Donor exposure to the plasticizer di(2-ethylhexyl)phthalate during plateletpheresis

Ex Vivo Model to Assess the Exposure of Patients to Plasticizers from Medical Devices during Pre-CAR-T Cells’ Apheresis

Background: The treatment of relapsed or refractory leukemia remains a major problem. Among the new therapeutic approaches, the use of modified T lymphocytes, called chimeric antigen receptor T cells (CAR-T cells), seems promising. The first step of their preparation is leukapheresis, which involves the collection of mononuclear cells from the patient. This medical procedure requires numerous medical devices (MDs) made of plasticized polyvinylchloride (PVC). These compounds can leach out of the devices during contact with the patient’s blood. The aim of our study was to evaluate the migration of the plasticizers contained in the MD during a simulated pre-CAR-T cell leukapheresis procedure, and to measure the patient’s and their lymphocytes’ exposure to them. Methods: The qualitative and quantitative composition of the MD used for pre-CAR-T cell apheresis was determined by gas chromatography–mass spectrometry (GC–MS). Then, an ex vivo leukapheresis model using an ethanol/water simulant was performed to evaluate the plasticizers’ migration under simulated clinical conditions of pre-CAR-T cells’ cytapheresis. The plasticizers released into the simulant were quantified by GC–MS. Results: Diethylhexylphthalate (DEHP) was found in the apheresis kit, with amounts ranging from 25% to 59% (g/100 g of PVC). Bis(2-ethylhexyl) adipate was detected at trace levels. A total of 98.90 ± 11.42 mg of DEHP was released into the simulant, corresponding to an exposure dose of 1.4 mg/kg for a 70 kg patient. Conclusions: Patients undergoing a pre-CAR-T cell apheresis are mainly exposed to DEHP, which can impact their health because of its endocrine disruption effect, but could also lead to a decrease in CAR-T cells’ efficiency/quality.

Relevance of di(2-ethylhexyl)phthalate blood levels for blood transfusion detection

Background: A method to detect the banned use of blood transfusions by athletes has proven elusive. In this article, we investigate the utility of analyzing contaminant levels in stored blood as a possible marker. The presence of the plasticizer di(2-ethylhexyl)phthalate (DEHP) was measured in red blood cells collected from transfused subjects. Results: GC-MS detected high levels of DEHP in stored red cells. However, values fell rapidly after the cells were reinfused, with only half of the samples exceeding a cut-off 4 SDs above the baseline 90 min postinfusion. Conclusion: It was demonstrated that intact DEHP could be measured in red blood cells. Owing to its short window of detection, this approach seems to have limited utility in the context of antidoping.

Evaluation of the Di(2-ethylhexyl)phthalate released from polyvinyl chloride medical devices that contact blood

Extraction methods that simulate those used in the clinic are recommended for obtaining extraction solutions. For polyvinyl chloride (PVC) medical devices that have contact with human blood, an alternative medium (ethanol/water mixture) is suggested as an extraction screening vehicle to evaluate the di(2-ethylhexyl)phthalate (DEHP) released. A test comparing the extraction ability between the alternative medium and whole blood from three healthy volunteers has been conducted. An experimental method is provided outlining the chemical analysis of the DEHP released from medical devices made with polyvinyl chloride (PVC). Gas chromatography-mass spectrometry (GC-MS) in the selective ion monitoring (SIM) mode was used to analyze and quantify the extracted DEHP. The linear range of the SIM method was 0.1-200 μg/mL, and the recoveries were 89.6-101.5% and 91.0-98.9% when using the ethanol/water mixture and whole blood as the extraction media, respectively. The validated method demonstrates that it is suitable for the determination of the DEHP released from PVC medical devices that have contact with blood. The results from the determination of the DEHP released will be compared with the limits derived from toxicological data for the parenteral exposure route and certain population groups, and the results will be used in the risk assessment of medical devices.

Adverse events and safety issues in blood donation--a comprehensive review

Although blood donation is generally safe, a variety of risks and complications exist, the most common being iron deficiency, vasovagal reactions and citrate-related events. In the last decades, extensive efforts have significantly improved recipient and product safety, but there is still great potential to optimise donor care. Many therapies in modern medicine depend on the prompt availability of blood products, therefore it is crucial to maintain a motivated and healthy donor pool in view of a limited number of healthy volunteers willing and able to give blood or blood components. We present a comprehensive review on adverse events addressing all types of blood donation including whole blood, plasma, platelet, peripheral blood stem cell, leucocyte and bone marrow donation. In addition, we outline strategies for the prevention and treatment of these events and give a blueprint for future research in this field.

Plasticizers excreted in urine: indication of autologous blood transfusion in sports

BACKGROUND

Misuse of autologous blood transfusions in sports remains undetectable. The metabolites of the plasticizer di-(2-ethylhexyl)phthalate (DEHP) were recently proposed as markers of blood transfusion, based on high urinary concentrations of these compounds observed in patients subjected to blood transfusion. This study evaluates DEHP metabolites in urine for detecting autologous blood transfusion.

STUDY DESIGN AND METHODS

One blood bag was drawn from moderately trained subjects and the red blood cells (RBCs) were reinfused after different storage periods. Group 1 (12 subjects) was reinfused after 14 days, and Group 2 (13 subjects), after 28 days of storage. Urine samples were collected before and after reinfusion for determination of the concentrations of three DEHP metabolites, mono-(2-ethylhexyl)phthalate, mono-(2-ethyl-5-hydroxyhexyl)phthalate, and mono-(2-ethyl-5-oxohexyl)phthalate.

RESULTS

Concentrations of DEHP metabolites on the days before reinfusion were in agreement with those described after common environmental exposure. A few hours after the reinfusion a significant increase was observed for all metabolites in all volunteers. Concentrations 1 day later were still higher (p < 0.05) than before reinfusion. Variations in urine dilution supported normalization by specific gravity. Concentrations of DEHP metabolites tended to be higher after longer storage times of RBCs.

CONCLUSION

Autologous transfusion with RBCs stored in plastic bags provokes an acute increase in the urinary concentrations of DEHP metabolites, allowing the detection of this doping malpractice. The window of detection is approximately 2 days. The method might be applied to urine samples submitted for antidoping testing.

Assessing exposure to phthalates - the human biomonitoring approach

Some phthalates are developmental and reproductive toxicants in animals. Exposure to phthalates is considered to be potentially harmful to human health as well. Based on a comprehensive literature research, we present an overview of the sources of human phthalate exposure and results of exposure assessments with special focus on human biomonitoring data. Among the general population, there is widespread exposure to a number of phthalates. Foodstuff is the major source of phthalate exposure, particularly for the long-chain phthalates such as di(2-ethylhexyl) phthalate. For short-chain phthalates such as di-n-butyl-phthalate, additional pathways are of relevance. In general, children are exposed to higher phthalate doses than adults. Especially, high exposures can occur through some medications or medical devices. By comparing exposure data with existing limit values, one can also assess the risks associated with exposure to phthalates. Within the general population, some individuals exceed tolerable daily intake values for one or more phthalates. In high exposure groups, (intensive medical care, medications) tolerable daily intake transgressions can be substantial. Recent findings from animal studies suggest that a cumulative risk assessment for phthalates is warranted, and a cumulative exposure assessment to phthalates via human biomonitoring is a major step into this direction.

Apheresis affects bone and mineral metabolism

BACKGROUND

Apheresis is a procedure to selectively obtain blood components. For the collection process citrate is routinely used. It inhibits coagulation by binding to ionized calcium and leads to metabolic alkalosis.

OBJECTIVE

Whether regular apheresis affects bone and mineral metabolism is unknown. The intention of this study was to investigate 1) the acute effects of apheresis on acid-base balance, bone and mineral metabolism and 2) to compare bone mineral density (BMD) at the lumbar spine and hip of donors to matched control subjects.

DESIGN

In this open, observational, single-center, cross-sectional study we enrolled 102 regular plasma and thrombocyte donors to pursue objective 1) and compared those to 102 matched controls (CTR) for objective 2).

RESULTS

Platelet donation led to significant decreases in serum ionized calcium (-17%) and phosphate (-18%), to marked increases in base excess (57%) and PTH levels (192%) during apheresis. Baseline biochemical comparisons between donors and CTR revealed significantly lower values for donors for serum calcium, albumin, and 25-hydroxyvitamin D levels. Mean Z-score at the lumbar spine adjusted for BMI, average physical activity and daily calcium intake was lower for donors (-0.28+/-0.11) when compared to CTR subjects (0.06+/-0.11, P<0.05). Total and neck femoral BMD was also lower in the donor group, however, this difference was not significant.

CONCLUSIONS

Exposure to citrate during the apheresis procedure acutely affects mineral and bone metabolism. Regular donations of blood components compromised BMD at the lumbar spine. If confirmed, strategies to prevent long-term effects on bone need to be formulated.

Reproductive and developmental toxicity of phthalates

The purposes of this review are to (1) evaluate human and experimental evidence for adverse effects on reproduction and development in humans, produced by exposure to phthalates, and (2) identify knowledge gaps as for future studies. The widespread use of phthalates in consumer products leads to ubiquitous and constant exposure of humans to these chemicals. Phthalates were postulated to produce endocrine-disrupting effects in rodents, where fetal exposure to these compounds was found to induce developmental and reproductive toxicity. The adverse effects observed in rodent models raised concerns as to whether exposure to phthalates represents a potential health risk to humans. At present, di(2-ethylhexyl) phthalate (DEHP), di-n-butyl phthalate (DBP), and butyl benzyl phthalate (BBP) have been demonstrated to produce reproductive and developmental toxicity; thus, this review focuses on these chemicals. For the general population, DEHP exposure is predominantly via food. The average concentrations of phthalates are highest in children and decrease with age. At present, DEHP exposures in the general population appear to be close to the tolerable daily intake (TDI), suggesting that at least some individuals exceed the TDI. In addition, specific high-risk groups exist with internal levels that are several orders of magnitude above average. Urinary metabolites used as biomarkers for the internal levels provide additional means to determine more specifically phthalate exposure levels in both general and high-risk populations. However, exposure data are not consistent and there are indications that secondary metabolites may be more accurate indicators of the internal exposure compared to primary metabolites. The present human toxicity data are not sufficient for evaluating the occurrence of reproductive effects following phthalate exposure in humans, based on existing relevant animal data. This is especially the case for data on female reproductive toxicity, which are scarce. Therefore, future research needs to focus on developmental and reproductive endpoints in humans. It should be noted that phthalates occur in mixtures but most toxicological information is based on single compounds. Thus, it is concluded that it is important to improve the knowledge of toxic interactions among the different chemicals and to develop measures for combined exposure to various groups of phthalates.

Di(2-ethylhexyl)phthalate (DEHP) exposure of voluntary plasma and platelet donors

Each year thousands of healthy volunteers undergo apheresis procedures to donate blood components and safe lives. However, many disposables used in apheresis contain di(2-ethylhexyl)phthalate (DEHP). This way, donors are exposed to DEHP, which is a reproductive and developmental toxicant in animals and a suspected endocrine modulator in humans. We quantified the DEHP exposure of six plasma donors, six discontinuous-flow platelet donors and six continuous-flow platelet donors by determining three specific metabolites in urine (5OH-MEHP: mono(2-ethyl-5-hydroxyhexyl)phthalate; 5oxo-MEHP: mono(2-ethyl-5-oxo-hexyl)phthalate and MEHP: mono(2-ethylhexyl)phthalate). We found maximum concentrations in urine samples after the discontinuous-flow plateletpheresis procedure with 826 microg/l for 5OH-MEHP, 774 microg/l for 5oxo-MEHP and 266 microg/l for MEHP (mean of the six volunteers). Metabolite excretions were found to be significantly (p<0.0001) higher for both plateletpheresis techniques compared to plasmapheresis and controls. Continuous-flow plateletpheresis led to significantly higher (p<0.0001) excretions than discontinuous-flow plateletpheresis. Mean absolute DEHP exposures were 1.2 mg for discontinuous- and 2.1 mg for continuous-flow plateletpheresis. Exposure for plasmapheresis (0.37 mg) was in the range of the controls (0.41 mg). Mean DEHP doses for both plateletpheresis techniques (18.1 and 32.3 microg/kg/day) were close to or exceeded the reference dose (RfD) of the US EPA and tolerable daily intake (TDI) value of the EU on the day of the apheresis. Therefore, margins of safety might be insufficient to protect especially young men and women in their reproductive age from effects on reproductivity. At present, discontinuous-flow devices should be preferred to avert conceivable health risks from plateletpheresis donors. Strategies to avoid DEHP exposure of donors during apheresis need to be developed.

What’s happening: An overview of potential adverse reactions associated with apheresis technology

The current status of potential adverse reactions associated with the use of apheresis technology is reviewed, focussing on three main areas: adverse events related to component collection, progenitor cells collection and therapeutic apheresis. Based on available information it is believed that apheresis technologies are safe and increasingly used in transfusion medicine, including in auto-transfusion and different types of therapy. Occasionally, however, for various donor/patient and operational reasons, mild or moderate adverse reactions do occur. The majority of these reactions are related to vascular access and anticoagulants used, which can be mostly eliminated with calcium/magnesium administration. The reactions associated with therapeutic apheresis are more frequent (6.75%) than the multi-components and stem cell collections. Most of these reactions are generally mild and only 0.89% has been classified as severe. A national registry of donor adverse reactions as well as a planned haemovigilance system may prove helpful in identifying the potential causes which might be associated with either to donor/donation and/or with a particular technology or procedure.

Intravenous exposure to di(2-ethylhexyl)phthalate (DEHP): metabolites of DEHP in urine after a voluntary platelet donation

In this study we investigated human metabolism and excretion of DEHP after intravenous exposure. For this purpose we determined the five major DEHP metabolites in urine samples of a volunteer before and after a platelet donation (dual-needle technique). Plateletpheresis procedures are known to cause a significant DEHP exposure. We observed a sharp increase in urinary DEHP metabolite concentrations after the procedure. Maximum concentrations of 5OH-MEHP, 5oxo-MEHP, 5cx-MEPP and MEHP observed 4 h after the procedure were 822, 729, 577 and 388 microg/l respectively. 2cx-MMHP was excreted at highest concentrations after 8 h (201 microg/l). Due to longer elimination half-times, 5cx-MEPP and 2cx-MMHP were the major metabolites excreted in urine 24 h after the exposure. The 24-h-cumulative excretion of 363 microg 5cx-MEPP, 353 microg 5OH-MEHP, 309 microg 5oxo-MEHP, 178 microg MEHP and 133 microg 2cx-MMHP indicates an absolute exposure of our volunteer of about 2.6 mg DEHP. Related to the body weight this equals a dose of 31.6 microg/kg body weight/day. This indicates that current risk or preventive limit values for DEHP such as the RfD of the US EPA (20 microg/kg/day) and the TDI of the European Union (20-48 microg/kg/day) can be exceeded on the day of the plateletpheresis. The amount of the dose excreted in urine, distribution of the metabolites in urine and all other elimination characteristics after intravenous DEHP exposure are comparable to oral exposure. There are no indications that toxicokinetic behaviour and the toxicity of DEHP are fundamentally different after the two routes of exposure. Therefore, toxicological endpoints observed for DEHP after oral application should also be considered relevant for medical procedures causing intravenous DEHP exposure, like apheresis procedures. Especially women in their reproductive age need to be protected from DEHP exposures exceeding the above mentioned preventive limit values.

Transfusion-related exposure to the plasticizer di(2-ethylhexyl)phthalate in patients receiving plateletpheresis concentrates

BACKGROUND

Di(2-ethylhexyl)phthalate (DEHP) is a plasticizer that can leach from medical devices including storage bags for plateletpheresis concentrates (PCs). In this study, the DEHP exposure to patients receiving PCs was determined and several variables were evaluated to reduce DEHP load to PC recipients.

STUDY DESIGN AND METHODS

In 12 patients, serum DEHP was assessed before and after PC transfusion. For in vitro investigations, PCs were produced either with donor plasma or with 65 percent additive solution (AS; T-Sol) and stored for 5 days. Washing of PCs was performed according to AABB standards. DEHP levels were determined by gas chromatography-mass spectrometry.

RESULTS

Transfusion of PCs led to a significant increase in serum DEHP. DEHP levels in the PCs continuously increased during storage, although the accumulation of DEHP was less in PCs stored in the AS, T-Sol, than when stored in plasma. Storage-related accumulation of DEHP contributed to a major part of the total DEHP load in PCs stored for 5 days. Washing of PCs led to a reduction of DEHP load.

CONCLUSION

Recipients of PCs are exposed to DEHP, although the total amount represents only a small percentage of the defined tolerable intake. Reduction of storage time, the storage of PC in T-Sol, or the exchange of the storage medium before transfusion are practicable means to reduce the DEHP load in PC.