2015 bcsls congress invited presentation - deb chen - final

Deb ChenPhD Candidate | Devine Laboratory at Centre for Blood Research 2015-09-26 | BCSLS Congress, Kelowna

Modifying Red Cell Concentrates: The Impact of Post-Production Treatments on Red Blood Cell Quality

2

Modifying Red Cell Concentrates: The Impact of Post-Production Treatments on RBC Quality

Outline

1. Red Cell Concentrates • Production and Storage• Red Blood Cell Storage Lesion• Post-Production Treatments

2. Current Post-Production Treatment• gamma-irradiation

3. Emerging Post-Production Treatment• pathogen inactivation technology

4. RBC Hemolysis: Biomarker Discovery for Quality Assessment

Product Production and StorageRed Cell Concentrates

Whole Blood (WB) Donation Differential Centrifugation Leukoreduction

Separation of Plasma &Platelets from RBC

• Preserved in SAGM (saline-adenine-glucose-mannitol)• Stored for a maximum of 42 days at 4 ± 2°C

Red Blood Cell Storage Lesion

• Biochemical and cellular changes in stored red cells:• metabolic modulation (e.g. ATP depletion)• morphological alterations • hemolysis (i.e., rupturing of red blood cells)

Red Cell Concentrates

Image adopted from Hovav T, et al. Transfusion. 1999 Mar;39(3):277-81.

D1 D21 D35

Adverse Effects of RBC Transfusion Contrasted With Other Risks


Image from Carson KL, et al. Ann Intern Med. 2012;157:49-58.

HIV = Human Immunodeficiency VirusHCV = Hepatitis C VirusHBV = Hepatitis B VirusTRALI = Transfusion-Related Acute Lung InjuryTACO = Transfusion-Associated Circulatory Overload

= per RBC unit transfused

= per person per year

Post-Production Treatments

• Gamma-irradiation

• RBC Washing

• Supernate Removal by Spinning

• Pathogen Inactivation


Transfusion-Associated Graft Verses Host Disease• Rare complication of blood transfusion

o Delayed presentation with fever, diarrhea, and characteristic rasho Occurs when the recipient’s immune system is unable to recognize donor T cells as foreign;

whereas donor T-cells recognizes host cells as foreign and mount an immunological attack

• Extremely high morbidity and mortality rate o with death occurring within 1 month in over 90% of cases

• No effective treatment• Supportive care, corticosteroids, and cytotoxic agents

Current Post-Production Treatment: Gamma-Irradiation

Gamma-Irradiation Treatment

• Currently the only approved strategy to prevent TA-GVHD

• How does it work? • Ionizing radiation penetrates the nucleated cells

(e.g., T cells) and damages DNA or generates free radicals that indirectly disrupts DNA integrity• Prevents proliferation of donor T cells in recipients


Impact on Red Cell Quality

• In Vitro Parameters:• Increased hemolysis – adherence to regulatory guidelines• Potassium leakage – risk of post-transfusion hyperkalemia


• Current gamma-irradiation guidelines (US and Canada)• Performed at any time during RCC storage• Irradiated units may be stored until the end of allowable shelf life,

but no longer than 28 days after irradiation

May diminish post-transfusion recovery and lead to potential adverse outcomes

The effect of timing of γ-irradiation on hemolysis


Weeks after irradia

tion

40.48 ± 0.18

(n = 61)

0.54 ± 0.34

(n = 43)

30.39 ± 0.22

(n = 68)

0.43 ± 0.24

(n = 70)

0.66 ± 0.44

(n = 57)

20.23 ± 0.12

(n = 67)

0.25 ± 0.12

(n = 70)

0.39 ± 0.18

(n = 64)

0.47 ± 0.29

(n = 45)

10.10 ± 0.06

(n = 72)

0.13 ± 0.07

(n = 73)

0.24 ± 0.21

(n = 67)

0.26 ± 0.17

(n = 69)

0.28 ± 0.15

(n = 70)

2 3 4 5 6Weeks before irradiation

A

n=896

Serrano, K., et al. Vox Sang. 2013. 106:379-381

13579111315171921232527

1 23 45 67 89 10

Days before irradiation0 2 4 6

AABBCouncil of Europe

Days

afte

r irr

adia

tion

B

British Council of Standard in Haematology

The effect of timing of γ-irradiation on potassium


11 d

12 d

13 d

14 d

15 d

16 d

17 d

21 d

23 d

24 d

28 d

30 d

31 d

32 d

35 d

37 d

38 d

39 d

42 d

0

10

20

30

40

50

60

70

80

40 d Irradiation

35 d Irradiation

28 d Irradiaiton

21 d Irradiation

14 d Irradiation

10 d Irradiation

7 d Irradiation

QMP 2012 5 d

QMP 2012 42 d

Days Post Collection

Supe

rnat

ant P

otas

sium

(mm

ol/L

)

n=84

Serrano, K., et al. Vox Sang. 2013. 106:379-381

RBC Washing

• Removes about 99% of the non-cellular fluid in a unit of blood, including plasma proteins, electrolytes, and antibodies.

• Saline washed RBCs are indicated for 1. massive transfusion2. patients with a history of severe allergic reactions3. neonates


Emerging Challenges to Blood Product Safety

Emerging Post-Production Treatment: Pathogen Inactivation Technology

Image from USC Institute for Emerging Pathogens and Immune Diseases

Image from State of Queensland, Dept. Agriculture, Fisheries & Forestry

Image from The Endless City

Image from Cynthia Goldsmith, US CDC

Pathogen Inactivation (PI) Technology


Prevent Disease Transmission Preserve Product Quality

Proactive strategy to better ensure a safe supply of blood products

Think-Pair-Share

Current Pathogen Inactivation Systems & Mechanism of Inactivation• PI Systems for Platelet Concentrate

• Theraflex UVC• Intercept Amotosalen + UVA• Mirasol Riboflavin (Vitamin B2) + UV

• PI Systems for Plasma Concentrate• Octaplas TNBP + Triton X100 • Theraflex Methylene Blue + Visible Light• Intercept• Mirasol


Image from MerckMillipore

Central Dogma of Molecular Biology• Generally describes the direction of information

flux in molecular biology

• Damage at the level of DNA will subsequently disrupts downstream processes• Inhibit pathogen proliferation (DNA replication)• Prevent disease transmission (pathogenic proteins or virulence

factors)


Image from Psiopticon

Application to Whole Blood?Emerging Post-Production Treatment: Pathogen Inactivation Technology

Component EffectivenessPotential Adverse Reactions

T-Associated GVHDT-Transmitted Disease

• Known pathogens• Emerging pathogens• Close infectivity “window”

Production Lab Complexity Cost of PI Technology

Routine Donor TestingCost in Ind. Component Tx

Cost Benefit

Impact on Red Cell Quality (Riboflavin + UV)


0 1 2 3 4 5 60

0.2

0.4

0.6

0.8

1

1.2

untreatedtreated

Weeks of Storage

Perc

enta

ge H

emol

ysis

(%)

0 1 2 3 4 5 60

5

10

15

20

25

30

35

40

untreatedtreated

Weeks of StoragePo

tass

ium

Leve

l (m

mol

/L)

n=6

• RBC derived from PI treated whole blood showed accelerated storage-related deterioration compared to those left untreated

Adopted from Schubert, P., et al. Transfusion, 2015. 55: 815–823.

SummaryModifying Red Cell Concentrates: The Impact of Post-Production Treatments on RBC Quality

• RBC undergo biochemical and biophysical changes during storage

• Residual viable donor T-cells are the culprit for TA-GVHD• Gamma-irradiation – current strategy• Pathogen Inactivation Technology – emerging strategy

• Post-production treatments negatively impacts RBC product quality• Percentage Hemolysis • Extracellular Potassium Levels

Balancing Quality and Safety - Where Do I Fit In?

RBC Hemolysis: Biomarker Discovery for Quality Assessment

Product Quality Product Safety

Product Quality

Product Safety

Acknowledgements

Devine LabDr. Dana Devine Christa Klein-Bosgoed Dr. Peter Schubert Ahmad Arbaeen Dr. Katherine Serrano Simi KarwalDr. Elena Levin Tony FangDr. Zhong-ming Chen Branika Culibrk Dr. Geraldine Walsh

Modifying Red Cell Concentrates: The Impact of Post-Production Treatments on RBC Quality

Financial SupportCanadian Blood Services Graduate Student Fellowship Program

Production TeamVolunteer Donors

2015 bcsls congress invited presentation - deb chen - final

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