“Go no Go” in plasma fractionation in the world’s emerging economies: still a question asked 70 years after the COHN process was developed!

Challenges associated with access to plasma-derived medicinal products in low middle-income and low-income countries

BACKGROUND AND OBJECTIVES

Plasma-derived medicinal products (PDMPs) are essential to treat many chronic conditions such as haemophilia and primary immunodeficiency. Patients living in low middle-income and low-income countries (LMICs and LICs, respectively) have limited access to PDMPs. The aim of this article is to explore the challenges of accessing PDMPs in LMICs and LICs.

MATERIALS AND METHODS

A review of the literature and reports on blood safety, plasma production and its utilization to produce PDMPs in LMICs and LICs was carried out.

RESULTS

There is huge wastage of recovered plasma in LMICs and LICs as a result of a lack of good manufacturing practice (GMP) in the production of plasma for fractionation. Together with the high cost of imported PDMP procurement, patients have limited access to such products.

CONCLUSION

There is a need to improve the situation by using domestically sourced plasma through the initiation of local plasma programmes through a stepwise approach to improve access to PDMPs in LMICs and LICs.

Applications of human and bovine serum albumins in biomedical engineering: A review

Serum albumin, commonly recognized as a predominant major plasma protein, is ubiquitously distributed among vertebrates, demonstrating versatility and widespread accessibility. Numerous studies have discussed the composition and attributes of human and bovine serum albumin; nonetheless, few systematic and comprehensive summaries on human and bovine serum albumin exist. This paper reviews the applications of human and bovine serum albumin in biomedical engineering. First, we introduce the differences in the structure of human and bovine serum albumin. Next, we describe the extraction methods for human and bovine serum albumin (fractionation process separation, magnetic adsorption, reverse micellar (RM) extraction, and genetic engineering) and the advantages and disadvantages of recently developed extraction methods. The characteristics of different processing forms of human and bovine serum albumin are also discussed, concomitantly elucidating their intrinsic properties, functions, and applications in biomedicine. Notably, their pivotal functions as carriers for drugs and tissue-engineered scaffolds, as well as their contributions to cell reproduction and bioimaging, are critically examined. Finally, to provide guidance for researchers in their future work, this review summarizes the current state of human and bovine serum albumin research and outlines potential future research topics.

Non-Cryoprecipitation Separation of Coagulation FVIII and Prothrombin Complex Proteins by Pseudoaffinity Calcium Elution Chromatography Using Anion Exchange Resin

Hemophilia A is treated with human plasma coagulation factor VIII (FVIII) replacement therapy and Hemophilia B with coagulation factor IX, which is purified from prothrombin complex concentrate (PCC). In this paper we evaluated the separation of FVIII and PCC by directly loading raw thawed plasma to an anion exchange resin (AEX). Under this relatively high ionic strength, most of the plasma proteins such as albumin, immunoglobulins and others were not adsorbed. Five resins commonly used in protein purification (plasma fractionation) were tested. With all resins, PCC was eluted by pseudoaffinity in a calcium gradient step. Afterwards, FVIII could be recovered with a good yield and high purification factor in the salt gradient step with 400–500 mM NaCl. Using ANX Sepharose FF and Q Sepharose FF, the CaCl₂ elution step was introduced after the intermediate wash with 200 mM NaCl, whereas using DEAE Sepharose FF, Fractogel EMD TMAE and Fractogel EMD DEAD, PCC eluted after the wash of the unbound proteins. Our results indicate that three important fractions: (1) albumin, immunoglobulin etc.; (2) PCC; and (3) FVIII can be separated in one chromatographic AEX column and the delicate and troublesome cryoprecipitation can be eliminated, making the purification of blood products faster and cheaper.

A retrospective audit to evaluate the appropriateness and rationalization of Fresh Frozen Plasma usage in a tertiary care hospital

Background

General guidelines describing the potential indications and contraindications of Fresh Frozen Plasma (FFP) exist. However, their implementation is inadequate, leading to inappropriate use in various clinical settings. This study aims to define the appropriateness of the FFP usage in terms of therapeutic versus prophylactic indications.

Methods

Retrospective audit was conducted over one year prior to and after an educational intervention (1122 patients for 6072 FFP units and 1061 patients for 4858 FFP units, respectively). Clinical diagnosis, indication for FFP transfusion, and coagulation profile were noted, and episodes of transfusion were divided into appropriate and inappropriate based on the guidelines of the British Committee for Standards in Hematology (2004 reviewed in 2018) and College of American Pathologists (1994).

Results

Initial audit found 51.8% of FFP transfusions to be inappropriate (3069 of 5922). Coagulation profile (with INR values less than 1.5 times of the normal) was the most common cause of inappropriate transfusion (15.08%). 56.7% of FFP were prophylactically transfused. Re-audit after educational interventions showed a 22.3% reduction in the number of inappropriate transfusions.

Conclusion

Inappropriate, as well as high prophylactic usage of FFP, was noticed in the initial audit, which reduced significantly after educational interventions. Regular CMEs, interactive sessions with clinicians, functioning Hospital Transfusion Committees, and prospective audits can affirm, further improve and reinforce the existing Hospital Transfusion Guidelines.

Treatment of MOG-IgG associated disease in paediatric patients: A systematic review

Aim to perform a systematic review of the literature on treatment of paediatric patients with MOG-IgG associated disease (MOGAD). Method We followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The search was conducted in Pubmed (MEDLINE) seeking articles of treatment of MOGAD in patients ≤ 18 years published between January 2012 and April 25th, 2020. Results We found 72 non-controlled studies (observational studies, case reports and expert recommendations). There were no randomized controlled trials (RCTs). The most commonly reported acute phase treatment was intravenous methylprednisolone in 88% followed by oral steroids in 67%, intravenous human immunoglobulin (IVIG) in 66% and plasma exchange in 33% of the studies. Long-term maintenance treatment was described by 53 studies mainly in relapsing disease course. The most frequently reported treatments were prolonged oral corticosteroids in 53% of the studies followed by azathioprine (51%), mycophenolate mofetil (45%), rituximab (41%) and periodic intravenous immunoglobulin (26%). Interpretation long-term treatment was reported mainly in relapsing MOGAD paediatric patients. However, the most frequently used medications are not those that have shown higher reduction in the annualised relapse rate in observational studies. RCTs with standardized outcomes are needed to confirm the safety and efficacy of current and new treatments.

Extending the pre-processing holding time of whole blood beyond 48 h reduces coagulation FVIII activity and immunoglobulin G content of recovered plasma

BACKGROUND

Plasma obtained via whole blood (WB) donation may be used either for transfusion or as recovered plasma (RP) for pooling and fractionation. In Canada, transfusable plasma must be processed within 24 h of phlebotomy, while the limit for RP processing is 72 h. We assessed the quality of RP produced by two WB processing methods and as a function of processing time.

STUDY DESIGN AND METHODS

RP units produced via the buffy coat method (BCM, n = 26) or whole blood filtration (WBF, n = 52) were tested for: the activities of prothrombin, fibrinogen, von Willebrand Factor (VWF), FV, FVII, and FVIII; the prothrombin time (PT); and total protein and IgG concentration. WBF RP units were evenly divided between those processed <48 h of phlebotomy (shorter-processed) or 48-72 h after phlebotomy (longer-processed).

RESULTS

WBF-RP did not differ significantly from BCM-RP in any tested parameter except for FV and FVIII, which exhibited mean reductions of 10.2% and 20%, respectively. Longer-processed WBF-RP did not differ significantly from shorter-processed WBF-RP in any tested parameter except for FVIII activity and IgG concentration, which exhibited mean reductions of 30.1% and 14.3%, respectively.

CONCLUSIONS

Canadian RP is currently fractionated into IgG, albumin, fibrinogen, and FVII/VWF concentrates irrespective of its method or time of processing. Our results supported the current approach of fractionating both BCM- and WBF-derived RP, but suggest that greater yields of immunoglobulin and FVIII/VWF products could be obtained if the maximum processing time was reduced from 72 h to 48 h.

Implementation of Plasma Fractionation in Biological Medicines Production

Context

The major motivation for the preparation of the plasma derived biological medicine was the treatment of casualties from the Second World War. Due to the high expenses for preparation of plasma derived products, achievement of self-sufficiency in human plasma biotechnological industry is an important goal for developing countries.

Evidence Acquisition

The complexity of the blood plasma was first revealed by the Nobel Prize laureate, Arne Tiselius and Theodor Svedberg, which resulted in the identification of thousands of plasma proteins. Among all these proteins, four of which are commercially important for production due to significant need of patients. These four products are: albumin, IgG, factor VIII, and Factor IX. The starting material for the production of biological drugs from plasma is natural which is different from synthetic starting material. So, the quality of plasma as starting material plays an important role in the quality of final product. Introducing new techniques for preparation of the biological drugs from human plasma has resulted in the improvements in purity of products, higher safety, and yield noticeably. Still, the backbone of the modern plasma fractionation technique is mainly based on cold ethanol fractionation of the human plasma that is almost the same as fractionation of crude oil, breaking it down into its components. The demand for IgG for treating immune deficiencies and coagulation factor VIII for hemophilia A determines how to design the plasma fractionation industry in terms of capacity. Nowadays, cold ethanol fractionation has followed by chromatographic methods, since they offer higher purity. In this review, we describe different methods of plasma fractionation such as cold ethanol fractionation, gel filtration, fractionation by salt, and fractionation by polyethylene glycol. There is no doubt that the four main products of human plasma are albumin, IgG, coagulation factor VIII, and IX, which their methods of separation from human plasma have been explained in this paper.

Conclusions

It can be concluded that plasma fractionation with ethanol at low temperature for the preparation of the main human plasma biological components including albumin, IgG, coagulation factors VIII, and IX is still the most widely used method at an industrial scale. Nowadays, this method is being used in combination with different chromatographic techniques in order to achieve a higher quality and the yield.

Cost-minimization analysis comparing intravenous immunoglobulin with plasma exchange in the management of patients with myasthenia gravis

INTRODUCTION

Myasthenia gravis (MG) exacerbations may be treated with intravenous immunoglobulin (IVIg) or plasma exchange (PLEX), which have equivalent effectiveness. This cost-minimization analysis compared IVIg with PLEX for treatment of patients with MG exacerbation.

METHODS

We combined the Ontario-based health cost data with clinical data from a randomized clinical trial. Analyses were undertaken from the perspective of a public healthcare insurer and from the perspective of a tertiary university hospital payer.

RESULTS

PLEX was less costly than IVIg among patients with a body mass index (BMI) > 15.7 kg/m(2) , from the perspective of the public healthcare insurer (P < 0.0001). However, PLEX was more costly than IVIg from the perspective of the hospital payer when the costs of blood products were excluded (P < 0.0001).

CONCLUSIONS

PLEX can be considered a short-term cost-minimizing therapy when compared with IVIg for treatment of MG exacerbation among patients with BMI >15.7 kg/m(2) , from the perspective of a public healthcare insurer. Muscle Nerve 53: 872-876, 2016.