A Comparative Evaluation of the Quality of Cryoprecipitate Prepared from 350 ml Versus 450 ml of Whole Blood and Different Methods of Thawing of Plasma: A Prospective Observational Study

INTRODUCTION

Cryoprecipitate is used in conditions like hypofibrinogenemia, massive transfusion with bleeding, and factor XIII deficiency. The current guidelines support the preparation of cryoprecipitate from 450ml whole blood. But 350 ml of whole blood collection is expected from low body weight (< 55 kg) donors. However, no standardized criteria exist for preparing cryoprecipitate from 350 ml of whole blood.

AIM

of the study : This study compared the fibrinogen and factor VIII levels in cryoprecipitate units prepared from 350ml versus 450ml whole blood collection. The study also compared the fibrinogen and factor VIII levels prepared by circulating water bath versus blood bank refrigerator (BBR) thawing method.

METHODOLOGY

A total of 128 blood bags were equally divided into groups A and B for 450 and 350ml whole blood collection further subdivided into subgroups based on thawing methods. The fibrinogen and factor VIII yield were analyzed in the cryoprecipitates prepared from both groups.

RESULTS

The factor VIII levels were significantly higher in cryoprecipitate made from 450ml whole blood collection (P= 0.02). The BBR method of plasma thawing resulted in better fibrinogen recovery than the cryo bath method. Whereas vice versa in the case of factor VIII recovery. A weak but significant positive correlation was noted in factor VIII levels with the plasma volume.

CONCLUSION

Over 75% of the cryoprecipitates prepared from 350 ml whole blood passed the fibrinogen and factor VIII quality control criteria. So, 350ml whole blood collection from low body weight (<55 kg) donors could be utilized to prepare cryoprcipitates. However, future clinical studies should focus on the cryoprecipitate's clinical efficacy prepared from 350 ml of whole blood.

Maintaining plasma quality and safety in the state of ongoing epidemic - The role of pathogen reduction

In the field of transfusion medicine, many pathogen reduction techniques (PRTs) are currently available, including those based on photochemical (PI) and photodynamic inactivation (PDI). This is particularly important in the face of emerging viral pathogens that may pose a threat to blood recipients, as in the case of the COVID-19 pandemic. However, PRTs have some limitations, primarily related to their adverse effects on coagulation factors, which should be considered before their intended use. A comprehensive search of PubMed, Wiley Online Library and Science Direct databases was conducted to identify original papers. As a result, ten studies evaluating fresh plasma and frozen-thawed plasma treated with different PI/ PDI methods and evaluating concentrations of coagulation factors and natural anticoagulants both before and after photochemical treatment were included in the review. The use of PI and PDI is associated with a significant decrease in the activity of all analysed coagulation factors, while the recovery of natural anticoagulants remains at a satisfactory level, variable for individual inactivation methods. In addition, the published evidence reviewed above does not unequivocally favour the implementation of PI/PDI either before freezing or after thawing as plasma products obtained with these two approaches seem to satisfy the existing quality criteria. Based on current evidence, if implemented responsibly and in accordance with the current guidelines, both PI and PDI can ensure satisfactory plasma quality and improve its safety.

Prolonged (post-thaw) shelf life of -80°C frozen AB apheresis plasma

BACKGROUND

Early plasma transfusion is important in the treatment of patients with major hemorrhage. Prolonged shelf life of AB type frozen −80°C and cold‐stored (4°C) deep frozen plasma (DFP) will improve strategic stock management, minimize need for resupply, and make pre‐hospital implementation more feasible.

METHODS AND MATERIALS

Plasma products type AB of different age and origin (−30°C Fresh Frozen [(FFP], −80°C DFP [short (±1 year) and long (±7 year)] stored) were thawed (Day 0), stored at 4°C, and sampled on Days 7 and 14. Additionally, samples of plasma containing blood products (Octaplas LG®, whole blood and platelets) were compared for coagulation factor activity, phospholipid clotting time (PPL), and kaolin TEG during 4°C or 22°C storage.

RESULTS

Coagulation profiles of FFP, short‐ and long‐stored −80°C DFP were not significantly different after thaw. Cold storage did not affect fibrinogen, Protein C, and Antithrombin III activities whereas factor V, VII, VIII, and Protein S decreased in all blood products. After 14 days DFP still meets the guidelines for clinical use, except for Protein S (0.4 IU/mL). With exception of Octaplas LG®, phospholipid activity and TEG coagulation were similar between plasma containing blood components during storage.

CONCLUSION

AB DFP quality was unaffected by almost 7 years of frozen storage. Quality of thawed 14‐day stored AB DFP met, with exception of Protein S, all minimal guidelines which implies that its quality is sufficient for use in the (pre)‐hospital (military) environment for treatment of major hemorrhage.

Evaluation of Coagulation Factors Activity in Different Types of Plasma Preparations

Fresh frozen plasma (FFP) is a crucial substitute therapy in management of bleeding; producing plasma from whole blood stored within 24 h offers operational flexibility and leukocyte filtration significantly reduce transfusion reactions, it is necessary to consider the impact of these plasma preparations on clotting factors activity. Total of 75 plasma samples collected from 25 blood donors distributed as 3 groups; FFP (Group A), leukocyte filtrated FFP (Group B) and plasma frozen within 24 h i.e. PF24 (Group C), for all samples prothrombin time (PT), INR, (APTT), Factors V, VII, VIII, IX levels and Fibrinogen were done, also comparing coagulation factors levels in FFP in different blood groups. There were significant difference between three groups in (PT), INR and (APTT): (P = 0.00). Concerning Factor VII: significant difference (P = 0.03) between the three groups, FFP had a significantly higher level of FVII compared to filtrated FFP (98.92 vs. 82.52%; P = 0.02), while no significant difference between FFP and PF24 was detected (P = 0.76). Factor VIII: had significant difference (P = 0.00) between the three groups, FFP and Filtrated FFP had no significant difference regarding level of FVIII (P = 0.72), but FFP had significantly higher level of FVIII compared to PF24 (P < 0.05). Concerning Fibrinogen level: no significant difference between FFP and filtrated FFP (P = 0.99), while FFP had a higher level versus PF24 (P < 0.05). On the Contrary, no significant difference between three groups in Factor V: (P = 0.22) and Factor IX: (P = 0.12). ABO blood group effect on studied parameters in FFP: FVIII was statistically higher in Non-O blood group (P = 0.03), other factors had no statistical differences (P > 0.05). The leukocyte filtration of FFP did not affect the majority of coagulation factors activities, although FVII level was reduced, it stills enough for surgical hemostasis. The PF24 resulted in reduced FVIII and fibrinogen levels but no significant changes in FV, FVII or FIX, thus, can be used for FFP indications except that specifically requiring replacement of FVIII and/or fibrinogen as Hemophilia or DIC. No significant difference in coagulation factors of FFP between O and non-O blood groups except FVIII that was reduced in O blood group.

The how's and why's of evidence based plasma therapy

Although traditionally fresh frozen plasma (FFP) has been the product of choice for reversing a significant coagulopathy, the modern blood bank will have several different plasma preparations which should all be equally efficacious in reversing a significant coagulopathy or arresting coagulopathic bleeding. Emerging evidence suggests that for a stable patient, transfusing plasma for an INR≤1.5 does not confer a hemostatic benefit while unnecessarily exposing the patient to the risks associated with plasma transfusion. This review will discuss the various plasma products that are available and present some of the current literature on the clinical uses of plasma.

Perioperative coagulation management--fresh frozen plasma

Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. This practice is not supported by the literature, is unlikely to be of benefit and unnecessarily exposes patients to the risks of FFP. The role of FFP in reversing the effects of warfarin anticoagulation is dependent on the clinical context and availability of alternative agents. Although FFP is commonly transfused in patients with liver disease, this practice needs broad reconsideration. Adverse effects of FFP include febrile and allergic reactions, transfusion-associated circulatory overload and transfusion-related acute lung injury. The latter is the most serious complication, being less common with the preferential use of non-alloimmunised, male-donor predominant plasma. FP24 and thawed plasma are alternatives to FFP with similar indications for administration. Both provide an opportunity for increasing the safe plasma donor pool. Although prothrombin complex concentrates and factor VIIa may be used as alternatives to FFP in a variety of specific clinical contexts, additional study is needed.

Instituting a thawed plasma procedure: it just makes sense and saves cents

BACKGROUND

The objectives of this time-series study were to elucidate the impact of a thawed plasma standard operating procedure (TP SOP) on plasma wastage and on cost savings.

STUDY DESIGN AND METHODS

This study compared plasma wastage for 1 year before versus 1 year after implementation of a TP SOP.

RESULTS

The plasma wastage and discard declined 79.7 and 64.9%, respectively, with a cost savings of $15,654.79 during the 1 year after implementation of the TP SOP. The risk that a unit of plasma would be wasted decreased 86.2% from Year 1 to Year 2 and the risk that a unit of plasma would be discarded decreased 76.3% from Year 1 to Year 2.

CONCLUSION

Our study showed the positive, sustained, impact of implementing a TP SOP. Twelve months after introducing the SOP our Blood Bank and Transfusion Medicine Services' plasma wastage and discard were dramatically reduced, saving thousands of dollars. Initiating a TP SOP just makes sense; it is easy to implement, conserves plasma, and saves cents.

Quality control of recovered plasma for fractionation: an extensive Italian study

BACKGROUND

This study was aimed at obtaining significant information on the quality of whole-blood plasma (WBP) delivered to a private pharmaceutical company by the blood transfusion centers (BTCs) of 10 Italian regions.

STUDY DESIGN AND METHODS

A statistical sampling plan of plasma units took into account the contribution each selected blood transfusion center, belonging to the 10 regions, made to the plasma pool annually delivered to the pharmaceutical company. A total of 1787 plasma units were selected for coagulation Factor VIII (FVIII:C) and Factor VIII antigen (FVIII:Ag) analysis.

RESULTS

The FVIII:C mean value was 0.99 IU per mL; it was significantly lower in O units (0.86 IU/mL) than in non-O units (1.08 IU/mL). The mean value of FVIII:Ag was 0.90 IU per mL; it was significantly lower in O units (0.78 IU/mL) than in non-O units (0.99 IU/mL). In units with a FVIII:C level of less than 0.70 IU per mL, the FVIII:Ag mean value (0.62 IU/mL) was higher in comparison to the FVIII:C mean value (0.57 IU/mL). Instead, in the units with a FVIII:C level of at least 0.70 IU per mL, the mean level of FVIII:C (1.08 IU/mL) was higher than that of FVIII:Ag (0.96 IU/mL).

CONCLUSIONS

The mean value of FVIII:C (0.99 IU/mL) in whole-blood plasma produced by the 10 Italian regions is higher than that reported in other studies. A total of 83.1 percent of units have a FVIII:C level of at least 0.70 IU per mL. The mean level of FVIII:Ag is lower than that of FVIII:C. FVIII:Ag is higher in those units with a FVIII:C level of less than 0.70 IU per mL, while it gradually decreases as FVIII:C exceeds 0.70 IU per mL, thus showing a greater resistance to handling of plasma in the production steps mostly affecting FVIII:C stability.

Factors influencing factor VIII activity in frozen plasma

BACKGROUNDS AND OBJECTIVES

Fresh frozen human plasma is an important raw material in the production of coagulation factor concentrates used in patients with haemorrhagic disorders. The aim of the study was to determine how the handling of plasma influences the recovery of coagulation factor VIII activity (FVIII:C), i.e. the influence of time between donation and freezing, of the freezing time and of the ice front velocity. We also studied a tentative eutectic point in human plasma.

MATERIALS AND METHODS

Aliquots of plasma from 12 different donors were kept at room temperature for 2, 4 and 6 h before start of freezing. We achieved fast freezing with a freezer that blows cooled air at a high velocity on the plasma containers. Freezing times were 0.5, 1, 4 and 24 h. Temperature was registered continuously during freezing. Plasma and NaCl solutions were frozen slowly to investigate the eutectic point.

RESULTS

Storage at room temperature for 6 h caused a small but statistically significant decrease in FVIII:C. Slow freezing with programmed freezing times of 4 and 24 h caused a more pronounced drop in FVIII:C as compared to that of 30 and 60 min. We found no eutectic point in plasma or in plasma with addition of 2 % (w/v) NaCl.

CONCLUSION

For an optimal yield of FVIII, freezing should start within 4 h after plasma donation. We propose the use of the term 'ice front velocity' instead of 'freezing speed', taking into consideration that the volume and shape of plasma containers may differ. We found only a marginal loss of FVIII:C when the ice front velocity was 26 mm/h or faster, but a significant loss when it was 9 mm/h or slower. We recommend freezing times of 60 min or shorter. We were not able to demonstrate any eutectic point in human plasma. We therefore recommend that the term eutectic point should not be used as a reference temperature in guidelines on plasma handling.

Study of coagulation factor activities in apheresed thawed fresh frozen plasma at 1–6°C for five days

The concern for the loss of activities of coagulation factors in thawed fresh frozen plasma kept at 1-6 degrees C for long periods has prevented transfusion services from using thawed plasma beyond 24 hours of storage. There is no mention of the method of collection of the plasma and/or the study of the bacterial growth in the studies reported in the literature. The present project was undertaken to investigate coagulation factor activities and bacterial growth in apheresed fresh plasma. Twenty apheresed plasma units from different blood groups were used. After the 24-hour expiration time of the thawed plasma kept at 1-6 degrees C, aliquots were taken at day 1, day 3, and day 5 of expiration time and were immediately frozen at -70 degrees C. Samples were assayed for activities of coagulation factors II, V, VII, VIII, X, XI, and fibrinogen (Fib). Our study reveals no statistically significant change in activities of coagulation factors II, VII, X, XI, and fibrinogen from day 1 to day 5 storage of plasma at 1-6 degrees C; however, there is a mean decrease of 8.8 and 14.3% in activities of factors V and VIII, respectively. All culture samples taken on day 5 storage were negative at 7 days. In conclusion, our results do not show a significant change in the activity of most coagulation factors in the thawed apheresis plasma stored at 1-6 degrees C over a 5-day period. Hence, it is feasible to transfuse the plasma beyond the 24-hour period without compromising the clinical outcome of patients with coagulopathy.

The quality of fresh-frozen plasma produced from whole blood stored at 4°C overnight

BACKGROUND

The aim of this study was to assess whether the quality of FFP produced from whole blood stored at 4 degrees C overnight is adequate for its intended purpose.

STUDY DESIGN AND METHODS

Fresh-frozen plasma (FFP) separated from whole blood (n = 60) leukodepleted (LD) after storage at 4 degrees C overnight (18-24 hr from donation, Day 1 FFP) was compared with that LD within 8 hours of donation (Day 0 FFP, the current standard method).

RESULTS

In more than 95 percent of Day 1 FFP units, levels of factor (F) II, FV, FVII, FVIII, F IX, FX, FXI, and FXII were greater than 0.50 U per mL except for von Willebrand factor (VWF) antigen and FVIII, where 92 and 87 percent of units, respectively, contained greater than 0.50 IU per mL. Compared with historical data on FFP stored for 8 hours, fibrinogen, FV, FVIII, and FXI were reduced by 12, 15, 23, and 7 percent, respectively, but other factors were not significantly reduced. Levels of VWF-cleaving protease activity were not different between FFP prepared from paired units of blood (n = 3) held for 8 or 24 hours, but were below the reference range in an additional 2 of 6 units held for 24 hours. The activities of protein S, protein C, antithrombin III, and alpha(2)-antiplasmin were reduced by less than 10 percent in Day 1 FFP (n = 20), but with final levels above the lower limit of the normal range in greater than 95 percent of units. Activated FXII antigen was not significantly raised in plasma stored for 18 to 24 hours, but levels of prothrombin fragment 1 + 2 were slightly increased (0.88 ng/mL, 18-24 hr; 0.65 ng/mL, < 8 hr).

CONCLUSION

These data suggest that there is good retention of relevant coagulation factor activity in plasma produced from whole blood stored at 4 degrees C for 18 to 24 hours and that this would be an acceptable product for most patients requiring FFP.

The quality of plasma collected by automated apheresis and of recovered plasma from leukodepleted whole blood

BACKGROUND

There exists a current lack of information about the composition of the different types of plasma. No direct comparisons between apheresis plasma (AP) and recovered plasma (RP) derived from in-line-filtered whole blood (WB) have been published to date.

STUDY DESIGN AND METHODS

Sixty AP units, 100 RP units from in-line-filtered WB held for 3 hours at 20 degrees C between donation and freezing, and an additional 100 RP units held for 15 hours at 20 degrees C before freezing were analyzed for coagulation factors and inhibitors, total protein, immunoglobulin G (IgG), and hemostasis and proteolysis activation markers. The influence of twice freezing and thawing on clotting factors V, VIII, and XI was also examined.

RESULTS

AP contains substantially greater activities of factor (F) V, FVIII, F IX, and FXI than RP frozen within 3 hours after WB donation. Prolonged holding of RP at 20 degrees C for more than 15 hours caused an additional reduction in FVIII, FXI, and protein S activities. Significantly greater levels of prothrombin fragments 1 and 2, platelet factor 4, and neutrophil elastase were found in RP compared with AP. IgG was lower in AP compared with RP. Twice freezing and thawing caused a marked drop in FV, FVIII, and FXI activity.

CONCLUSION

Higher FVIII and F IX potencies in AP compared with RP can be expected to result in greater yields when used for purification of these clotting factors. AP is presumably more efficient than RP for treating coagulopathies. RP, however, may contain higher IgG levels than AP.

Effects of extended storage of whole blood before leucocyte depletion on coagulation factors in plasma

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the quality of leucocyte-depleted plasma produced from leucocyte-depleted whole blood, stored for different periods of times before filtration through polyurethane filters.

MATERIALS AND METHODS

Whole blood was collected, from 48 voluntary donors, into quadruple blood bag sets with integrated whole-blood filters, and stored at room temperature for 1, 2, 6, or 18 h before filtration. Five samples were taken: one directly from the donor; one immediately after collection; one before and one after filtration; and one from plasma units before freezing. All samples were analysed for the following parameters: prothrombin time; activated partial thromboplastin time; prothrombin fragments F1+2; fibrinogen; factors VIII, XI and XII; von Willebrand factor antigen; ristocetin cofactor activity; collagen-binding capacity; multimers; and complement C3a-desArg.

RESULTS

Different whole-blood storage times before filtration did not have a significant effect on the stability of coagulation factors. The activity of all investigated coagulation factors in plasma was generally above 90 U/dl, even after 18 h of storage of whole blood before filtration. von Willebrand factor multimeric distribution remained stable throughout the process. However, activation of complement did occur during storage.

CONCLUSIONS

Leucodepleted plasma originating from leucodepleted whole blood maintains a satisfactory level of coagulation factors, even after the storage of whole blood for 18 h at room temperature before filtration.

Manufacture and composition of fresh frozen plasma and virus-inactivated therapeutic plasma preparations: correlation between composition and therapeutic efficacy

The clinical efficacy of the therapeutic plasma used in the treatment of congenital and acquired severe coagulopathy depends on the potency of clotting factor and inhibitor activities. The composition of plasma strongly depends on the conditions under which it is produced. A low citrate anticoagulant-to-blood ratio, short intervals between donation and plasma separation and rapid freezing markedly improve the preservation of unstable coagulation factors. The influence of different leukocyte reduction filters on plasma quality still requires clarification. Recent trials on long-term storage conditions suggest that keeping plasma at -30 degrees C or colder over a period of 24-36 months prevents substantial decrease in clotting factor activities including factor VIII (FVIII). Three types of therapeutic plasma are currently available. Quarantine-stored fresh frozen plasma (FFP) contains physiological activities of therapeutically relevant plasma proteins, but carries a risk of transmitting blood-borne viruses that cannot be detected by human immunodeficiency virus (HIV) and hepatitis B and C screening. In contrast, solvent/detergent-treated plasma (SDP) and methylene blue/light-treated plasma (MBP) is virtually free of HIV and hepatitis C virus (HCV) subtypes. Virus inactivation procedures can have the consequence of reducing several clotting factors and inhibitors in SDP and MBP to varying degrees. However, pooling of plasma units before solvent/detergent (SD) treatment results in well-standardized protein levels of SDP. At least five prospective trials and four observational studies covering different clinical settings suggest that SDP and FFP do not substantially differ in their clinical efficacy or in their tolerance. By way of contrast, there is a lack of data about the clinical efficacy and tolerance of MBP compared to FFP.