Post on 31-Mar-2015
Current Status of Pathogen Reduction Methods
James P. AuBuchon, MD
President & Chief Executive OfficerPuget Sound Blood Center
Professor of Medicine and of Laboratory MedicineUniversity of Washington
Seattle, Washington
SAFETY
Transfusion safety is like an onion…
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Modified from: Morens DM et al. Nature 2004;430:242-9.
Chikungunya virus; Dengue fever
“Emerging” Pathogens
Ocean virus
Photoactive compounds: Genomic disruptionPsoralen derivatives (amotosalen)RiboflavinMethylene blue
Chemicals: Physical disruptionSolvent/detergent technology
Direct radiation effect Genomic disruptionUVC
Chemicals: Short-term activation Genomic disruption S-303 (FRALE: Frangible Anchor Linker Extender)
Currently Under Investigation or in Use
Pathogen Inactivation Methods
Methods: Available or ApproachingPlasma
Quarantined plasmaSolvent/detergent treatmentMethylene blue + lightAmotosalen + UVRiboflavin + UVUVC alone
PlateletsAmotosalen + UVRiboflavin + UVUVC alone
Red cells/Whole bloodS-303Riboflavin + UV
PI Plasma: The Similarities
Reduction in procoagulant activity: 10-20%Effect of implementation: Clinical utility
Rock G. Vox Sang 2011;100;169-78.
PI Plasma: The DifferencesSD Plasma↓Allergic reactions (1/50,000 units)
↓TRALI [0 ?]
NAT for non-enveloped viruses (HAV, B19)
Reduction in HMW vWF + ADAMTS-13 retentionReduction in anticoagulant proteins thrombosis [?]
MB PlasmaSlightly greater fibrinogen + F VIII reduction
Cardigan R et al. Transfusion 2009;49:696-703.
Evaluation MB Plasma Clots by Thromboelastometry
THROMBIN GENERATION CLOT FORMATION
MAXIMUM CLOT FIRMNESS
Less thrombin
Slower
Strength OK
PI Plasma: The DifferencesSD Plasma↓Allergic reactions (1/50,000 units)
↓TRALI [0 ?]
NAT for non-enveloped viruses (HAV, B19)
Reduction in HMW vWF + ADAMTS-13 retentionReduction in anticoagulant proteins thrombosis [?]
MB PlasmaSlightly greater fibrinogen + F VIII reduction
France: 11 severe allergic reactions (1 death)
UV ± Photosensitizer PlasmaUVC alone: ↓ F XI (no clinical trials)
Implementation Increased use [?] Reduced TTP response
Nubret K et al. Transfusion 2011;51:125-8.
PI Platelets: The Similarities
Some loss of platelets through process (small; manageable)
UV light Identifiable platelet damageIncreased metabolic rateIncreased activation during storage
(↓mt DNA transcription)
Using UVC to Inactivate
Walker WH et al. Vox Sang 2007;93(suppl 2):69.
Control Treated
Platelets 9.4±1.6 9.1±1.3 x 108/mLHSR 68±1 61±8%pH 7.29±0.12 7.09±0.05Aggr: Collagen 62±7 69±7%Glucose 63±9 41±8 mg/dLLactate 12.5±0.9 15.2±1.0 mM
Illumination: 0.4J/cm2
Testing: Day 8
Picker SM et al. Transfusion 2009;49:1224-32.
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Mirasol
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In vitro Assessment of Functional Properties
Picker SM et al. Vox Sang 2009;97:26-33.
0
2
4
6
8
10
12
14
1 5 7 8
Control
Intercept
Mirasol
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Storage time, days
Treatment Effect: Metabolic Changes
PI Platelets: The Similarities
Some loss of platelets through process (small; manageable)
UV light Identifiable platelet damageIncreased metabolic rateIncreased activation during storageReduced recoveryReduced survival
15-25%
Van Rhenen D et al. Blood 2000;96:819a.
Treated Control
Units transfused/patient 7.5+5.8 5.6+5.5 p > 0.05
Count increment (109/L):1h post-transfusion 27.6+13.3 35.8+23.3 p < 0.0224h post-transfusion 16.4+9.5 24.7+17.6 p = 0.004
Corrected count increments:1h post-transfusion 13,100+5400 14,900+6200 p = 0.1124h post-transfusion 7300+5400 10,600+7100 p = 0.02
Clinical Trial: Amotosalen-Treated PlateletsThe euroSPRITE Trial
McCullough J et al. Blood 2001;98:450a.
WHO Grade 2, 3 or 4 bleeding: No difference between groupsPlatelet content of treated units: 7.5% lessPost-transfusion counts: 22-26% lower in treated group
French/Belgian experience: No increase in usageLoss: 8%
Clinical Trial: Amotosalen-Treated PlateletsThe SPRINT Trial
Murphy S et al. Transfusion 2006;46:24-33.
Comparison by dose:Equivalent effect from similar dose
Clinical Trial: Riboflavin-Treated PlateletsThe MIRACLE Trial
n = 110
CCI1h: 31% decrease (primary outcome measure)
Transfusion 2010;50:2362-75.
50,000
40,000
30,000
20,000
10,000
0
-10,000
CCI
Mirasol Control Mirasol Control
MAX
75%
MEAN
50%
25%
MIN
CCI1h CCI24h
Clinical Trial: Riboflavin-Treated PlateletsThe MIRACLE Trial
n = 110
CCI1h: 31% decrease (primary outcome measure)
No differences observed Clinical bleeding assessment Inter-transfusion interval
Transfusion 2010;50:2362-75.
CCI1h: 31% decrease (primary outcome measure)
Pathogen-Inactivated Platelets in Routine Use
Osselaer JC et al. Transfusion 2007;47:19A.
3 yr before 3 yr after adoption of INTERCEPT platelets(Used in place of bacterial detection and gamma irradiation)
Before AfterPatients 690 756Transfusions 6829 7538Transfusions/patient 9.9 10.0
Platelets collected/unit 6.6x1011 6.7x1011
Storage period 5d 7dOutdating 9.1% 1.2%
PI Platelets: The Similarities
Some loss of platelets through process (small; manageable)
UV light Identifiable platelet damageIncreased metabolic rateIncreased activation during storageReduced recoveryReduced survival
Interaction with leukocytes’ DNA Reduction in alloimmunizationConsideration of replacement of γ-irradiation
Marschner S et al. Transfusion 2010;50:2489-98.
Prevention of Alloimmunization
MECHANISM INHIBITED BY PHOTINACTIVATED PI
MECHANISM NOT INHIBITED BY PHOTINACTIVATED PI
Prevention of Graft versus Host Disease
Adducts:Amotosalen + UV 1/83 base
pairsGamma irradiation 1/37,000 base
pairs
R Dodd Vox Sang 2002;83(Suppl 1):267-70.Osselaer JC et al. Blood 2007;110:849a.
Prevention of GvHD in murine modelInhibition of APC function
Inhibition of cytokine production
PI Platelets: Concerns
SPRINT Trial (FDA)Respiratory distress: 5 test vs. 0 control (n=671)Independent, blinded review of all (148) pulmonary events No association with PI platelets
Corash L et al. Blood 2011;117:1014-20.
PI Platelets: Concerns
HOVON Trial
Kerkoffs J-LH et al. BJH 2010150:209-17.
Heme/Onc pts (n=295)Expected: ≥ 2 plt transfusions
Plasma (n=99)357 transfusion events
292 per protocol
PAS III (n=94)381 transfusion events
278 per protocol
PR – PAS III (n=85)391 transfusion events
257 per protocol
Primary endpoint: CCI1hr
Secondary endpoints: CCI24hr, bleeding, transfusion needs and intervals, reactions
Early cessation: Lower CCI1hr
Increased bleeding
PI Platelets: Concerns
HOVON Trial
Heme/Onc pts (n=295)Expected: ≥ 2 plt transfusions
Plasma (n=99)357 transfusion events
292 per protocol
PAS III (n=94)381 transfusion events
278 per protocol
PR – PAS III (n=85)391 transfusion events
257 per protocol
Primary endpoint: CCI1hr
Secondary endpoints: CCI24hr, bleeding, transfusion needs and intervals, reactions
SPONTANEOUSLYREPORTED;
UNBLINDED TRIAL
Kerkoffs J-LH et al. BJH 2010150:209-17.
PI Platelets: Concerns
Kerkoffs J-LH et al. BJH 2010.
Maximum grade of bleeding (%)
Plasma PAS III PR – PAS IIIGrade 1 12% 11% 19%Grade 2 6% 4% 7%Grade 3 1% 0 6%
CLINICALSIGNIFICANCE?
APPROPRIATE TO COMBINE?
6-7d Storage of Amotosalen-Treated Platelets
Lozano M et al. ISBT 2010.
Untreated PI Platelets
Patients 100 101
CCI1hr 9,383 8,163
CI1hr 21,600 19,400/μL
CI24hr 15,200 11,100
Interval 2.3 2.2d
HSCT: 67%
p < 0.05Δ = 17% (<30%)
6d: 20% 7d: 80%
p < 0.05
NS
NS
Antimicrobial Peptides Studied
Mohan KVK et al. Transfusion 2010;50:166-73.
Bacterial Reduction by Antimicrobial Peptides
Mohan KVK et al. Transfusion 2010;50:166-73.
Bacterial Reduction by Antimicrobial Peptides
Methods: Available or Approaching
PlasmaQuarantined plasmaSolvent/detergent treatmentMethylene blue + lightAmotosalen + UVRiboflavin + UV
PlateletsAmotosalen + UVRiboflavin + UVUV alone
Red cellsS-303Riboflavin + UV
S-303 Mechanism of Action
Similar to amotosalen but no UV activation required
t1/2 = 25 min
S-300-
NO NUCELIC ACID INTERACTIONS
pH ACIDIC
NEUTRAL
ACTIVATION
Effect of S-303 on RBC Recovery and Survival35d storage
Rios et al. Transfusion 2006;46:1778-86.
Treated Control
24h Recovery 81.7+6.3% 84.5+6.2% p = 0.048
Survival 37.4+8.9d 37.6+6.7d p > 0.05
n = 29, paired11 full-unit reinfusions
Problems with RBC Pathogen Inactivation
NEOANTIGENY
ACRIDIN
E
ACRIDIN
E
Y
No Monocyte Mononuclear Assay activity.
North A et al. Vox Sang 2007; 93(suppl 1):167-8.
Problems with RBC Pathogen InactivationModified S-303 Process: Glutathione: 2 20mM at neutral pHY
ANTI-ACRIDINE
S-303 Treatment and ImmunogenicityAugmented Rabbit Model
RBC Recovery(log scale)
Time
Rabbits immunized with S-303 + KLHS-303TRMT
UNTREATED RBCs
mS-303TRMT
Recently completed: Blinded crossover autologous reinfusion trial
North A et al. Vox Sang 2007; 93(suppl 1):168.
Riboflavin Treatment and ImmunogenicityBaboon Model
RBC Recovery
(%)
Time (h)
Quinacrine mustard trmt
Goodrich RP et al. Transfusion 2009;49:64-74.
100 200 300 400 500
10
20
30
40
50
60
70
80
90
Riboflavin + UV
Control RBCs
Unlabeled infusions: Days 0, 21, 42, 4951Cr infusion: Day 56
Ab demonstrated
No Ab demonstrated
Current Status of Pathogen Reduction Methods
But can the system accommodate?
Yes, PI works.
Osselaer JC et al. Transfusion 2009;49:1412-22.
All Patients Hematology Patients
Platelet Transfusions Required
Impact of Conversion to PI Platelets
Before PI
After PI
“If someone says it’s not about the money,it’s about money!”
Intercept Platelet conversion experience - Strasbourg
Cazenave JP et al. Vox Sang 2007; 93(suppl 1):51-2.
Kit cost: 75€/apheresis unitPersonnel time: 3€
Costs avoided:Bacterial detection: 30€Per new test: 10€
For France: Cost neutral with apheresis proportion85% 55%
Reduction of Economic Impact
APHERESISPLATELET
WHOLEBLOOD Plt Plt
Plt
Plt
Plt
Plt
Plt
Plt
Plt
Plt
Plt
PltPlt
PltPlt PltPlt PltPlt PltPlt PltPlt
PltPlt PltPlt PltPlt PltPlt PltPlt
PltPlt PltPlt PltPlt PltPlt PltPlt
DOUBLEPOOL
TREATEDPOOLED
PLTS
TREATEDPOOLED
PLTS
TREATEDAPHERESISPLATELET
APHERESISPLATELET
TREATEDAPHERESISPLATELET
Pathogen Inactivation Technologies
An opportunity to improve patient safetyand
simplify blood banking.