Blood Of The Future Advanced Modifications Of Blood Components

(1)

Blood Of The Future – Advanced

Modifications Of Blood

Components

Dr. Lilach Bonstein

Blood Bank and

Platelet & Neutrophil Immunology Laboratories

(2)

(3)

(4)

(5)

(6)

(7)

Blood Safety

Blood transfusions have never been

safer but there will always be a risk

(8)

Canadian Blood Services Surveillance Report 2015

(9)

CMV

Chagas Disease (Trypanosoma cruzi)

(10)

Bacterial Contamination

• In western countries

bacterial contamination

of transfusions products

is more frequent than

viral infections

(11)

Main issues to address:

• Demand/Donors

• Safety

• Storage (length, conditions)

• ABO compatibility , Alloimmunization,

refractoriness

• Adverse reactions

(12)

Platelet transfusion demand

• Rise in platelet component demand

• Ageing population

• Changes in medical treatments

(13)

Room Temperature PLTs

“One-size-fits-all” Storage Solution

• Platelets are stored at room

temperature (RT) (20°C-24°C) • increased risk of bacterial

growth

• shorter shelf life → reduced availability → greater burdens on donors

• requirements for dedicated

incubators and agitators

• risk for febrile nonhemolytic transfusion reactions

• reduced product efficacy due to storage lesion (impaired hemostatic function)

(14)

Platelet Storage Lesion

• Morphologic/functional changes

: disc-to-sphere shape change,

activation, degranulation, and aggregation

• Metabolic changes

: increased glycolysis , decrease in pH

• storage lesion is associated with

decreased in vivo recovery

,

(15)

Modified Platelet Products

• Modified platelet products should:

1. function

hemostatically as live platelets

2. not transmit

infection

3. have a long duration of

action

4. have

simple storage

requirements

5. have long

shelf life

(16)

1 st

modification:

(17)

PAS Reduce Transfusion Reactions

(18)

C.D. Josephson et al. Transfusion and Apheresis Science (2010)

ABO-mismatched Platelet

Transfusions

Clinically significant hemolysis is a rare but potentially severe

complication of administering an ABO-mismatched platelet

transfusion.

(19)

Percentage Of Type O Platelets Donors At The Platelet Donation Unit In RAMBAM month Donors Type O donors 01.2016 167 55 32% 02.2016 154 46 30% 03.2016 185 55 30% 04.2016 187 59 31%

(20)

2 nd

modification:

Pathogen Reduction/Inactivation

Technology

(21)

• Bacterial infection prevalence

ranges between 1:1000 and 1:5000 per platelet concentrate unit, while the risk in red cells is much lower.

• Testing of pathogen - a reactive way of avoiding transmission (Bacterial screening, emerging pathogens)

• PRT - a proactive way to deal with pathogens

(22)

Pathogen Reduction Technology (PRT)

• PRT crosslink the nucleic acids present in susceptible

pathogens, blocking replication and preventing their

proliferation.

(23)

Amotosalen/UVA – Intercept by

Cerus Riboflavin/UVB - Mirasol PRT by Terumo BCT

Compound Adsorption Device (CAD)

At the moment there are no commercial available PRT for red

cells or whole blood

(24)

Pathogen Reduction

Risks vs. Benefits

Benefits

• Reduction of known viruses, bacteria and parasites

• Potential reduction of emerging and unknown pathogens

• Reduced need for testing? • Enlarge donor pool?

• Platelet storage for up to 7 days

• Alternative to gamma-irradiation to prevent TA-GvHD

• Replacement of CMV serology testing

Risks

• Damage to transfuion products

• Toxicity to recipient

• Toxicity to processing personnel

• Toxicity to environment

(25)

3 rd

Modification:

Improved Haemostatic Function Of

Stored Platelets

• Platelets were routinely stored cold

(4C) until the early

1980’s

• practice switched to room temperature (RT) storage due

to the

longer circulation of RT platelets

, thought to be

(26)

Cold Stored (4C) Platelets

• Recognition of the

success

of whole blood (WB)

transfusion in military

operational settings has

engaged a debate on

reintroduction of

cold-stored WB in treatment of

critical bleeding

in civilian

health care.

• The

hemostatic function of

the platelets

contained in

cold-stored WB

has been

questioned.

(27)

Cold Stored (4C) Platelets

• pre-activation

- more

effective at achieving

hemostasis.

• have

better adhesion and

aggregation

functionality

• less

bacterial

contamination

• can be stored for

15 days

in PAS

(28)

cold platelets aggregate better

Room temperature (RT) storage decreases aggregation by day 3; 4C storage maintains better aggregation

Reddoch KM, et al. Shock 2014

4C 4C 4C

RT

(29)

4C storage in 65% PAS 35% plasma kept flat on the bench-top or agitated on a Helmer Shaker

Cold Platelets Do Not Require Agitation

(30)

Platelet Transfusions At Rambam Medical Center

1-8.2016

Units (SDP) Units (SDP) hemato-oncology adults 971 surgery 31 hemato-oncology pediatrics 429 cardiology 67 oncology 34 neurosurgery 80 internal 171 trauma 9 ICU 171 total 1605 total 358

1. ≥ 20% of patients are not oncology

(31)

• cold-stored apheresis

platelets were

approved

by the FDA

for the

resuscitation of

bleeding

patients.

• FDA allows storage of

apheresis platelets for

three days at refrigerator

temperature

(32)

Quality Control Of Cold-stored Apheresis Platelet

Concentrates

Norwegian Armed Forces Joint Medical Services

• In connection with an ongoing clinical trial of cold-stored

platelets for the treatment of bleeding in patients undergoing cardiothoracic surgery at Haukeland University Hospital in

Norway, in vitro quality controls were performed to ensure that platelet concentrates meet the EU requirements

• Aims: To evaluate in vitro quality and platelet function of

leukoreduced apheresis platelet concentrates in platelet additive solution stored at 2–6°C for 14 days.

• Conclusions: Cold-stored platelet concentrates meet the quality requirements when stored agitated for up to 14 days. Changes in pH and metabolic parameters reflected the expected low

metabolism. When evaluated by thromboelastography and impedance aggregometry, platelet function was preserved

(33)

Maximising Platelet Usage By Delaying

Refrigerated Storage

Australian Red Cross Blood Service

• Aims: To determine whether delaying

refrigerated storage of pooled platelets until near expiry is

comparable to immediate

refrigerated storage with respect to platelet quality and extending platelet shelf-life.

• Conclusions: The metabolic and

activation profile of cold-delayed platelets was similar to cold stored platelets during a 21 day storage period

• These data suggest that transferring platelets that are near expiry into refrigerated storage may be a viable option for maximising platelet

inventories, by extending the shelf life of platelets beyond 5 days.

(34)

Cold Platelets - Utilization

• Easy to integrate into blood product supply chains

• Unlikely to be suitable for

prophylactic

transfusion

• Dual inventories

- may be challenging

• Necessary if proved as superior resuscitation

product for

active hemorrhage

(35)

Cryopreserved Platelets

•The idea was born in the US navy use by the Dutch military in Bosnia and

Afghanistan

•To provide platelets in distance war zones

• “walking blood bank”

•freezing is the only technique to extend the shelf lives of blood products.

• Cryopreservation of platelets at − extend the shelf life from 5 days to 2 years.

(36)

Cryopreserved Platelet

Possible Applications

• management of

alloimmunized platelet-refractory

patients (autologous platelets during remission)

• Bank of

HLA typed

platelets

• Autologous platelets

for cardiac patients after

bypass surgery

• forward-combat

surgical facilities

(37)

Cryopreserved Platelet Transfusions

outcome studies outcome studies outcome studies platelets were hemostatically effective 3 trauma studies significantly less bleeding vs standard platelets 1 cardiac (bypass) study (9) CCI – 11 100 ± 3600 19 hematology/oncolo gy patient studies

(autologous) (5) bleeding times improved after transfusion (3) no improvement or a variable response (3) patients being supported only with cryopreserved platelets had no bleeding

more than 3000 cryopreserved platelet transfusions were

given to 1334 patients, no adverse effects were observed

Up to date, no large controlled clinical trial with thawed frozen platelets was conducted

(38)

The Hemostatic Activity Of

Cryopreserved Platelets

JOHNSON ET AL. TRANSFUSION 2014 TEG variables:

R-time (time to clot initiation; min) – significant decrease

MA, maximum amplitude (clot strength; mm) - significant decrease K-time (speed of clot formation; min) - not significantly changed

α-angle (clot growth; degrees) - not significantly changed

(39)

Cryopreserved Platelets Demonstrate A

Reduced Response To Collagen

Stimulation

• Aims

: To determine whether cryopreserved platelets were

capable of

responding to collagen stimulation

in vitro.

• Conclusions

: Cryopreservation of platelets

induces dramatic

changes in the platelet phenotype and significantly impairs

the response of platelets to collagen stimulation

• further efforts are required to delineate how the transfused

(40)

Cryopreservation Of Buffy Coat Platelet

Concentrates Photochemically Treated With

Amotosalen And UVA Light

Karolinska Institutet, Stockholm, Sweden

• PLTs cryopreserved (CPPs) in 5% dimethyl sulfoxide (DMSO) are currently in clinical development. INTERCEPT-treated CPPs may lower the patient safety risks

• Aims: to analyze potential effects of the INTERCEPT treatment on CPPs as compared to untreated CPPs. Functional, phenotypic and apoptotic properties of such PLTs were analyzed.

• Conclusions: CPPs show a number of ultra-structural rearrangements questioning their functional integrity.

• PCT CPPs exert hemostatic potential in vitro, not different to untreated CPPs.

• the use of PCT is feasible and may prevent CPPs from being a potential source of infection

(41)

Identification Of Procoagulant Platelet Subsets In

Cold-stored And Cryopreserved Platelets Using A

Novel Cell Death Marker

• Cold-storage (2–6°C) and cryopreservation (80°C with DMSO) of

platelets lead to platelet activation and microparticle release, which raises concerns of increased risk of thrombosis following

transfusion of these products.

• A novel cell death marker, GSAO, can be used to identify procoagulant platelets (Hua, Blood 2015)

• Aims: To evaluate the impact of different modes of storage on the

activation and procoagulant profile of platelet concentrates.

• Conclusions: Cold-storage and cryopreservation of platelet concentrates have a significant impact on the activation and

procoagulant profile of platelets, whereby cold-storage is a potent

activator and cryopreservation induces a large proportion of

procoagulant platelets.

• The clinical impact of these storage effects remains to be elucidated.

(42)

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British (right) and US Army dried

plasma units WWII

(44)

Available dried plasmas

• French Lyophilized Plasma

(FLYP), produced by the

French

Military Blood

Institute

• LyoPlas N-w, produced by

the

German

Red Cross

• Bioplasma FDP, produced by

National Bioproducts

Institute, Pinetown,

South

Africa

(45)

Lyophilized platelets

• potentially be the best approach

to platelet storage

• The ideal product - light,

temperature stable, have a long shelf life, and be rehydrated at the point of care with little processing.