BLOOD COMPONENT THERAPY-II

DR.SAURAV SINGH

TERMS APHERESIS: It is a Greek word that means to separate or

to remove. In apheresis,blood is withdrawn from a donor or patient in anticoagulant solution and separated into components. One or more component is retained and remaining constituent are returned to the patient.

PLASMAPHERESIS: The process of removing the plasma from

red cells is termed plasmapheresis. Similarly terms are given to removal of

other components like Platelet(PLATELETPHERESIS), Red cells(ERYTHOCYTAPHERESIS),or Leukocyte(LEUKAPHERESIS)

PLATELETSo There are two methods from which

platelets can be obtained:◦Differential centrifugation of unit of

whole blood (platelet concentration).◦Plateletpheresis

Platelet concentration: Platelet concentrate is prepared from

centrifugation of whole blood within 6hrs of donation and is centrifuged at low spin to produce platelet rich plasma(PRP)

• PRP is transferred to satellite bag and spun at high speed to get platelet (at bottom) platelet poor plasma (at top). Platelet poor plasma is returned to the primary bag leaving behind 50-60 ml of plasma with platelet.

• Platelet is stored at 20-24 degree C, with agitation which causes exchange of gases, maintenance of pH and reduces platelet aggregates and should be used within 5 days.

PLATELET CONCENTRATE

RANDOM DONOR PLATELET(RDP)

Prep from whole blood donationsVol-50-60mlPlatelets- 5.5x109/bag or moreRed cells- <1.2x109/bagWhite cells- <0.12x109/bag

It may be supplied as single unit or Pooled unit of 4-6 donors

SINGLE DONOR PLATELETS(SDP)

Prep by platelet pheresis in cell separatorVol – 150-300mlPlatelets – 150-500x 109/bag

Platelets can be stored in bags made up of Polyvinylchloride(PVC) with Di (2-ethylhexyle) phthalate(DEHP) plasticizer up to 72 hrs at room temp. while certain polyolefin with no plasticizer maintains the platelet function and pH for 7 days.

One unit of platelet concentration contains >45x109 platelet, so transfusion of one unit raises platelet count by 5000/microlitre

Plateletpheresis: single donor is connected to the blood separator machine in which whole blood is collected , platelet is separated and retained while rest of component is returned to the donor.

This method yields large number of platelet from single donor(6 units of whole blood) upto 30,000-60,000/microlitre

Dosage: As a guide, each unit of random

donor platelet should raise platelet in an adult by 5000 to 10000/cumm.

1 unit /10 kg body weight of RDP is required

Bleeding, fever, infection, splenomegaly, alloimmunization, and intravascular consumption, each decreases the expected increment. Response to platelet infusions should be continually monitored as essential elements of patient management.

QUALITY CONTROL(QC)Parameter QC reqd Frequency of

control

Vol 40-70 ml All units

Platelet count >5.5X1010/unit 4 units/month

pH >6.0 -do-

Residual leucocytes

2X109/unit -do-

RBC Traces-0.5 ml -do-

10

o The usual indications are:• Thrombocytopenia due to decrease in

platelet production like aplastic anaemia ,hematologic malignancies ,following radiotherapy or chemotherapy.

• or due to increased platelet destruction like ITP, DIC,alloimmune thrombocytopenia, drug induced thrombocytopenia, septicemia.

• Heriditary disorders of platelet dysfunction and massive blood transfusion.

• Infections like dengue and leptospirosis

o Most of the adverse reaction with platelet transfusion • is due to presence of leucocytes and

plasma leading to febrile non-haemolytic transfusion reaction , allergic reaction

• Septicemia due to bacterial contamination

• Alloimmunisation .

Leucoreduced platelets To minimize the adverse effects of

leucocytes present in blood components , the use of leukocyte reduced platelets have been instituted.

It can be accomplished by two methods:

Filtration Apheresis component programme.

Platelet agitator

Platelet agitators maintain donor platelets in an even suspension throughout the blood plasma. Platelet agitators are used for storing platelets at a specified temperature range usually between 20°C-24°C

PLASMA COMPONENTS

FRESH FROZEN PLASMA (FFP):Plasma is separated from whole

blood by centrifugation and is transferred to satellite bag which is rapidly frozen at -80 degree C and then the temp is brought to -18 to -30 deg C. This process is done within 6 hrs.

Storage- FFP can be stored for 1yr at -30 degree C and when required should be thawed at 37 degree C .

Contents of 1 unit of FFP prepared from 450ml of whole blood.

PLASMA 175 – 250ml Fibrinogen 200 – 400 mgm Rich in factor VIII and I ; Labile factor

V DOSAGE: About 5-10 units / kg body weight.

QC of FFP Parameter QC Frequency of

control

Volume 200-220 plasma 4 units/month

Stable coagulation factors

200 units of each factor

-do-

Factor VIII 0.7 units /ml -do-

Fibrinogen 200-400 mg -do-

Indications of FFP:◦Deficiency of multiple coagulation factors

as in liver disease, massive transfusion, DIC .

◦Familial factor V deficiency◦Deficiencies of factor II,VII,IX,X◦Antithrombin deficiency ◦Inherited coagulation factor deficiency.

CRYOPRECIPITATECryoprecipitate is prepared from

FFP.FFP is kept in the refrigerator upside down at -30 deg C and then at 4-6 deg C ,FFP melts. This melted FFP moves to another bag,10-20 ml of FFP left is the cryoppt and FFP in other bag is cryo poor plasma.

When required for transfusion, cryoppt is thawed at 4 deg C in circulating water bath.

Cryoprecipitate contains factor VIII,von Willebrand factor, fibrinogen, F XIII and fibronectin.

The usual dose of cryoprecipitate in treating hypofibrinogenemia is an initial infusion of 10 bags, followed by 10 to 20 bags or as necessary to keep the fibrinogen level above 100 mg/dl. The half-life of fibrinogen is about 4days.

Indications:Used in treatment of Factor VIII

deficiency, von Willebrand disease, F XIII deficiency and hypofibrinogenaemia.

CRYO POOR PLASMAThis is the supernatant remaining from

the production of cryoprecipitate. It is relatively deficient in high molecular weight forms of Von wille brand factor while retaining normal levels of the vWF-cleaving metalloprotease.

Use-  Treatment of chronic relapsing thrombotic thrombocytopenic purpura.

Liquid plasma

Plasma removed from liquid whole blood up to five days after the expiration of the whole blood .

Plasma may be stored in the liquid state at

I – 60 C.It contains stable clotting factors, however labile clotting factor such as factor VIII and factor V are lost.

USE: In deficiency of stable clotting factor(II,VII,IX,X,XI).

Solvent/Detergent treated plasmaPlasma is treated with the

solvent tri(n-butyl) phosphate (TNPB) and the detergent Triton X-IOO to inactivate lipid-enveloped viruses such as hepatitis B and C and HIV.

It has no effect on non-enveloped viruses like hepatitis A and parvovirus B 19.

GRANULOCYTE CONCENTRATE Granulocyte concentrate is rarely used

because:Most infections are controlled with antibiotics.A granulocyte concentrate prepared from a single donor has insufficient granulocyte and contaminated with red cells.

Transfusion of granulocyte is associated with significant risks.

Granulocyte for transfusion can be obtained single donor unit by differential centrifugation or by leucapheresis.

Leucapheresis is preferred because it yields more granulocyte,which can be further be enhanced by using corticosteroids.

Each concentrate contains approximately 1010 granulocytes which are about one tenth of the normal adult’s daily production and that is far fewer than that of an infected patient. Granulocytes are fragile and may be stored no longer than 24 h. The usual concentrate contains about 250 ml of plasma and has a Hct of 15 to 20 percent. ABO compatibility is necessary.

Indications: Patients with severe neutropenia

with documented bacterial or fungal infections. Patients not responding to antibiotics.

There is evidence that granulocyte transfusions can benefit a selected group of patients: those with gram-negative sepsis or progressive localized infections, severe granulocytopenia, and temporary suppression of leukocyte production.

BLOOD DERIVATIVES

HUMAN ALBUMIN -- Comprised of 96% albumin and 4%

alpha and beta–globulin. -- Prepared by cold fractionation of

pooled plasma.

INDICATIONS -- Used as replacement fluid in

therapeutic plasma exchange and treatment of diuresis resistant edema.

-- In hypovolemic shock, hypotension associated with hypovolemia in liver failure or protein losing conditions.

FACTOR VIII CONCENTRATE -- Prepared by fractionation from

large pools of plasma -- Heat treated to eradicate any HIV

or hepatitis virus contaminants. -- Available in freeze-dried forms INDICATIONS: -- Hemophiliacs -- severe Von Willebrand’s Disease

FACTOR IX CONCENTRATE -- Both plasma derived and

recombinant factor IX concentrates are available.

INDICATIONS: -- Hemophilia B

PROTHROMBIN COMPLEX CONCENTRATE

-- Combination of blood clotting factors II,IX,X and sometimes factor VII as well as protein C and S.

INDICATIONS: -- Inherited deficiency of factor IX,X or

II -- Hemophilia A with inhibitor

antibodies against factor VIII and who are non responsive to factor VIII concentrate.

IMMUNOGLOBULINS -- Prepared by cold ethanol

fractionation of pooled plasma. -- They are of two main types: Non- specific immunoglobulins -- Prepared from pooled plasma of

non-selected donors -- Composed of antibodies against

infectious agents prevalent in the donor population

INDICATIONS: -- Passive prophylaxis against

hepatitis A. -- Congenital or acquired

hypogammaglobulinaemia . -- Autoimmune thrombocytopenic

purpura to raise platelet count.

Specific immunoglobulins -- Prepared from donors who have

specific high titer IgG antibodies. INDICATIONS: -- Specific immunoglobulin for passive

prophylaxis against hepatitis B,varicella zoster,cytomegalovirus,or tetanus.

-- Anti-RhD immunoglobulin used for prevention of immunization against RhD antigen in RhD-negative mothers during pregnancy.

RECENT ADVANCESSemi automated methodsMethods for Apheresis

◦Manual method◦Automated methos

Pharmacological products as alternative to blood components.

Semi automated methods:◦ Preparation of L-R

cells concentrate◦ Preparation of

platelet from buffy coat

OPTIPRESS: automatic extractor having two plates,one is stationary and other expels plasma in empty satellite bag and red cells into bag containing SAGM.

OPTIPACKS:•Contains one 600ml bag made up of PVC having 63ml CPD phlebotomy needle is attached. this bag is connected to two 400ml bags ,one for collection of plasma and the other platelets which can be stored for 5 days .

APHRESIS

Apheresis is collection of anti-coagulated whole blood from a donor, its separation into components, retention of desired component and return of remaining constituents back to the donor with the help of automated cell separator machines.

ADVANTAGES OF APHRESIS

Reduced multiple donor exposure◦Reduced risk of alloimmunization◦Reduced incidence of transfusion

transmitted diseasesFull and effective transfusion dosePurer product:

◦leucocyte reduced productsHigh quality productFewer donor reaction due to return of

fluid

Types of cell separatorsIntermittent flow cell separator

(closed system)Continuous flow cell separatorAutomated separation techniques by

centrifugationCell separation by membrane

filtration Continuous magnetic cell separator

(immunomagnetic)

Automated separation technique by centrifugation:◦Centrifugal force separates blood into

different component depending upon the specific gravity.

◦Blood is drawn from an automatic pump Anticoagulant is added to the tube and blood is pumped into rotating bowl chamber in which layering of components occurs based on the density. The desired component is retained and rest returned to donor either by continuous flow or by intermittent flow.

Separation by Membrane Filtration:◦Filtration of plasma through membrane

which allows collection of plasma from a healthy donor.

◦Membranes are arranged as hollow fibres which expels the cellular elements in the flow of blood.

◦Most commonly used apheresis devices are: Haemonetic corporation: Platelets, plasma,

leucocytes. Baxter: Plasma, platelets, red cells, leucocyte Gambro: Plasma, platelets, leucocyte and

peripheral blood stem cells.

HAEMONETIC: It is intermittent centrifuge

separator. The anticoagulated blood is

pumped into rotating bowl .This incoming blood is separated.The red cells move to the periphery and plasma to inside of rotating bowl and the white cells and plasma between red cells and plasma.

Using optical detectors and fluid surge elutriation process,the desired component is retained.

HAEMONETICS CENTRIFUGE

GAMBRO(Cobe) Continuous flow centrifuge cell

separator where two arm blood is drawn and returned.

Here flat membrane is used to separate the cells of blood from plasma.

Allows lower WBC and RBC contamination in platelets.

BAXTER Continuous flow technology. CS 3000 has two separation

containers firstly for collection of leucocytes reduced platelets and other for white cells (CS 3000 plus).

REFERENCESDGHS Manual of blood

transfusion 2003 Essential of clinical Haematology

– Shirish M kawathalkar INTERNET

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