alpha 1-Antitrypsin therapy in a case of thrombotic thrombocytopenic purpura

In thrombotic thrombocytopenic purpura (TTP), activated leucocytes release elastase which mobilises unusually large von Willebrand factor (vWF) multimers from the endothelium. We investigated the effect of an inhibitor of leucocyte elastase (alpha 1-antitrypsin) on circulating vWF and platelet count in a patient with chronic relapsing TTP. alpha 1-antitrypsin consistently normalised vWF multimeric composition but failed to increase platelet count and induce remission. Plasma cryosupernatant, which never normalised vWF, always induced laboratory and clinical remission within 96 hours. In chronic relapsing TTP, unusually large vWF multimers are not the main cause of intravascular platelet aggregation.

[Viral safety of intravenous immunoglobulins G for therapeutic use]

Even though IV IgG concentrates are considered to be among the safest products derived from human plasma, some preparations have been associated with the sporadic transmission of NANB hepatitis and, specifically of hepatitis C. The risk of transmission may have decreased markedly for several IgG preparations since the availability of an immunological test to detect the antibodies against HCV in the starting plasma, but it has not been fully eradicated. Thus, in addition to established viral inactivation treatments, such as acid pH incubation, new methods have been (or are being) implemented to further reduce the risk of HCV infection through IV IgG concentrates. Among these methods are the solvent-detergent treatment already shown to be highly effective for the inactivation of HCV and other enveloped viruses in clotting factor concentrates, and nanofiltration for the specific removal of viruses on the basis of their size. Also, chromatographic methods have helped to improve the overall safety of the product not only by removing viruses but also by improving purity and thus favoring a better in vivo tolerance. This paper reviews the reported cases of HCV transmission and the viral validation data for various IV IgG processing steps and current specific viral inactivation methods. An overview of the present safety status of IV IgG concentrates is presented as well as the recent introduction of new promising techniques for the overall improvement of the safety of this plasma derivative.

Nanofiltration, a new specific virus elimination method applied to high-purity factor IX and factor XI concentrates

We have validated the use of two new regenerated multilayered structured cellulose membranes (BMM), Planova 15 N and Planova 35 N, with respective mean pore sizes of 15 and 35 nm, as a new filtration system to eliminate viruses in highly purified factor IX and factor XI concentrates. Virus spiking experiments indicated that single dead-end filtration on the membranes could remove more than 5.7-7.8 log10 of human immunodeficiency virus, bovine viral diarrhoea virus, porcine pseudorabies virus, reovirus type 3, and simian virus 40, as well as the small non-enveloped viruses, poliovirus Sabin type 1 and bovine parvovirus. In vitro control tests and animal studies (Wessler stasis model, rat hypotension model) of the two concentrates did not reveal any significant differences with the non-nanofiltered material. Viral filtration of plasma derivatives on porous polymeric membranes might be an essential step in the improvement of their viral safety.

Large-scale preparation of highly purified human C1-inhibitor for therapeutic use

A two-step chromatographic procedure has been developed to purify human C1-inhibitor from cryoprecipitate-poor plasma after removal of vitamin K-dependent proteins and antithrombin III. The procedure, which is fully compatible with modern plasma fractionation schemes, includes anion-exchange chromatography on DMAE-Fractogel EMD, viral inactivation by solvent-detergent treatment, adsorption on SO3-Fractogel EMD and viral removal by nanofiltration on 35- and 15-nm pore size membranes. Overall yields were about 45% and 58% for antigen and activity, respectively, providing 60-70 mg of highly purified inhibitor per litre of plasma. The purified inhibitor had a specific activity of 6.5 +/- 0.5 units/mg protein, representing a more than 400-fold increase in purity compared with plasma. C1-inhibitor purity with respect to total protein was greater than 80%. The main contaminant was complement component C3 which accounted for 4-10% of the total protein. Minor contaminants included low amounts of IgM, IgG, IgA, fibrinogen and albumin. Complement component C4 was undetectable. The purified inhibitor was stable throughout the purification process and for more than 24 h at room temperature after reconstitution of the freeze-dried material. Animal tests in rats and mice demonstrated that the C1-inhibitor concentrate was well tolerated at relatively high doses.

Purification of factor VIII/von Willebrand factor from human plasma on immobilized lentil lectin

Human factor VIII/von Willebrand factor (FVIII/vWF) was shown to bind to immobilized lectins from Arachis, Ulex, Concanavalia, and Lens species. The protein/lectin interaction displayed higher affinities for the lectins from the last two species. However, the Lens culinaris lectin immobilized on Sepharose 4B (LCA-Sepharose) provided a more selective and flexible affinity system for the purification of FVIII/vWF than Concanavalia lectin. Chromatography on LCA-Sepharose of a purified FVIII containing a small proportion of vWF required a weak acidic medium (pH 6.3) and relatively slow kinetics (about 20 cm/h flow rate). The bound FVIII was specifically dissociated from LCA-Sepharose by methyl-alpha-D-mannopyranoside, and to a lesser extent by other monosaccharides such as D-glucose, methyl-alpha-D-glucopyranoside, D-mannose, and D-galactose. Application to whole plasma resulted in a capacity for FVIII/vWF of about 28 U/ml gel. Specific activities for eluted FVIII and vWF were 3 and 2.2 IU/mg protein, respectively, with respective FVIII:c and vWF:RCo recoveries of 57 and 40% from starting plasma. Coagulation factors II, X, VII, IX, V, and XI and fibrinogen were eliminated in the LCA matrix breakthrough fraction, improving the stability of the purified FVIII molecule. Purity of the LCA eluate was further enhanced by ion-exchange chromatography on DEAE-Fractogel TSK 650 M which reduced the amount of protein contaminants and provided a FVIII/vWF fraction with higher specific activity (45-80 IU/mg protein depending on the chromatographic conditions). The overall process yield was 45 and 25% for FVIII:c and vWF:RCo, respectively.

[Industrial pasteurization of plasma and criteria of quality]

The approach followed in the design of a large-scale pasteurization treatment (60 degrees C for 10 hours in the liquid state) of fresh frozen plasma is presented. Various aspects thought to influence the viral safety of such a product are discussed. They are based largely upon the fact that, although it is subjected to a specific viral inactivation treatment, this plasma does not benefit from any fractionation steps known to participate in the potential elimination of infectious agents during the manufacture of plasma derivatives. Consequently, the plasma is obtained from regular plasmapheresis donors, and the plasma donations used to make the pool must be negative for anti-HIV-1 and -2, anti-HCV, anti-HBc, anti-HTLV-1 and -2, HBs antigen and parvovirus B19 antigen, and have a normal level of ALT. The batch size is limited to 100 plasma units to limit the potential infectious risk associated with very large batches, especially if an infectious agent, resistant to pasteurization, is present. Pasteurization has been chosen for this procedure, as applied to plasma derivatives, has been shown to inactivate a broad spectrum of viruses, both enveloped and non-enveloped. The process is relatively simple. The frozen plasma units are opened, and the plasmas are mixed and thawed at 30 degrees C to avoid the formation of cryoprecipitate. The liquid plasma is transferred to a sterilized container and stabilizers are added. The mixture is then transferred to the pasteurization unit to be heat-treated at 60 degrees C for at least 10 hours under gentle mixing. Following cooling, the mixture is ultrafiltered to eliminate the stabilizers and to concentrate the plasma pool to its initial volume. The plasma is sterile-filtered, then dispensed into bottles and frozen. Virus validation of this pasteurization process, carried out by independent virology laboratories, have confirmed the ability of the process to inactivate more than 4 to 6 logs of non-enveloped or enveloped, DNA or RNA, viruses, including HIV-1 and Sindbis virus, in less than 5 hours of heat-treatment. The biological characteristics of the pasteurized plasma include a good preservation (75 to 95%) of the activity of clotting factors, including FI, FV, FVIII, FXI, and FXIII, and protease inhibitors. The overall clottability of the plasma, as expressed by the APTT, is almost unchanged.(ABSTRACT TRUNCATED AT 400 WORDS)

A therapeutic, highly purified factor XI concentrate from human plasma

A highly purified factor XI (FXI) concentrate was prepared from human plasma by a process comprising a filter adsorption step and chromatography on a cation exchange resin. The freeze-dried FXI, which solubilized quickly, had high specific activity (130-150 U/mg protein), high potency (approx. 100 U/mL), and excellent stability for at least 24 hours at room temperature in the liquid state. The overall recovery was about 220 U of FXI per liter of plasma. Minor protein contaminants (C1-inhibitor, fibronectin, IgG, and alpha-2-macroglobulin) were found to be between 0.13 and 0.46 mg per 1000 U of FXI. Fibrinogen and relevant coagulation factors (factors II, V, VII, IX, X, XII, XIII, and VIII/von Willebrand factor) were undetectable, as evidenced by immunologic and immunoelectrophoretic data. Components of the kinin system were present in trace amounts or were undetectable. No evidence of activated factors such as factors Xa and IXa was found. Proteolytic activity, as assessed by S-2288 chromogenic substrate, was negligible and thrombin was undetectable. A solvent-detergent treatment was included prior to chromatographic purification to enhance viral safety against lipid-enveloped viruses. In vitro and in vivo animal studies demonstrated the absence of thrombogenic, hypotensive, or toxic effects. No thrombogenic activity was found in the Wessler model in rabbits at doses of 900 to 1100 U of FXI per kg of body weight. This FXI preparation could be beneficial in substitution therapy of congenital or acquired FXI deficiency, especially as a way to avoid the use of fresh-frozen plasma.

A pasteurized therapeutic plasma

A process to subject pooled human plasma to a viral inactivation treatment by heating in the liquid state for 10 hrs at 60 degrees C (pasteurization) has been designed and evaluated. Activity recovered from clotting factors and protease inhibitors exceeded 80%. Overall clotting activity remained good. No activation of coagulation factors was detected. The process did not generate aggregates. No side effects (toxicity, hypotension, variation in heart rate, thrombogenicity) could be detected in animal models. Virus kill studies, using 7 lipid-enveloped and non-enveloped viruses including HIV-1 and Sindbis virus, revealed inactivation levels similar to those obtained for plasma derivatives. Thus, pasteurisation of human plasma can be achieved in conditions that allow good recovery of biological properties while ensuring a high degree of inactivation of lipid-enveloped and non-enveloped viruses.

Chromatographic preparation of a therapeutic highly purified von Willebrand factor concentrate from human cryoprecipitate

A therapeutic highly purified von Willebrand factor (vWF) concentrate has been prepared from cryoprecipitate by a three-step chromatographic procedure. After solvent/detergent treatment to inactivate viruses, the cryoprecipitate solution was chromatographed on DEAE-fractogel TSK 650 M to separate vWF from most cryoprecipitate proteins, including factor VIII (FVIII) and fibrinogen. A second DEAE-fractogel TSK 650 M was then performed to further purify vWF and to allow concentrating it to over 100 U ristocetin cofactor activity/ml. The last step on immobilized gelatin removed fibronectin and increased the purity of vWF. vWF was recovered with about 18 and 40% yield in antigen and collagen-binding (CB) activity, respectively, from cryoprecipitate. vWF was obtained in an essentially pure state corresponding to a purification factor of over 10,000-fold from plasma. Immunonephelometric and SDS-PAGE analyses of the concentrate did not reveal any detectable cryoprotein contaminants, especially fibrinogen, fibronectin, immunoglobulins and albumin. The content in intermediate- and high-molecular-weight multimers in the concentrate was similar or higher than that of plasma, as the ion-exchanger selectively favored the binding and concentration of the larger multimeric forms while reducing the amount of the smaller forms with abnormal structure and low activity. Other characteristics of the concentrate included a CB activity to antigen ratio of 1.69 and a high capacity (86%) to correct platelet adhesion in a perfusion system. Clinical use of this standardized vWF concentrate has been shown to be efficacious in the treatment of vWF patients.

A highly purified factor VIII:c concentrate prepared from cryoprecipitate by ion-exchange chromatography

A new ion-exchange chromatographic procedure has been developed to produce a highly purified factor VIII (FVIII) concentrate from plasma cryoprecipitate. Solubilized cryoprecipitate, after adsorption on aluminium hydroxide and cold precipitation, was treated with 0.3% tri(n-butyl)phosphate and 1% Tween 80 at 25 degrees C for at least 8 h to inactivate lipid-enveloped viruses. The fraction was then loaded onto a column packed with DEAE-Fractogel TSK 650 M and chromatographed. Most proteins and TnBP-Tween 80 flowed through the gel unretarded. FVIII:c, which bound to the gel, was eluted by increasing the ionic strength, then was directly filter-sterilized without ultrafiltration or addition of a protein stabilizer. Chromatographic recovery of FVIII:c was 80-90%. After freeze-drying, FVIII:c was at a concentration of 42.5 +/- 9.5 IU/ml and had a specific activity of 175.4 +/- 37.8 IU/mg (n = 40), corresponding to a purification factor of over 12,000 from plasma. The typical yield of the freeze-dried FVIII:c from cryoprecipitate was 55-65%. FVIII:c was stable for over 24 h at room temperature in the liquid state. The mean content of fibrinogen and immunoglobulin G was only 65 and 100 mg/l, respectively, corresponding to 1.4 and 2.3 mg/1,000 IU FVIII:c. This concentrate, which is much purer than traditional FVIII concentrates, has been found to be well tolerated and effective in clinical treatment of hemophilia A patients.

Biochemical and physical properties of a solvent-detergent-treated fibrin glue

A fibrin glue preparation has been obtained from pooled human plasma using a procedure which includes a solvent-detergent (SD) treatment to inactivate lipid-enveloped viruses. The SD treatment inactivated greater than or equal to 5.5 log10 of HIV in less than 45 min, and greater than or equal to 5 log10 and greater than or equal to 6.5 log10 of VSV and Sindbis virus, respectively, in less than 2 h. The product was found to contain high quantities of fibrinogen (116 +/- 2.49 g/l; n = 12), factor XIII (35 +/- 2.88 U/ml) and von Willebrand factor (23 +/- 1.9 U/ml ristocetin cofactor activity), and relatively low levels of fibronectin (5.9 +/- 0.51 g/l). Plasminogen, the precursor of plasmin, which may play a negative role by decreasing the resistance of the fibrin clot, was at only 0.03 g/l. Cellulose acetate electrophoresis showed 95% gamma-proteins and 5% alpha-2-beta proteins. Sodium dodecyl sulfate polyacrylamide gel electrophoresis under reducing conditions detected three main protein bands with apparent molecular weights of 65, 56 and 47 kilodaltons, probably corresponding to the alpha, beta, and gamma fibrinogen subunits. Other characteristics of the product included (1) high clottability of fibrinogen (over 85%); (2) absence of low molecular weight fibrin degradation products; (3) rapid solubilization at room temperature (less than 10 min); (4) high tensile strength (202 +/- 27 g/cm2 after 2 h of application), and (5) high elasticity of the fibrin clot. In addition, scanning electron microscopy revealed a highly organized structure showing tridimensional arrangement of the fibrin fibers. SD treated fibrin glue should efficiently replace autologous fibrinogen or cryoprecipitate preparations for surgical application.