Current Status of Pathogen Reduction Methods James P. AuBuchon, MD President & Chief Executive...

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.

Fib

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, MF

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2

4

6

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10

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Control

Intercept

Mirasol

Control

Intercept

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

Lac

tate

, m

M

Storage time, days

Treatment Effect: Metabolic Changes



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


No differences observed Clinical bleeding assessment Inter-transfusion interval

Transfusion 2010;50:2362-75.


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%



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.


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


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.


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



DOUBLEPOOL

TREATEDPOOLED

PLTS

TREATEDPOOLED

PLTS

TREATEDAPHERESISPLATELET

APHERESISPLATELET

TREATEDAPHERESISPLATELET

Pathogen Inactivation Technologies

An opportunity to improve patient safetyand

simplify blood banking.

Current Status of Pathogen Reduction Methods James P. AuBuchon, MD President & Chief Executive...

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