays performed well in the classification of clearly normal and abnormal samples. Laboratories performing PS activity assays should be aware of potential interferences in samples positive for FV Leiden or containing certain anticoagulant medications.

OBJECTIVES: To present the recommendations and supporting literature for selection and processing of RBC products in critically ill children developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.DESIGN: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children METHODS:: The panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The RBC processing subgroup included five experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.RESULTS: Five recommendations reached agreement (> 80%). Irradiated cellular products are recommended for children at risk of transfusion-associated graft versus host disease due to severe congenital or acquired causes of immune deficiency or when the blood donor is a blood relative. Washed cellular blood components and avoidance of other plasma-containing products are recommended for critically ill children with history of severe allergic reactions or anaphylaxis to blood transfusions, although patient factors appear to be important in the pathogenesis of reactions. For children with history of severe allergic transfusion reactions, evaluation for allergic stigmata prior to transfusion is recommended. In children with severe immunoglobulin A deficiency with evidence of antiimmunoglobulin A antibodies and/or a history of a severe transfusion reaction, immunoglobulin A-deficient blood components obtained either from an immunoglobulin A-deficient donor and/or washed cellular components is recommended.CONCLUSIONS: The Transfusion and Anemia Expertise Initiative consensus conference developed recommendations for selection and processing of RBC units for critically ill children. Recommendations in this area are largely based on pediatric and adult case report data.

BACKGROUND Patients undergoing therapeutic plasma exchange (TPE) may present with risks for hemorrhage or thrombosis. Use of replacement fluids devoid of coagulation factors will decrease factor levels and platelet levels. There are no established guidelines for hemostasis management in these situations. MATERIALS AND METHODS A survey to evaluate current hemostasis management practice during TPE was conducted using online survey software. One response per institution was analyzed based on a hierarchical algorithm, excluding membrane filtration users, resulting in a maximum of 107 respondents. Descriptive analysis was performed with results reported as the number and frequency (%) of respondents to each question. RESULTS Apheresis Medicine physicians, alone (59.4%) or jointly with the requesting provider (29.2%), choose the replacement fluid. Based on a theoretical patient case receiving five TPEs approximately every other day, the percent of respondents who would use albumin with or without normal saline was 94.7% with no history of a bleeding or clotting disorder, 1.1% with active bleeding, and 8.8% with hypofibrinogenemia (

Neuromyelitis optica (NMO) is a relapsing inflammatory disease of the central nervous system that predominantly affects the spinal cord and optic nerves. The clinical hallmark of the disease is a step-wise deterioration of visual and spinal cord function. This study reviews patients with steroid resistant relapsing NMO presenting for therapeutic plasma exchange (TPE) at our institution from December 2005 to December 2012. A total of five patients were treated with single volume TPE. Both subjective and objective clinical response to TPE was estimated by three different sources (the patient, a Transfusion Medicine physician, and the treating Neurologist) with the patient and Transfusion Medicine physician's final assessment of response made at the time of the last TPE in the series and the treating neurologist's assessment of response made at the time of the next neurological exam after the last TPE. A total of 17 TPE series were performed with the average course of therapy being three series (ranged 1–5) with five TPE (ranged 3–7) per series. All patients demonstrated improvement with each series of TPE and all procedures were well tolerated with only transient and well-described reactions all of which were successfully resolved with minor or no sequelae. J. Clin. Apheresis 29:171–177, 2014. © 2013 Wiley Periodicals, Inc.

To assess the state of current practice in coagulation laboratories regarding three pressing issues: staffing, handling Ebola specimens, and testing/billing for tests that measure direct oral anticoagulants (DOAC).A survey and analysis of specialized coagulation laboratories in North America was conducted.Approximately 4,000 special coagulation tests-per-technologist-per-year was rated as either a "good" staffing level or "adequate-but-ideally-need-more" employees. Requiring technologists to perform more than that was rated as an "inadequate" staffing level. For Ebola patients, coagulation testing is mostly performed by point-of-care. Only 26.1% would perform coagulation tests for Ebola specimens within their laboratory (rather than at the bed side or a separate designated space outside the laboratory). Coagulation tests offered for Ebola patients were limited: prothrombin time (63.0% of laboratories), activated partial thromboplastin time (37.0%), D-dimer (13.0%), and fibrinogen (8.7%); 26.1% of laboratories did not offer any coagulation tests for Ebola patients. Approximately 35% of special coagulation laboratories bill for at least one laboratory test for DOACs: 33% bill for an anti-Xa calibrated with rivaroxaban, 17% bill for an anti-Xa calibrated with apixaban, and 27% bill for at least one of several tests for dabigatran. Approximately 48% do not offer any tests for DOACs.These results may help laboratories negotiate for additional technologists if needed, prepare for Ebola specimens, and manage the demand for laboratory tests for new DOAC anticoagulants.

Platelets play a crucial role in the pathogenesis of atherosclerosis, thrombosis, and stroke. Aspirin used alone or in combination with other antiplatelet drugs has been shown to offer significant benefit to patients at high risk of vascular events. Resistance to the action of aspirin may decrease this benefit. Aspirin resistance has been defined by clinical and/or laboratory criteria; however, detection by laboratory methods prior to experiencing a clinical event will likely provide the greatest opportunity for intervention. Numerous laboratory methods with different cutoff points have been used to evaluate the resistance. Noncompliance with aspirin treatment has also confounded studies. A single assay is currently insufficient to establish resistance. Combinations of results to confirm compliance and platelet inhibition may identify "at-risk" individuals who truly have aspirin resistance. The most effective strategy for managing patients with aspirin resistance is unknown; however, studies are currently underway to address this issue.

Wilson's disease (WD) is an autosomal-recessive disorder of impaired copper metabolism resulting in accumulation of copper primarily in the liver but ultimately in many organs and tissues. A small number of patients with WD initially present with fulminant hepatic failure (FHF), hypercupremia, and intravascular hemolysis. The therapeutic goals for these patients include quickly removing the copper and preparing the patient for liver transplantation. Here, we report on a 6-year-old male with WD in FHF with anemia, renal insufficiency, and coagulopathy. The patient received a series of therapeutic plasma exchanges (TPE) as adjunctive therapy to remove copper and stabilize his coagulopathy and anemia until a transplant was possible. A total of five single plasma volume (1500 mL) TPE were performed over the course of 11 days with plasma as the replacement fluid. Laboratory results demonstrated temporary improvement after each procedure. Liver transplantation was performed 12 days after beginning TPE and 35 days after admission to the hospital. TPE was a successful adjunctive therapy to bridge this patient with WD to transplantation.

Background Daily low‐dose aspirin is recommended for primary prevention of myocardial infarction and stroke in higher‐risk patients. Population trends in aspirin use for cardiovascular disease (CVD) prevention in an urban population (Minneapolis/St. Paul, 2010 population 2.85 million) from 1980 to 2009 were evaluated. Methods and Results Surveys of randomly selected adults aged 25 to 74 years were collected at 5‐year intervals. Self‐reports of regular aspirin use for CVD prevention and history of CVD were obtained. Six cross‐sectional surveys included 12 281 men and 14 258 women. Age‐adjusted aspirin use for primary prevention increased during this period from 1% to 21% among men and 1% to 12% among women. Aspirin use was highest in those aged 65 to 74 years. For secondary prevention, age‐adjusted aspirin use increased from 19% to 74% among men and 11% to 64% among women. While data are based on self‐report, a substudy using a biochemical indicator of aspirin use (serum thromboxane B 2 ) supports the validity of self‐report. Conclusions Aspirin for CVD prevention is commonly used by a large and growing portion of the general population. It is not known if this is based on professional advice or self‐prescribed use. It is also likely that many who would benefit do not use aspirin and others use aspirin inappropriately.

BACKGROUND: Acute hemorrhagic leukoencephalitis (AHLE) is a rare, fatal, central nervous demyelinating disease characterized by a rapid fulminant clinical course. Successful management requires early diagnosis, aggressive management of cerebral edema, and immunosuppression. Therapeutic plasma exchange (TPE) is infrequently used and commences after initial management fails. CASE REPORT: A 31-year-old man presented with right arm weakness, whose symptoms rapidly progressed to hemiplegia and aphasia. The patient was initially managed with glucocorticosteroids. Decompressive craniotomy and brain biopsies were performed when his intracranial pressure increased. Brain biopsy findings were consistent with AHLE. Mycoplasma pneumonia immunoglobulin G and immunoglobulin M serologies revealed recent infection. Despite surgical and medical management, he decompensated on Day 11, and TPE was initiated. The patient received a total of 10 TPE treatments. On the fourth day of TPE treatment, he was extubated. Twenty-one days after TPE began, he was ambulating with near normal muscle strength and was discharged. Four months after initial presentation, the patient has normal strength and is working full-time. CONCLUSIONS: AHLE has a fulminant course requiring accurate and rapid diagnosis. Successful therapy requires aggressive management of intracranial pressure and immunosuppression. Two other reports of AHLE document successful management with TPE. Each of these patients survived with minimal neurologic impairments. Given the likely immune-mediated nature of this disease, combined treatment of steroids, surgery, and TPE may lead to shorter hospital stays and improved neurologic outcomes. Clinical studies are needed to further study the effect of TPE on neurologic outcome in AHLE.

This study investigated the relationship between anti-factor Xa (anti-FXa) and activated partial thromboplastin time (aPTT) for monitoring intravenous unfractionated heparin (IV-UFH) in patients with continuous-flow left ventricular assist devices (CF-LVADs).CF-LVADs have become mainstream therapy for patients with advanced heart failure. Thromboembolic events, device thrombosis, and bleeding continue to be a challenge with this technology. Adequate anticoagulation is required to prevent these adverse events.A prospective study of consecutive patients implanted with a CF-LVAD was conducted. Paired samples were considered concordant if aPTT values fell into expected ranges for subtherapeutic, therapeutic, and supratherapeutic anti-FXa levels. Heparin dosing was on the basis of anti-Xa levels.A total of 340 paired values from 38 patients were evaluated. Anti-FXa and aPTT were discordant in 253 samples (74.4%), with a high degree of variability in aPTT for any given anti-FXa level (r(2) = 0.57). Results were discordant in 104 samples (63.8%) from patients undergoing bridging therapy with warfarin and in 149 samples (84.2%) from patients with device obstruction and/or hemolysis (p0.001). The most common pattern of discordance was a supratherapeutic aPTT value despite a therapeutic anti-FXa level (49.1% for bridging vs. 75.8% for device obstruction and/or hemolysis; p0.001).Levels of aPTT were disproportionately prolonged relative to the corresponding anti-FXa levels in CF-LVAD patients, particularly those with device obstruction. Hemolysis and warfarin administration may falsely elevate aPTT, resulting in overestimation of heparin concentration and under-anticoagulation. Use of aPTT and anti-FXa to guide heparin therapy may lead to different estimates of heparin concentration in the same patient.

We analyzed results from the External quality Control of diagnostic Assays and Tests program to assess current clinical laboratory practice and performance of different methods for factor XIII (FXIII) testing internationally. FXIII proficiency testing data from all eight surveys conducted in 2010 and 2011 were analyzed (1,283 results), comparing the three available methods for detecting FXIII deficiency, thus including clot-solubility qualitative activity, quantitative activity, and antigen. Clot-solubility qualitative assays detected a deficiency in only 16% (11/69) of samples with less than 2% FXIII. Assays using added thrombin detected more deficiencies (33%) than did assays without added thrombin (11%). The most commonly used quantitative activity method tended to produce higher results for low FXIII samples than other quantitative activity methods. Antigen results generally showed good accuracy compared with expected levels. The mean interlaboratory coefficients of variation showed wide variability, especially for samples with less than 10% FXIII activity. Laboratory self-classification of results (as normal vs. abnormal) was good, and was slightly better for specimens with ≤ 25% FXIII than for specimens with 26 to 70% or those with >70% FXIII. We conclude that quantitative activity assays perform better for detecting FXIII deficiency than clot solubility assays, although some quantitative activity assays overestimate low FXIII levels.

BACKGROUND: Patient blood management (PBM) has become a topic of intense interest; however, implementing a robust PBM system in a large academic hospital can be a challenge. In a joint effort between transfusion medicine and information technology, we have developed three overlapping databases that allow for a comprehensive, semiautomated approach to monitoring up-to-date red blood cell (RBC) usage in our hospital. Data derived from this work have allowed us to target our PBM efforts. STUDY DESIGN AND METHODS: Information on transfusions is collected using three databases: daily report, discharge database, and denominator database. The daily report collects data on all transfusions in the past 24 hours. The discharge database integrates transfusion data and diagnostic billing codes. The denominator database allows for rate calculations by tracking all patients with a hemoglobin test ordered. A set of algorithms is applied to automatically audit RBC transfusions. The transfusions that do not fit the algorithms’ rules are manually reviewed. Data from audits are compiled into reports and distributed to medical directors. Data are also used to target education efforts. RESULTS: Since our PBM program began, the percentage of appropriate RBC orders increased from an initial 70%-80% to 90%-95%, and the overall RBC transfusions/1000 patient-days has decreased by 67% in targeted areas of the hospital. Our PBM program has shaved approximately 3% from our hospital’s blood budget. CONCLUSION: Our semiautomated auditing system allows us to quickly and comprehensively analyze and track blood usage throughout our hospital. Using this technology, we have seen improvements in our hospital’s PBM.

Introduction: Aspirin (ASA) is recommended for the primary prevention (PP) of cardiovascular disease (CVD, defined as a first myocardial infarction or stroke) by the American Heart Association, Centers for Disease Control, and the U.S. Preventive Services Task Force. Rates of current ASA use for primary prevention of CVD are not well established. Furthermore, self-reported ASA use may be higher than actual use. We thus investigated self-reported and validated ASA use in a Minnesota population. Hypotheses: Current ASA use for primary prevention is low and self-report overestimates actual use. Methods: A population-based telephone survey was conducted of males 45-79 and females 55-79 years of age in a Minnesota community in 2012. Subjects were classified as PP or secondary prevention (SP) based on a history of CVD or previous cardiovascular procedures. Self-reported aspirin use was validated by measurement of serum thromboxane B 2 (sTXB 2 ), a stable metabolite of thromboxane A 2 , measured in a subset (n=54) using the Thromboxane B 2 EIA Kit (Cayman Chemical, Ann Arbor, MI) and reported as median (IQR). Results: A sample of 103 subjects (response rate 56%, age 64±9, 67% male) included both PP (n=74) and SP (n=29) cohorts. Risk factors were prevalent in both PP and SP groups: hypertension (41 vs 62%); diabetes (12 vs. 38%); hyperlipidemia (46 vs 76%); and current smoking (20 vs 23%). Daily aspirin use was reported by 37% of the PP vs. 76% of the SP groups. Within the PP group, most (96%) took aspirin to reduce the risk of CVD events. sTXB 2 levels were 165.6 (18.5, 250.1) ng/mL in aspirin non-users and were 2.8 (0.5, 12.0) ng/mL in self-reported aspirin users. A sTXB 2 cutpoint of 25 ng/mL to validate ASA exposure was associated with a sensitivity of 94% and specificity of 73%. Conclusions: Self-report of ASA use is a valid measure. Use is relatively low in a contemporary primary prevention population.

Background: Existing literature shows mixed conclusions regarding the impact of ABO incompatibility on outcomes following hematopoietic cell transplantation (HCT). As the future for umbilical cord blood (UCB) expansion technologies is bright, we assessed whether this typically-overlooked graft characteristic impacted various outcomes following UCB transplantation (UCBT) for non-malignant disorders (NMD). Patients and Methods: A prospectively maintained institutional BMT program database was queried for all patients undergoing first UCBT for NMD and their demographic, disease and transplant-related characteristics. For each transplant, UCB and recipient ABO compatibility was considered (1) matched, (2) major mismatched (recipient isoagglutinins against UCB antigen), (3) minor mismatched (UCB isoagglutinins against recipient antigen), or (4) bi-directional mismatched. In double UCBT, only the compatibility status of the dominant unit was considered. The impact of ABO incompatibility was assessed on the following outcomes using Kaplan-Meier and cumulative incidence functions: graft failure, aGvHD (grade II - IV and III - IV), cGvHD, platelet recovery, and overall survival. Cumulative red blood cell transfusion exposure per patient between HCT days 0 and +100 (c-RBC) was obtained from laboratory records. Donor hematopoietic chimerism values on the myeloid fraction of peripheral blood were reviewed at day +100 and most recent time assessed. HLA typing was at the antigen level for HLA-A and -B and allele level at -DRB1; in double UCBT, the matching status of the dominant unit was considered. Results: Through December 2014, 270 patients have undergone first UCBT for various NMD (inherited metabolic disorder = 165; marrow failure = 71; other = 34). The mean age at UCBT was 7.9 years (± 9.6). Most patients had a maximal performance score before UCBT (Lansky/Karnofsky of 100, n = 162; 60%) and were male (n = 164; 61%). Most patients received a single UCB unit (n = 225; 83%) and the majority of grafts were unrelated (n = 253; 94%). The average total nucleated cell dose was 8.0 x 107/kg (± 6). With respect to HLA-matching, 79 (29%) received matched, 133 (49%) single-mismatched and 57 (21%) two-mismatched grafts. Most patients received myeloablative conditioning (n = 209; 77%) and GvHD prophylaxis with cyclosporine and mycophenolate mofetil (n = 150; 56%). Negative CMV serostatus in both the graft and recipient was most common (n = 172; 64%). ABO compatibility for the cohort was as follows: matched, n = 93 (34%); major mismatch, n = 72 (27%); minor mismatch, n = 80 (30%); bi-directional mismatch, n = 23 (9%). ABO compatibility status was indeterminate in 2 transplants. Among all 4 ABO compatibility groups, no significant difference was seen in age, gender, NMD diagnosis category, conditioning intensity, HLA-matching, cell dose, number of UCB units, transplant era, performance score, GvHD prophylaxis, or CMV serostatus. Related UCB unit transplants were more likely to be ABO matched. Table 1 shows outcomes by ABO compatibility group with a median follow-up time of 4.5 years (range, 0.5 - 20). ABO compatibility status did not appear to impact any outcomes assessed, though a trend toward increased grade III - IV aGvHD was seen in recipients of major mismatched units. Table 1. Outcomes after UCBT for NMD by ABO Compatibility Status Outcome ABO Match (n=93) Minor Mismatch (n=80) Major Mismatch (n=72) Bidirectional Mismatch (n=23) P-value Overall survival, 5 y estimate (95% CI) 65% (53-74) 72% (59-81) 68% (54-78) 76% (51-89) 0.62 aGVHD (II - IV) (95% CI) 20% (12-29) 25% (15-35) 27% (16-38) 28% (8-49) 0.75 aGVHD (III - IV) (95% CI) 8% (2-15) 8% (2-14) 20% (10-29) 5% (1-14) 0.09 cGVHD at 5 y (95% CI) 8% (2-15) 7% (1-13) 8% (1-15) 5% (1-15) 0.96 Graft failure (95% CI) 19% (11-28) 20% (11-29) 25% (15-35) 17% (2-34) 0.83 Platelet recovery at 1 y (95% CI) 74% (65-83) 75% (65-85) 67% (55-78) 70% (48-91) 0.77 Day 100 chimerism, ≥ 80% (95% CI) 69% (58-79) 70% (60-81) 66% (54-78) 75% (56-94) 0.89 Most recent chimerism, ≥ 80% (95% CI) 79% (71-87) 75% (65-84) 66% (55-77) 74% (56-92) 0.33 c-RBC (Day 0 to +100) median (inter-quartile range) 11 (6-16) 10 (6-20) 10 (6-19) 14 (8-21) 0.75 y = year; CI = confidence interval Conclusion: ABO compatibility status did not seem to impact outcomes following UCBT for our large NMD cohort. Further analysis of the cohort to exclude interference on some outcomes assessed will be needed for a more definitive conclusion. Disclosures No relevant conflicts of interest to declare.

The direct antiglobulin test (DAT) is a laboratory test that detects immunoglobulin and/or complement on the surface of red blood cells. The utility of the DAT is to sort hemolysis into an immune or nonimmune etiology. As with all tests, DAT results must be viewed in light of clinical and other laboratory data. This review highlights the most common clinical situations where the DAT can help classify causes of hemolysis, including autoimmune hemolytic anemia, transfusion-related hemolysis, hemolytic disease of the fetus/newborn, drug-induced hemolytic anemia, passenger lymphocyte syndrome, and DAT-negative hemolytic anemia. In addition, the pitfalls and limitations of the test are addressed. False reactions may occur with improper technique, including improper washing, centrifugation, and specimen agitation at the time of result interpretation. Patient factors, such as spontaneous red blood cell agglutination, may also contribute to false results. Am. J. Hematol. 87:707–709, 2012. © 2012 Wiley Periodicals, Inc.

Background: Intravenous immunoglobulin (IVIG) is used to treat an increasing number of conditions. IVIG contains immunoglobulin G (IgG) directed against many targets, including red blood cell (RBC) antigens. Methods/materials: We report on three patients identified within a 7-month period in a single institution who developed haemolysis because of passively transferred anti-A. Results: The patients were a 34-year-old A (non-A1) D-positive male with aplastic anaemia, a 61-year-old A1 D-negative female with myasthenia gravis and a 57-year-old AB D-positive female lung transplant recipient. The haemoglobin decreased from 11·1 to 5·3 g dL−1 over 2 days, 12·8 to 7·8 g dL−1 over 6 days and 7·8 to 6·0 g dL−1 over several hours, respectively. All three patients had a negative antibody screen, positive direct antiglobulin test for IgG only and an elution containing anti-A1 reactivity. The patients were transfused with O RBC with an appropriate rise in haemoglobin. Conclusion: These cases illustrate the potential severity of haemolysis after IVIG because of passively transferred antibodies to blood group antigens. Lack of recognition of IVIG as a cause for haemolysis by clinicians may be further confounded if routine testing fails to detect the passively transferred ABO blood group antibodies.

Dear Sir, Pure red cell aplasia (PRCA) is an uncommon complication of ABO-incompatible haematopoietic stem cell transplantation. It is characterised by anaemia, reticulocytopenia and absence of erythroid precursors in a morphologically normal-appearing bone marrow (Sawada et al., 2009). Most cases of PRCA resolve spontaneously within weeks to months. While a small subset of patients has a protracted disease course requiring continued red blood cell (RBC) transfusions, there is no approved standard of care for PRCA. Tapering of immunosuppressives (including steroids and calcineurin inhibitors), plasma exchange, rituximab and anti-thymocyte globulin have all been employed with varying success rates (Booth et al., 2013). Here we describe a case of PRCA after ABO-incompatible transplant that responded remarkably to treatment with subcutaneous administration of the proteasome inhibitor bortezomib. A 60-year old woman received a non-myeloablative, human leucocyte antigen (HLA)-matched, ABO-mismatched sibling donor transplant for lenalidomide-refractory myelodysplastic syndrome (5q−). She received fludarabine/busulfan conditioning and tacrolimus/methotrexate for graft versus host disease (GVHD) prophylaxis. The donor was blood type A Rh-positive, and the recipient was O Rh-positive. The patient’s post-transplant course was complicated by delayed engraftment, thrombocytopenia and autoimmune haemolytic anaemia. She received pentostatin 4mg/m2 and donor lymphocyte infusion (DLI) for delayed engraftment on day 100. When seen at our institution 22 months post-transplant, she had transfusion-dependent anaemia (requiring RBC transfusions every 2–3weeks) and reticulocytopenia. Bone marrow biopsy showed erythroid aplasia and preserved haematopoiesis in other cell lines; dysplasia was absent, and parvovirus testing was negative. The patient had evidence of complete engraftment based on short tandem repeat analysis with 95–100% donor DNA in CD3 positive peripheral blood cells as well as bone marrow. Blood typing reflected transfused type O Rh-negative RBCs. Neither type A cells from the donor or Rh-positive cells from the patient were detected using either manual test tube or automated solid phase (Galileo Echo, Immucor, Norcross, GA, USA) methods, and reactions for anti-A and anti-B were 4+. The direct anti-globulin test (DAT) was negative using a saline test tube method with murine monoclonal antibodies for IgG and C3d (Immucor). The patient had a history of anti-S, -C and -K, an unidentified antibody, and autologous anti-D. At presentation to our institution the antibody screening was negative, though an unidentified antibody was subsequently detected. Anti-A and anti-B titres were performed using A1 and B cells (Immucor) and a gel card system [buffered gel and anti-human globulin anti-IgG (Rabbit), ID-Micro Typing System, Micro Typing Systems Inc., Pompano Beach, FL, USA]. High titres of anti-A (IgG 512 and IgM 32) and anti-B (IgG 256 and IgM 32) isohaemagglutinins were detected. Isohaemagglutinin titres remained elevated despite transfusion with washed RBCs to reduce passive transfer of an anti-A. She was treated with prednisone 60mg/day, rituximab 375mg/m2 weekly four times and methylprednisolone 1 g weekly six times without response. Eventually, all immunosuppressive medications were discontinued to induce a graft vs recipient response. Two subsequent bone marrow biopsies continued to show nearly absent erythropoiesis, and the rare erythroid cells present lacked the blood group A antigen (Fig 1a–c). Anti-A and anti-B titres remained elevated so, therefore, PRCA was thought to be due to the recipient’s plasma cells making anti-A antibodies. Therapy was changed to more effectively target plasma cells. Bortezomib is a potent inducer of apoptosis in plasma cells, and therapy was initiated by administering subcutaneous bortezomib 1·3mg/m2 weekly four times. The patient responded remarkably well to therapy. A month after completion of bortezomib, the patient’s haemoglobin measured 12·1 g/dL, reticulocyte count was 174 × 109/L and IgM and IgG anti-A titres were both

Estrogen receptor and c-Myc are frequently overexpressed during breast cancer progression but are downregulated in many aggressive forms of the disease. High levels of the EphA2 tyrosine kinase are consistently found in the most aggressive breast cancer cells, and EphA2 overexpression can increase metastatic potential. We demonstrate, herein, that estrogen and Myc negatively regulate EphA2 expression in mammary epithelial cells. These data reveal EphA2 as a downstream target of estrogen and Myc and suggest a mechanism by which estrogen and Myc may regulate breast cancer.

Introduction Pure red cell aplasia (PRCA) is an uncommon complication of ABO-incompatible hematopoietic stem cell transplantation. It is characterized by anemia, reticulocytopenia and absence of erythroid precursors in a morphologically normal-appearing bone marrow. Most cases of PRCA resolve spontaneously within weeks to months. A small subset of patients has a protracted disease course requiring continued red blood cell (RBC) transfusions. There is no approved standard of care for PRCA. Tapering of immunosuppressives such as steroids and calcineurin inhibitors, plasma exchange, rituximab, and anti-thymocyte globulin have all been employed with varying success rates. We report a case of PRCA after ABO-incompatible transplant that responded remarkably to treatment with bortezomib. Case Presentation A 60 year old female received a non-myeloablative HLA-matched ABO-mismatched sibling donor transplant for lenalidomide-refractory myelodysplastic syndrome (5q-). She received fludarabine/busulfan conditioning and tacrolimus/methotrexate for GVHD prophylaxis. The donor was blood type A Rh-positive and the recipient was O Rh-positive. The patient's post-transplant course was complicated by delayed engraftment, thrombocytopenia and autoimmune hemolytic anemia. When seen at our institution 22 months post-transplant, she had transfusion-dependent anemia requiring RBC transfusions every 2-3 weeks and reticulocytopenia. Bone marrow biopsy showed erythroid aplasia and preserved hematopoiesis in other cell lines, dysplasia was absent and parvovirus testing was negative. The patient had evidence of complete engraftment based on short tandem repeat analysis. Blood typing reflected transfused type O Rh-negative RBCs. Neither A cells from the donor nor Rh-positive cells from the patient were detected. High titers of anti-A and anti-B isohemagglutinins were detected despite transfusion with washed RBCs to reduce passive transfer. She was treated with prednisone 60mg/day, rituximab 375 mg/m2 weekly x4 and methylprednisolone 1g weekly x6 without response. Eventually, all immunosuppressive medications were discontinued to induce a graft versus recipient response. Two subsequent bone marrow biopsies continued to show nearly absent erythropoiesis, and the rare erythroid cells present lacked the blood group A antigen. Since PRCA was thought to be due to the recipient's plasma cells making anti-A antibodies, bortezomib, a potent inducer of apoptosis in plasma cells, was initiated. Subcutaneous bortezomib 1.3 mg/m2 was administered weekly x4. The patient responded well to therapy. A month after completion of bortezomib, the patient's hemoglobin measured 12.1 g/dL, reticulocyte count was 174 x109/L and IgM and IgG anti-A titers were both < 1. Bone marrow biopsy showed relative erythroid hyperplasia, and the majority of the erythroid precursors expressed blood group A. The patient continues to do well and at the time of her most recent evaluation, her hemoglobin was 13.9 g/dL. She has also remained transfusion-independent. Discussion PRCA after major ABO-incompatible transplant is thought to be caused by persistence of recipient plasma cells that continue to secrete anti-donor isohemagglutinins. Antibody titers may remain elevated for a longer duration in patients receiving non-myeloablative preparatory regimens. Bortezomib is a proteasome inhibitor that selectively induces apoptosis in plasma cells. Bortezomib has been used successfully to treat anti-body mediated rejection in both renal and liver transplant patients. A case of PRCA following ABO-mismatched hematopoietic transplant that was successfully treated with IV bortezomib has also been reported. To our knowledge, this is the first reported case of isohemagglutinin-mediated PRCA after ABO-mismatched transplant that responded favorably to subcutaneous bortezomib. Limitation The lack of long-term follow-up data precludes any assessment about the durability and persistence of response to bortezomib. Conclusion Bortezomib is an effective treatment for patients with PRCA mediated by residual host isohemeagglutinins after ABO-incompatible hematopoietic transplantation. Disclosures: Off Label Use: Our presentation describes the use of bortezomib for treatment of pure red cell aplasia after ABO-incompatible hematopoeitic stem cell transplantation. Vercellotti:Sangart Inc.: Research Funding; Seattle Genetics, Inc.: Research Funding.

ZAP-70 is a tyrosine kinase protein involved in T cell signaling, overexpression of which is associated with a poor prognosis in CLL. Clinical information on 32 pts with CLL, and 6 pts with prolymphocytic transformation (PLT) followed at our institution was retrospectively reviewed for Rai stage, ZAP-70, CD38, FISH and response to treatment to determine the prognostic association among these factors. Ages ranged from 37 to 78 (median 59). 5/32 pts with CLL had received prior initial therapy, while 17/19 pts had not. They eventually were all treated with fludarabine based regimens either as salvage or upfront. The remaining 8/32 had not required therapy. Response to therapy was correlated with ZAP-70 expression as measured by immunohistochemistry using a monoclonal antibody to ZAP-70 (clone 2F3.2).17/32 patients (53%) were ZAP-70 positive, as were 3/6 (50%) of the patients with PLT. Of the patients with CLL who were ZAP-70 positive, 5 (30%) were stage 0-II, and 12 (70%) were stage III/IV, while18% did not require therapy. Of the 13 who were treated there were 4 (31%) CR, and 5 (38%) PR. Of the patients who were ZAP-70 negative, 50% (7/14) had stages 0-II and 50% had stage III/IV disease. 5/14(36%) were not treated. Of the 9 who were treated there were 2 CR 22%, and 7 PR 78% (p=0.01). 3 PLT patients were previously treated for CLL with fludarabine-based combinations. When they required therapy for PLT, two achieved a CR (one to rituximab/fludarabine/cytoxan_ZAP-70 positive patient, and one to R-CHOP combination_ZAP-70 negative), and another a PR (to R-EPOCH combination_ZAP-70 negative patient). Of the previously untreated PLT patients, two ZAP-70 positive patients achieved a CR (one to rituximab/fludarabine/cyclophosphamide, and one to R-CHOP). One ZAP-70 negative patient was refractory to fludarabine/rituximab combination. Conclusion: ZAP-70 positive CLL is more likely to be refractory to treatment, while ZAP-70 negative pts achieved a higher ORR (p=0.01). Although pts who were ZAP-70 positive were more likely to have advanced stage, 30% of these pts had early stage disease. As such, ZAP-70 did not closely correlate with stage, and may be an independent prognostic factor in these pts. Response to treatment could also not be predicted by ZAP-70 expression. ZAP-70 Number of Pts Previous Treatment Number of Pts Response Positive 16 No 10 3CR, 4PR Yes 3 1CR, 1PR Negative 14 No 7 2CR, 5PR Yes 2 2PR

Cytogenetic abnormalities detected by fluorescent in situ hybridization (FISH) can predict differences in survival in patients with CLL. Patients (pts) with the 13q14 deletion experience a longer median survival that those with the 17p13.1 deletion. Overexpression of ZAP-70 and CD38 correlate with a poor prognosis. Data on 44 pts currently enrolled on a prospective CLL prognostic study were analyzed for cytogenetic abnormalities by FISH and CD38 by flow. Pt age ranged from 25 to 85 (median 59). 25/44 patients (57%) were followed without any therapy. Zap-70 expression was measured by immunohistochemistry using a monoclonal antibody to ZAP-70 (clone 2F3.2). Results: 22/44 (50%) pts were found to have abnormal cytogenetics. Of the 22 abnormalities, 17 had a 13q14 deletion (including one with an additional 11q22.31 deletion, and two with nullisomy 13q), five patients had trisomy 12, one patient a 17 p13.1 deletion. 8/44 patients overexpressed CD38. Of the pts with an isolated 13q deletion, 12/16 (75%) were CD38 negative and 10/17 (59%) were followed without any therapy, compared to 20/27 (74%) and 14/27 (52%) in those with other cytogenetic features respectively. Of those with other abnormal FISH findings, 4/5 pts (90%) with trisomy 12 were CD38 negative, a patient with 17p13.1 deletion and another patient with both 13q14 and 11q deletion were also CD38 positive. Of the patients with normal FISH results 19/21 (90%) were CD38 negative. ZAP-70 overexpression was noted in 22/26 pts with available data including 8/10 (80%) patients with and 13/26 (50%) patients without the 13q del. Conclusion: The presence of the 13q14 deletion appeared to be independent of CD38 expression. Further studies to determine the association of 13q14 deletion with ZAP-70 expression are warranted, as is the correlation with clinical data.