PLASMA DERIVATIVES

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PLASMA DERIVATIVES

• Abid Hussain Llohn

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Plasma - Contents

• More than 700 proteins
• Transport proteins
• Immunoglobulins
• Lipoproteins
• Complement factors
• Coagulation factors
• Proteinase inhibitors

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Plasma - Production

• 30 Millions liters annually
• Norway 53000 liters (2006)
• Whole blood
• 97 (Norway)
• Plasmapheresis
• 75 (USA)

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Fresh Frozen Plasma (FFP)

• Pooled plasma (SD-plasma)
• Quarantine plasma
• Single unit pathogen reduced FFP
• Methylene blue (MBLT-plasma)
• Psoralen (PLT-plasma)
• Riboflavin (RLT-plasma)

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Plasma - Production

• Selection of blood donors
• Virus testing of blood donors
• Virus testing av plasma
• Quality control
• Volume
• Factor VIIIc
• Residual cells
• Erythrocytes lt 6.0 x 109/l
• Leukocytes lt 0.1 x 109/l
• Platelets lt 50 x 109/l
• Visual changes

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Plasma - Production

• Venipuncture
• Donation time
• Continuous mixing with anticoagulants
• Striping
• Separation
• Rapid freezing to 30ºC
• Storage
• 36 months at below -25ºC
• 3 months at -18 ºC to -25ºC

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Rapid freezing to 30ºC
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Plasma Fractionation - Methods

• Differential solubility of proteins
• - Cryoprecipitation
• Differential interaction of proteins with
• solid media
• - Chromatography
• - Ultra filtration
• Differential interaction with physical fields
• - Centrifugal techniques
• - Electrophoresis

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Plasma
ethanol
8 Ph 7.2 I 0.14
Supernatant-1 Ethanol 25 pH 8.9 I 0.09
Precipitate-I
Fibrinogen, fibronectin, f VIII, C1q, C1r, C1s
Supernatant-I1III Ethanol 18 pH 5.2 I 0.09
Precipitate-IIIII
F II, V, VII, IX, X, fibrinogen
Supernatant-1V-1 Ethanol 40 pH 5.8 I 0.09
Precipitate-IV-1
Antithrombin III, a-1 proteinase inhibitor,
complement components, immunoglobulin M,
ceruloplasmin, a-lipoprotein, albumin
Supernatant-1V-4 Ethanol 40 pH 4.8 I 0.11
Precipitate-IV-4
Transferrin, haptoglobin, ceruloplasmin, a- and
ß-globulins, a-lipoprotein, albumin
Supernatant-V
Precipitate-V Ethanol 10 pH 4.5 I0.1
Albumin, a- and ß-globulins
Supernatant Ethanol 40 pH 5.2 I 0.01
impurities
Cohn fractionation method
Supernatant
Albumin
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Plasma Fractionation

• Yield per liter plasma
• Albuminativ 26.5 g 5
• Octagam 4 g 5
• Gammanorm 3.7 g
• Octaplas 4,6 X (200 ml)
• Octanate 170 IU (150)
• SD-cryo 500 IU
• Nanotiv 270 IU 10
• Octaplex 500 IU
• Atenativ 570 IU

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Pathogen Reduction

• Solvent Detergent (SD)
• Pasteurization
• Dry heat
• Low pH
• Nanofiltration
• Chromatography
• Photochemical

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SD Virus Inactivation

• PLASMA
• FILTRATION
• CASTOR OIL EXTRACTION
• CHROMATOGRAPHY
• FILLING

• THAWING
• S/D TREATMENT
• FILTRATION
• STERILE FILTRATION
• LABELLING FREEZING

0.3 TNBP (Tri-N-Butylphosphate) 1 Triniton
X-100
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SD Virus Inactivation

• Most validated extensively used technology
• Eliminates all lipid-enveloped viruses, bacteria,
  protozoa
• No direct effect on non-lipid-enveloped viruses
• HAV, Parvovirus B19?
• No case of viral disease transmission after
  transfusion of more than 5.5 millions units of
  SD-treated plasma in Europe 350,000 units in
  South Africa
• Association with venous thrombosis?
• PrPres

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Methylene blue light treatment

• Binds to nucleic acid, lipids proteins
• Activation of MB by light generates reactive
  oxygen species, mainly singlet oxygen. Guanine as
  primary target.
• No inactivation of intracellular pathogens or
  white cells
• Reduced activity of coagulation proteins
  Fibrinogen (24-39),
• FVIII (13-33)

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Psoralen light treatment

•  

Excess amotosalen HCl is removed by Compound
Absorption Device (CAD) (Activated charcoal in
diethyl benzene matrix)
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Psoralen light treatment

• Reduced activity of coagulation factors
• Factors I, V, VII, VIII, X (17-30)

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Riboflavin (RF) light treatment

• RF (Vitamin B2) causes damage of nucleic acid by
  photo-oxidation of guanine
• An oxygen independent reaction between
  activated
• photosensitizer and guanine
• Formation of oxygen radicals, responsible
  for majority of
• destruction of nucleic acids
• RF can be activated by visible light or UVA
• Removal of residual by-product/metabolites not
  necessary
• Effective against virus, bacteria protozoa
• Coagulation-active proteins are well-preserved

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Plasma products - usage

• FFP - Indication
• Complex deficiencies of coagulation factors
  (liver disease, DIC, massive transfusion)
• Substitution therapy in coagulation factors
  deficiencies when specific factors are lacking
  (FV, FXI)
• Rapid reversal of oral anticoagulants
• Thrombotic thrombocytopenic purpura
• Exchange transfusion in newborn

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FFP- dosage

• Factor deficiencies
• 5-20 ml/kg body weight
• PT/APTT 1.5 times the normal values
• TTP
• Daily exchange of minimum one plasma
  volume
• ? platelets count (100) ? LD

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FFP Precautions

• IgA deficiency
• Plasma protein allergy
• Previous reactions to FFP
• Cardiac decompensation
• Pulmonary oedema
• Not to be used as volume expander
• Contra indicated in IgA deficiency with anti-IgA
  antibodies

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Prothrombin Complex Concentrate

• Octaplex
• Factor II, VII, IX, X
• Protein C, S
• Heparin
• Virus reduction measures include solvent
  detergent (SD) treatment and nanofiltration
• Indication
• Congenital deficiency of any factor in PC when
  purified specific factor is not available
• Urgent operation or bleeding among patient
  getting oral anticoagulants (coumarin)
• Bleeding caused by overdose of coumarin
• Bleeding caused by hepatitis, cirrhosis, other
  form of liver disorders

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PCC (Octaplex)

• Dosage
• Bleeding perioperative prophylaxis during vit.
  K antagonist treatment
• Bleeding perioperative prophylaxis in
  congenital deficiency
• Required units body wt (kg) x desired
  factor II rise (IU/ml) X 50
• Reciprocal of the estimated recovery F
  VII, IX 100, F X 59
• Contraindications
• Known allergy to heparin or heparin induced
  thrombocytopenia
• Hypersensitivity to the active substances

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Recombinant Factor VIIa (NovoSeven)

• Indications
• Congenital FVII deficiency
• Haemophilia A B patients
• with inhibitors to FVIII FIX
• Glanzmanns thromboasthenia

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Factor VIII Concentrate

• Pathogen reduction includes S/D treatment with
  TNBP/Tween 80 and dry heat
• Indications
• Haemophilia A
• Acquired factor VIII deficiency

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Factor VIII concentrate (Octanate)

• Dosage
• Required units body wt (kg) x desired
  factor VIII rise () X 0.5

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Recombinant Factor VIII

• 5 rFVIII registered in Norway
• Recombinate, Kogenate, ReFacto,
• Adenate, Helixate

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Factor VIII inhibitors

• 15-35 of patients under treatment
• 50 of patients with low titre (lt than 20 BU/ml)
• Treatment
• High titre ? High doses of FVIII
• FEIBA
• rFVIIa
• Desensitization with daily FVIII infusions
• IVIG

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Factor IX

• Treatment prohylaxis of bleeding in patients
  with heamophilia B
• Dosage
• Required units body wt (kg) x desired factor
  VIII rise () (IU/dl) X 0.8
• Otherwise same as for factor VIII
• rFIX (BeneFix)

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Cryoprecipitate

• Contents (SD-kryo)
• von Willebrand factor
• Factor VIII
• Fibrinogen
• S/D-treatment only
• Indications
• Von Willebrands disease
• Hypofibrinogenaemia

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Antithrombin

• Pathogen inactivation by S/D treatment and heat
• Indications
• Congenital deficiency
• Prophylaxis of DVT thromboembolism in
  clinical risk patients (during surgery or
  peri-partum period)
• Acquired antithrombin deficiency DIC

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Immunoglobulins

• Intravenous Ig (Octagam)
• Humane normal IgG (95 av proteins)
• IgA 0.02 mg / ml of solution
• Distribution of IgG subclasses
• IgG1 ca 60
• IgG2 ca 32
• IgG3 ca 7
• IgG4 ca 1
• Pathogen reduction includes S/D treatment with
  TNBP/Tween 80 and pasteurization
• IM/SC Ig (Gammanorm)

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IVIg Therapeutic indications

• REPLACEMENT THERAPY
• Primary immunodeficiencies
• Myeloma or CLL with severe secondary
  hypogammaglobulinaemia and recurrent infections
• Children with congenital AIDS repeated
  bacterial infections
• IMMUNOMODULATORY EFFECT
• Idiopathic thrombocytopenic purpura
• Guillain Barré syndrome
• Kawasaki disease
• Allogenic bone marrow transplantation
• Dermato/polymyositis
• Demyelinating polyneuropathy
• Myasthenia Gravis
• Post-transfusional purpura
• Autoimmune neutropenia
• Patients with FIX, FVIII inhibitors

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Immunoglobulins

• Mechanism of action
• Blockade of Fc receptors on macrophages
• Induction of inhibitory Fc?RIIB receprors
• Saturation of FcRn transport receptors
• Inhibition of activation of endothelial cells
• Attenuation of complement-mediated damage
• Neutrization of bacterial toxins
• Neutralization of superantigens
• Adverse reactions
• Passive antibody transfer
• Thromboembolism
• Renal dysfunction
• Aseptic meningitis

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Albumin

• 4 Albumin
• Shock associated with significant
  hypoalbuminaemia
• Therapeutic plasma exchange
• Cardiothoracic surgery, to prime the pump in
  patients with poor left ventricular function and
  other complicating factors
• 20 Albumin
• Extremely low albumin in critically-ill patients
• Burns
• Paracentesis of ascites in patients with
  cirrhosis or when the volume exceeds 6 liter
• Haemodialysis 

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Other Plasma Proteins

• FEIBA (Factor Eight Inhibitor Bypassing Activity)
• Fibrin Sealant (Quixil)
• Alpha-1-antitrypsin (Prolastin)

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Litterature

• Rossys principles of Transfusion Medicine
• Mollisons Blood transfusion in Clinical
  medicine, 11th edition
• Solheim BG, Cid J, Osselaer J-C. Pathogen
  reduction technologies. Global perspectives in
  transfusion medicine Bethesda MD AABB Press,
  2006
• Irina Knezevic-maramica and Margot S. Kruskall.
  Intravenous immune globulins An update for
  clinicians. Transfusion 2003431460-1480
• Guide to the preparation, use and quality
  assurance of blood components, 13th edition