Introduction: Steady advances in the treatment of acute myeloid leukemia (AML) have improved outcomes in high-resource settings, with a 5-year overall survival rate of 29% and rising in the United States. In contrast, a diagnosis of AML in many resource-limited settings automatically confers a less than 10% one-year survival rate. To better understand this significant disparity, as well as how to narrow it, it is important to gather data illustrating the current landscape of AML management in resource limited-settings, including patient characteristics, disease-related and treatment-related factors. Here we examine the population of patients with AML at a single large academic medical center in Western Kenya that serves a catchment area of more than 20 million people. Objectives: To describe characteristics of patients presenting with AML at Moi Teaching and Referral Hospital (MTRH) hematology and oncology clinic between 2014 and 2020, to help identify areas of need to inform future interventions. Methodology: Retrospective, cross-sectional chart review study of all newly diagnosed patients (age 15 years and older) with AML presenting to the MTRH adult hematology and oncology clinic from January 2014 to December 2020. Results: We reviewed the charts of 113 patients with AML. The median age at diagnosis was 40 years (range 15-86 years), with an average age of 42 years. Forty-nine percent (n=55) were female. Thirty-five patients did not have French American British (FAB) subtypes documented (this method remains the main form of AML disease classification in this resource-limited setting). M2 subtype was the most common (n= 24). Seven patients had acute promyelocytic leukemia (APML), of which 4 died due to bleeding complications and lack of access to ATRA. Three APML patients who had access to ATRA were alive more than 1 year after diagnosis. White blood count (WBC) at diagnosis ranged between 600/cm3 and 336,000/cm3 with neutrophil predominance. Mean hemoglobin at presentation was 7g/dl (range 2.6g/dl-16g/dl). Most patients had been transfused with red blood cells prior to presentation and continue to require more transfusion. Platelet counts ranged between 4,000/cm3 to 782,000/cm3 with 36% of patients (n=41) having a count of less than 50,000/cm3. Fifty patients with AML received low dose subcutaneous cytarabine (20mg subcutaneous twice a day for 10 days every 4 to 6 weeks) and 3 patients had etoposide added to their treatment (50mg/m2 intravenous once a day for 7 days). No patient was treated with standard intensive induction chemotherapy, (7+3), due to lack of adequate supportive care. Only 5 of 63 (7.9%) non-APML patients whose outcomes were established survived for more than 12 months. The median overall survival at after diagnosis was 45 days. Thirteen percent of patients were lost to follow up (n= 15) and 1 patient was referred to another facility for possible induction with 7+3. Conclusion: AML remains a disparately lethal disease in resource-limited settings, where it impacts a relatively healthy, young patient population. In well-resourced settings, many of these patients would have a reasonable chance at long term survival and potential cure, but in Western Kenya most patients die within a few months of diagnosis. Due to the lack of adequate supportive care resources, even the younger patients mostly did not receive standard-of-care intensive induction therapy. The outdated FAB classification system is still in use. Lack of access to improved diagnostics, appropriate supportive care (antimicrobials and transfusion products) and limited availability of newer, effective, and less toxic treatment regimens are the main impedance to care. More efforts are needed to improve the management of acute leukemia in under-resourced countries. Disclosures LeBlanc: Pfizer: Consultancy, Other: Advisory Board; Otsuka: Consultancy, Honoraria, Other; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Flatiron: Consultancy, Other: Advisory board; Helsinn: Consultancy, Research Funding; Duke University: Research Funding; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Amgen: Consultancy, Other: travel; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Jazz Pharmaceuticals: Research Funding; Astellas: Consultancy, Honoraria, Other: Advisory board; American Cancer Society: Research Funding; Heron: Consultancy, Honoraria, Other: advisory board; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding; CareVive: Consultancy, Other, Research Funding; NINR/NIH: Research Funding; UpToDate: Patents & Royalties.

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Introduction: Persons with hemophilia (PWH) who develop need for surgery usually require a huge amount of clotting factor concentrate (CFC) infusion to manage their bleeding during the procedure and up to a few days or weeks afterwards until they achieve tissue healing. Managing such patients in a resource limited setting (RLS) is challenging endeavor due to limited availability of clotting factor concentrates to replace their specific deficient clotting factor. The peri-operative treatment for PWH who have antibodies against CFC is even more complicated because by-passing agents (BPA) remain largely unavailable and require more frequent administration. Health care institutions in most RLS depend on limited donations of these products and therefore surgical procedures performed require intricate planning to enable the use of the minimum required CFC or BPA to achieve optimal hemostasis. We sought to highlight our experience in managing patients with Hemophilia A who have antibodies against CFC who presented with need for surgery at Moi Teaching and Referral Hospital in western Kenya. Methods: We reviewed patients charts of PWH A who presented at MTRH for surgery between 2020 and 2021 and documented their factor levels, blood counts and inhibitor levels. Three PWH A had high responding inhibitor levels. The clotting factor concentrates (CFC) used were a combination of activated Prothrombin Complex Concentrates (aPCC) and recombinant Activated Factor VII (rFVIIa) with Antifibrinolytics to achieve hemostasis. Hemostasis was monitored by the patients' hemoglobin levels (Hb) in grams per deciliter (g/dl), clinical examinations of the surgical sites and patients reported symptoms. Results: Case 1: 42-year-old with severe hemophilia A and inhibitor of 143BU, presented with femur fracture needed fixation with platting. Surgery was done one year after the injury because of unavailability of adequate bypassing agents during the time of injury. Day 1-7 of surgery, patient was given rFVIIa 270mcg/kg 6hourly with Tranexamic acid, then reduced at 180mcg/kg 6hourly on days 8-9 post surgery. He was then switched to aPCC 100IU/kg first dose then at 75IU/kg 12hourly on days 10-14, then at 75IU/kg 24hourly days 15-17. Tranexamic acid was stopped before infusion of aPCC. Just after the surgery, was transfused two units of blood. He was started physiotherapy day 14 post-operation. Patient pre-operative Hb was at 17.6g/dl, the Hb post-operation remained stable between 15g/dl and 12g/dl. There was some blood oozing noted during the first change of dressing but site remained clean and dry with reduction of limb swellings by 3cm. Case 2 : 8-year-old with severe hemophilia A and inhibitor of 6BU, had bilateral undescended testis needed bilateral orchidopexy and circumcision. The surgery proceeded after 2 months of the schedule. He was given rFVIIa at 180mcg/kg 6hourly on Day 1 and 2 of surgery with Tranexamic Acid 8 hourly. On the evening of day 2 post surgery, he was switched to aPCC at 100IU/kg 24hourly to day 4 post surgery. He continued with Tranexamic acid 6 hourly, given 6 hours after aPCC infusions. Patients Hb remained stable at 13g/dl pre and postoperatively with no noted bleeding at the surgical sites. Case 3: 3year old with moderate hemophilia A, presented with extensive subdural hematoma causing midline shift and loss of speech, needed emergency surgery. Burr hole was done with factor replacement then noted to have inhibitor of 6BU a days after the surgery. He was immediately given aPCC at 100IU/kg 12hourly for 10 days. His Hb remained stable at 10-9g/dl pre- and post-operatively with dry surgical site. Revaluation head Computerized tomography (CT) scan showed resolving hematoma with no midline shift. Conclusion: All the patient had adequate hemostasis during the surgery period with only the first case needing blood transfusion. There were no reported bleeding complications or thrombosis seen post-surgery and on follow up reviews. Despite the challenges faced it was possible to achieve adequate hemostasis needed for the surgical interventions using moderate doses of BPA, attesting to the potential that RLS are capable in managing hemophilia patients with inhibitors. We recommend further studies on the minimal dosing recommendations of BPA needed to achieve adequate hemostasis in surgical management of hemophilia patients with inhibitors in resources constrained environments. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.