Recommendations for Therapeutic Apheresis by the Section "Preparative and Therapeutic Hemapheresis" of the German Society for Transfusion Medicine and Immunohematology

Efficient manufacturing of CAR-T cells from whole blood: a scalable approach to reduce costs and enhance accessibility in cancer therapy

BACKGROUND

Chimeric antigen receptor T (CAR-T) cells have significantly advanced the treatment of cancers such as leukemia and lymphoma. Traditionally, T cells are collected from patients through leukapheresis, an expensive and potentially invasive process that requires specialized equipment and trained personnel. Although whole blood collections are much more technically straightforward, whole blood starting material has not been widely utilized for clinical CAR-T cell manufacturing, in part due to lack of manufacturing processes designed for use in a good manufacturing practice (GMP) environment. Collecting cellular starting material from whole blood without leukapheresis could reduce manufacturing complexity and cost, thereby improving accessibility to CAR-T cell therapy.

METHODS

Whole blood samples were collected from eight healthy donors and one pediatric B-cell acute lymphoblastic leukemia (B-ALL) patient. These samples were processed using the Sepax C-Pro (Cytiva) instrument to isolate mononuclear cells (MNCs) via density gradient separation. CAR-T cells were then manufactured from the isolated MNCs using a GMP-compliant 7-day protocol, whereby T cells were activated with anti-CD3 and IL-2, transduced with GMP lentiviral vector encoding a CD19/CD22 bispecific CAR, and expanded in gas permeable cell culture bags. The resulting CAR-T cells were then evaluated for their phenotypic and functional properties using flow cytometry, cytokine release and cytotoxicity assays.

RESULTS

From an average 77.7 mL of whole blood from healthy donors (range = 29-96 mL), we isolated an average of 42.2 × 106 CD3⁺ T cells (range 7.3-63.0) postprocessing. CAR-T cell cultures were initiated from thaw using 1-10 × 106 starting CD3+ T cells, yielding a median T cell number of 105 × 106 cells on day 7 (range 61-188 × 106). We observed 66 ± 11% mean transduction efficiency and produced a mean of 77.4 × 106 transduced CAR-T cells (range 30.8-143.5 × 106). Similar results were obtained when using a blood sample (28mL) obtained from a patient with relapsed B-ALL who had received recent chemotherapy.

CONCLUSIONS

Therapeutically relevant doses of CD19/CD22 CAR-T cells can be successfully manufactured from whole blood. On average, 80 mL of whole blood yields enough CAR-T cells to create a single dose for a pediatric patient (50 kg) at a dosage of 1 × 106 CAR-T cells/kg. For larger patients, scaling up is straightforward by collecting a larger blood volume. This method also demonstrates a cost-effective approach to T cell activation and expansion which, alongside a more straightforward collection of whole blood, makes it more widely accessible especially for middle- and low-income countries. By reducing costs and labor, this strategy has the potential to significantly expand global access to CAR-T cell therapy.

Use of Therapeutic Plasma Exchange and Intravenous Immunoglobulin to Prevent Complications in a K+ Sensitized Pregnancy

The K antigen is a major cause of hemolytic disease of the fetus and newborn (HDFN). K-HDFN is unique in that it can result in destruction of not just mature erythrocytes but fetal erythrocyte progenitors, causing severe fetal anemia earlier in pregnancy than other antigens. This poses a danger to fetal health as intrauterine transfusion (IUT), the preferred method of managing HDFN, becomes riskier earlier in pregnancy. This report follows a K-negative mother managed with an alternative treatment, designed to delay the need for IUT.  The patient is a 32-year-old K-negative female, G2P1001, sensitized against K by her previous pregnancy with a 256 anti-K antibody titer. To prevent HDFN, she opted for preventative treatment to lower her immune response. She received three rounds of therapeutic plasma exchange, which lowered her titer to 64, followed by weekly IVIG administration at a dosage of 1g/kg body weight. Fetal anemia was monitored via middle cerebral artery Doppler imaging. The fetus did require two IUTs; however, they were not required until the third trimester. A healthy baby was delivered at 36 weeks with mild anemia and a positive direct antiglobulin test. The standard of care for K-sensitized pregnancies involves watchful waiting and correction of anemia with IUT. However, K-HDFN, if untreated, can cause severe anemia in early pregnancy when IUT is less viable. This case study joins a handful of others in reported literature where a K-sensitized pregnancy was treated prophylactically with immune-modulating therapies and argues that these treatments deserve further recognition and study.

Small but mighty: Case report and practical guidance for peripheral blood stem cell collection in small infants

Modern apheresis devices, with increased procedural precision, automation, and monitoring, have been shown to allow for safe delivery of apheresis therapies in young children. Medical advances are increasing demand for apheresis procedures like mononuclear cell collection in infants <10 kg, including stem-cell supported chemotherapy, cell collection for chimeric antigen receptor T cell development, and now ex vivo gene therapies for rare genetic diseases. Nevertheless, safe delivery in small infants involves a range of unique considerations and challenges, beyond just size, and experience will vary between centers. In this case report we describe our experience performing mononuclear cell collection in our smallest patient to date and outline a practice guideline developed following a literature review and discussion with both international experts and device representatives. This case may help to inform other clinicians aiming to provide apheresis care to very small infants in their own centers.

Use of Therapeutic Apheresis methods in ICU

Apheresis is a modern medical approach in which plasma or cellular components are separated from the whole blood. Apheresis can be either diagnostic or therapeutic. Diagnostic apheresis is typically applied in hematology and cancer research. Therapeutic Apheresis (TA) includes a broad spectrum of extracorporeal treatments applied in various medical specialties, including Intensive Care Unit (ICU). Considering the complexity of the pathophysiologic characteristics of various clinical entities and in particular sepsis, apheresis methods are becoming increasingly applicable. Therapeutic Plasma Exchange (TPE) is the most common used method in ICU. It is considered as first line therapy for Thrombotic Thrombocytopenic Purpura (TTP) and Guillain Barre Syndrome, while the current data for sepsis are scarce. Over the last decades, technologic evolution has led to increasing application of new and more selective methods based on adsorptive techniques. In this review we will describe the current data of characteristics of different techniques, safety and clinical impact of apheresis methods used in ICUs.

Therapeutic Plasma Exchange Versus FcRn Inhibition in Autoimmune Disease

Therapeutic plasma exchange (TPE or PLEX) is used in a broad range of autoimmune diseases, with the goal of removing autoantibodies from the circulation. A newer approach for the selective removal of immunoglobulin G (IgG) antibodies is the use of therapeutic molecules targeting the neonatal Fc receptor (FcRn). FcRn regulates IgG recycling, and its inhibition results in a marked decrease in circulating autoantibodies of the IgG subtype. The difference between FcRn inhibition and PLEX is often questioned. With anti-FcRn monoclonal antibodies (mAbs) and fragments only recently entering this space, limited data are available regarding long-term efficacy and safety. However, the biology of FcRn is well understood, and mounting evidence regarding the efficacy, safety, and potential differences among compounds in development is available, allowing us to compare against nonselective plasma protein depletion methods such as PLEX. FcRn inhibitors may have distinct advantages and disadvantages over PLEX in certain scenarios. Use of PLEX is preferred over FcRn inhibition where removal of antibodies other than IgG or when concomitant repletion of missing plasma proteins is needed for therapeutic benefit. Also, FcRn targeting has not yet been studied for use in acute flares or crisis states of IgG-mediated diseases. Compared with PLEX, FcRn inhibition is associated with less invasive access requirements, more specific removal of IgG versus other immunoglobulins without a broad impact on circulating proteins, and any impacts on other therapeutic drug levels are restricted to other mAbs. In addition, the degree of IgG reduction is similar with FcRn inhibitors compared with that afforded by PLEX. Here we describe the scientific literature regarding the use of PLEX and FcRn inhibitors in autoimmune diseases and provide an expert discussion around the potential benefits of these options in varying clinical conditions and scenarios.

Bioinspired Multifunctional Silver Nanoparticles for Optical Sensing Applications: A Sustainable Approach

Silver nanoparticles developed via biosynthesis are the most fascinating nanosized particles and encompassed with excellent physicochemical properties. The bioinspired nanoparticles with different shapes and sizes have attracted huge attention due to their stability, low cost, environmental friendliness, and use of less hazardous chemicals. This is an ideal method for synthesizing a range of nanosized metal particles from plants and biomolecules. Optical biosensors are progressively being fabricated for the attainment of sustainability by using opportunities offered by nanotechnology. This review focuses mainly on tuning the optical properties of the metal nanoparticles for optical sensing to explore the importance and applications of bioinspired silver nanoparticles. Further, this review deliberates the role of bioinspired silver nanoparticles (Ag NPs) in biomedical, agricultural, environmental, and energy applications. Profound insight into the antimicrobial properties of these nanoparticles is also appreciated. Tailor-made bioinspired nanoparticles with effectuating characteristics can unsurprisingly target tumor cells and distribute enwrapped payloads intensively. Existing challenges and prospects of bioinspired Ag NPs are also summarized. This review is expected to deliver perceptions about the progress of the next generation of bioinspired Ag NPs and their outstanding performances in various fields by promoting sustainable practices for fabricating optical sensing devices.

Extracorporeal Photopheresis in Graft-versus-Host Disease

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity following allogeneic hematopoietic stem cell transplantation. Extracorporeal photopheresis (ECP), which exposes mononuclear cells to ultraviolet A irradiation in the presence of a photosensitizing agent, has shown efficacy in the treatment of GVHD. Recent observations in molecular and cell biology have revealed the mechanisms by which ECP can reverse GVHD, including lymphocyte apoptosis, differentiation of dendritic cells from circulating monocytes, and modification of the cytokine profile and T cell subpopulations. Technical innovations have made ECP accessible to a broader range of patients; however, logistical constraints may limit its use. In this review, we scrutinize the development of ECP from its origins to recent insights into the biology underlying ECP efficacy. We also review practical aspects that may complicate successful ECP treatment. Finally, we analyze how these theoretical concepts translate into clinical practice, summarizing the published experiences of leading research groups worldwide.

COVID-19, Hypertriglyceridemia, and Acute Pancreatitis: A Case Report and Clinical Considerations

Acute pancreatitis (AP) is a serious condition that can result in numerous negative outcomes including death. The underlying causes of AP are varied, with both COVID-19 and hypertriglyceridemia being documented in the medical literature. Here, we present the case of a young man with a pre-existing diagnosis of prediabetes and class 1 obesity who developed severe hypertriglyceridemia, AP, and mild diabetic ketoacidosis while concurrently infected with COVID-19. It is crucial for healthcare providers to be vigilant in recognizing the potential complications associated with COVID-19, regardless of whether the patient has received a vaccination.

Rheopheresis: A narrative review

INTRODUCTION

Rheopheresis is an extracorporal selective double-filtration procedure with an initial separation of plasma from the whole blood and a further filtration of the plasma through a second filter in order to eliminate a certain number of high molecular weight proteins such LDL, Lp(a), fibrinogen, α2-macroglobulin, Factor von Willebrand, and IgM Immunoglobulin.

METHODS

In this narrative review we discuss the available data on the effects of Rheopheresis in various clinical conditions.

RESULTS

Rheopheresis is considerd to exert a rapid effect on clinical conditions associated with seriously affected microcirculation and rheologic parameters such as, the dry age-related macular degeneration (AMD), sudden sensorineural hearing loss (SSHS), peripheral artery disease (PAD), calciphylaxis, systemic sclerosis and diabetic foot.

CONCLUSIONS

Rheopheresis is a promising technique for conditions associated with affected microcirculatory rheologic parameters.

Leucocytoclastic Vasculitis, Cryoglobulinemia, or Plasma Cell Leukemia: A Diagnostic Conundrum

Plasma cell leukemia is rare and could be life-threatening. Even rarer and equally life-threatening is cryoglobulinemia. Both of them occurring together paints a grim clinical picture. We present the case of a 63-year-old male with plasma cell leukemia complicated by cryoglobulinemia with skin lesions. The report briefly reviews the clinical and diagnostic characteristics of plasma cell leukemia and well as available treatment options. It also highlights the need to consider non-chemotherapy-based regimens and clinical trials in the care of plasma cell leukemia patients.

Extracorporeal Photopheresis in Graft-versus-Host Disease

Background and Summary

Extracorporeal photopheresis (ECP) is a leukapheresis-based procedure used in the therapy of acute and chronic graft-versus-host disease (aGvHD, cGvHD) and other diseases. Based on the substantial efficacy and the excellent safety profile in the absence of immunosuppression ECP has established itself as a major treatment form for steroid-refractory GvHD. Here we review the current literature on ECP as a treatment option for patients with aGvHD as well as cGvHD.

Key Messages

ECP is a well-established second-line therapy for cGvHD. Its role in the treatment of aGvHD is less clear but also points towards an effective second-line therapy option. In the future ECP could play a role in the prevention of GvHD. More experimental and randomized controlled trials are needed to define the best patient selection criteria, settings, and therapy regimens for GvHD.