Complement activation products in liquid stored plasma and C3a kinetics after transfusion of autologous plasma.

BACKGROUND AND OBJECTIVES: Keeping a small stock of liquid plasma readily available for transfusion is common practise in Sweden. We report data on complement activation markers in plasma components during storage in the liquid state and the kinetics of C3a-(desArg) after transfusion of autologous plasma with high content of C3a-(desArg). MATERIAL AND METHODS: Plasma components were prepared by apheresis or from whole blood. C3 fragments (C3a-(desArg), C3d,g, iC3), and soluble terminal complement complex (sC5b-9) were investigated. C3a-(desArg) kinetics was investigated in regular apheresis donors. RESULTS: Apheresis plasma prepared by membrane centrifugation had significantly higher level of C3a-(desArg), C3d,g and sC5b-9 from day 0 and low iC3, than plasma prepared by other methods. By storage day 7, C3a-(desArg)-levels were above the reference value in 88% of all components. After re-infusion of autologous plasma with high C3a-(desArg) content, there were rapid a(1) and a(2)-distribution followed by a slower b-elimination phase. CONCLUSION: Plasma components prepared by different methods and stored in the liquid phase differ significantly in the amount and timing of complement activation. C3a-(desArg) present in plasma is rapidly eliminated after transfusion. Autologous plasma could be used to study complement kinetics in different clinical situations.

Unexpected effects of donor gender on the storage of liquid plasma.

BACKGROUND: Swedish regulations in effect since 2006 allow the storage of plasma for transfusion up to 14 days at 2-6 degrees C and for 3 years at < or = -30 degrees C. In this study, the quality of currently used plasma components was investigated. MATERIALS AND METHODS: Plasma components, prepared from whole blood or by apheresis, either leucocyte depleted or not leucocyte depleted, were stored at 2-6 degrees C as liquid plasma or as thawed fresh-frozen plasma; 31% were from female donors. Concentration, function and activation markers of the plasma coagulation systems were investigated during storage for up to 42 days. RESULTS: Cold-induced contact activation was the dominant storage lesion, occurring earlier and at higher frequency in plasma from females. Increased kallikrein-like activity led to changes in activated partial thromboplastin time, prothrombin time, protein C and C1 inhibitor (C1INH). C1INH function dropped to 53% on Day 14 in cold-activated plasma components. CONCLUSION: Contact activation may be triggered before Day 14, especially in plasma from females, and may progress as a result of the consumption of C1INH. The data suggest that lack of cold-induced contact activation may be an important quality criterion. To achieve this, plasma from male donors could be selected for transfusion and the storage time limited to 7 days.

Adverse events and problems in therapeutic hemapheresis. A report from the Swedish registry.

BACKGROUND: Since 1996 adverse events (AE) in therapeutic apheresis (TA) have been more extensively registered in Sweden. This report analyzes the extent and relation of AEs to procedures and diagnoses. MATERIALS AND METHODS: Reporting of TA performed in Sweden was centralized. A separate system for the registration of AE in TA was established and the data received were entered into a central database for registration and analyses. Fifteen of all 35 apheresis units reported both TA and AE during 1996-1999. These centers performed 75% of all TA procedures. Adverse events included medical symptoms, vascular access problems, technical and other problems. RESULTS: More than 14,000 procedures were registered during the observation period. No fatalities occurred. AEs occurred in 3.7% (1996), 4.6% (1997), 4.2% (1998) and 4.4% (1999) of procedures. Interventions during the adverse event were performed in about 65% of the events. Apheresis procedures were interrupted due to an adverse event in about 1%. Adverse events occurred in 5.6% of plasma exchanges, 1.9% of plasma modulations and 6.8% of cytapheresis procedures. Paresthesia was registered in 22% and hypotensive events in 20.5%. Other more frequent symptoms were urticaria (14.4%), shivering (7.4%) and nausea (7.4%). AEs were most frequent in patients with Goodpasture's syndrome (12.5%), TTP/HUS (10.5%) and GuillainBarré syndrome (11.0%). CONCLUSION: AEs are few, often mild and less common in plasma modulation than plasma exchange. AEs are more frequent during TA of patients with certain diagnoses such as TTP/HUS.

The supply of blood products in 10 different systems or countries.

Countries vary greatly in their ability to produce their own blood products including albumin and IVIgG. Part of this variability depends on the supply of plasma within the country. As has been seen most recently in the UK, the quality of the plasma and its acceptability for plasma fractionation must also be considered. Therefore concerns regarding the quality of the plasma have been added to those regarding the quantity.Only a few countries are nationally self sufficient in plasma. This has a marked effect on blood product availability and therefore the ability to treat patients. Unlike most pharmaceuticals, the plasma fractionation industry must rely, for its raw products, on plasma obtained from blood donors. As such this puts it in a potentially compromised situation since neither the supply nor the quality of the raw material can be assured and both of those will vary with time. This paper reviews the processes through which blood products are made available in 10 different systems including: Canada, England, France, Italy, Norway Scotland, Sweden, Switzerland, South Africa and USA. A series of specific questions were posed and the responses received from the various coauthors and other respondents provide comparative data on blood product availability in different areas of the world.

International forum: Europe. Buffy-coat-derived platelet concentrates: Swedish experience.

The need for source material for plasma products such as factor VIII preparations and improving the quality of red cells for transfusion became determining factors in the choice of methods for blood components in the 1970s and 1980s in Sweden. The possibility to make platelet concentrates (PC) from buffy coats (BC-PC) instead of from platelet-rich plasma (PRP-PC), as first described in England and The Netherlands, using an additive solution as the major component of the platelet storage medium, as first described by Rock et al., has been shown to influence favourably the national supply of blood components and has become accepted as the normal standard procedure in the first half of the 1990s. Leucocyte-depleted PCs, produced from pools of 4-6 BCs, used in all multiple platelet transfusions to thrombocytopenic patients, have strongly reduced the demand for HLA compatible PCs. Nationwide, 79% of the demand of PCs is supplied as BC-PCs, mostly leuco-depleted which, so far, have compared favourably with apheresis-PCs for cost-effectiveness.

Some relations between light transmission changes and biochemical parameters of stored platelet packs.

In the present work a computerised method for continuous monitoring of light transmission through platelet packs was evaluated. On series (Series 1) of 50 platelet concentrates was studied over a 5-day period, and thereafter the pH, extracellular lactate dehydrogenase (LDH) and platelet factor 4 (PF4) in the concentrates were determined. A second series (Series 2) of 52 concentrates was also monitored over 5 days, and thereafter the pH, extracellular LDH and intracellular concentrations of ATP, ADP and AMP were determined. 11 and 14 of the concentrates of Series 1 and 2, respectively, demonstrated long lasting transmission increases (> or = 3.0 days). In the total of 102 platelet concentrates 34 were observed to have late (< 1.0 day) or no transmission increase. It is concluded, that the present optical method identifies both a group of platelet concentrates having long lasting transmission increases and a group consisting of platelet concentrates having late or no transmission increase. Compared to the latter concentrates preparations with long lasting transmission changes demonstrated significant biochemical alterations. These observations could be applicable in the quality control of platelet concentrates.

Correlation of aggregometry responses to changes in light transmission through platelet packs.

The transmission of light through 22 platelet packs was monitored during storage with a specially designed apparatus in order to estimate the quality of the platelet concentrates without risking contamination. The changes in light transmission during a 7 day storage period were compared with other properties of platelets upon day 1 and day 7, namely aggregometry responses (to collagen, ADP, and calcium ionophore A23187), platelet factor 4 release, lactate dehydrogenase extracellular activity and pH. On day 7 additional aggregometry tests were carried out with pairs of activators (collagen + ADP, collagen + A23187, collagen + epinephrine, and collagen + arachidonic acid). The 8 concentrates judged as being inferior in quality by the optical apparatus also, with 1 exception, showed inferior quality as assessed from aggregometry responses and/or biochemical analyses.

In vivo production of thromboxane and prostacyclin in patients following total hip arthroplasty.

The in vivo production of thromboxane and prostacyclin was studied by measurements of their major urinary metabolites in eight patients undergoing total hip arthroplasty. Specific methods based on gas chromatography-mass spectrometry were used to measure the urinary excretion of 2,3-dinor-TxB2 and 2,3-dinor-6-keto-PGF1 alpha. The excretion of these metabolites increased about 10-fold during the intra and immediate postoperative period and 4 days after surgery was still higher than during the preoperative period. The increased thromboxane formation reflects probable activation of platelets whereas the increased prostacyclin could be part of a vascular defense against induced thrombotic activity. These findings may have pathophysiological implications.

Blood substitution and complement activation.

Complement activation was studied in 45 patients undergoing total hip arthroplasty under epidural anesthesia. The patients were randomly allocated to three groups. In Group I blood loss was replaced with microaggregate-poor erythrocyte concentrate (SAGM-ERC) plus 3% dextran-60 as plasma substitute, and postoperative analgesia was maintained with intramuscular ketobemidone. In Group II blood loss was replaced as in Group I, but epidural anesthesia was prolonged 12 h postoperatively and kept at a level of T4 with 0.5% bupivacaine. In Group III blood loss was replaced with non-frozen stored plasma plus SAGM-ERC, and postoperative analgesia was maintained with ketobemidone as in Group I. All groups received pre- and postoperative thrombo-prophylaxis with dextran. The plasma concentration of C3a-des-arginine (C3a-desArg) was measured by radioimmunoassay preoperatively, immediately after operation and 3, 6 and 18 h postoperatively. No significant differences in plasma C3 and C4 were found between the groups. C3a-desArg was significantly (P less than 0.01) increased up to 6 h postoperatively in Group III compared with both the preoperative value and Groups I and II. It is demonstrated that infusion of plasma can enhance or initiate endogenous complement activation. Blood component therapy with SAGM-ERC and 3% dextran-60, on the other hand, did not significantly increase the plasma level of C3a-desArg irrespective of the type of postoperative analgesia.

The evaluation of maternal anti-D concentrations during pregnancy.

Anti-D quantitation by the AutoAnalyzer technique has been shown to be a helpful aid in assessing the severity of D alloimmunization during pregnancy. In this study, the technique has been used both to detect antibody boosting after amniocentesis and to differentiate active D immunization from the presence of passive antibodies. The AutoAnalyzer technique and the more generally used indirect antiglobulin test titration method showed good agreement at titre levels of 32 or lower. A titre of 32 was found to be a good discriminative level to separate the mildly affected from the more severely affected newborns suffering from Rh haemolytic disease. At higher titre levels, however, the AutoAnalyzer technique was the method of choice for correct clinical assessment of the severity of D alloimmunization.

A management programme for Rh alloimmunization during pregnancy.

A management programme for the control and treatment of Rh0 (D) immunized during pregnancy is presented. A total of 34,650 births were registered during a 4.5 year period and included 63 D positive newborns to D-immunized mothers. The outcome of all infants has been evaluated according to the severity of the haemolytic disease. Exchange transfusion was unnecessary in 43 mild cases (68.3%). Fourteen infants (22.2%) required exchange transfusion, and in 6 severe cases (9.5%) maternal plasma exchange and exchange transfusion was performed. No detrimental effects or deaths occurred among the infants suffering from Rh haemolytic disease. We recommend that the frequency and volume of plasma exchange therapy should be individually adjusted to suit each patient and the effect monitored regularly through maternal anti-D levels using a sensitive quantitative technique.

Three per cent dextran-60 as a plasma substitute in blood component therapy. I. An alternative in surgical blood loss replacement.

Microaggregate-poor erythrocyte concentrate with 3% dextran-60 as a plasma substitute was compared with microaggregate-poor whole blood for replacement of intra-operative and immediately postoperative blood loss. Sixty patients undergoing total hip arthroplasty randomly received either of these two forms of therapy. In accordance with the clinical routine of our orthopedic department, an infusion of 500 ml of 6% dextran-70 (Macrodex) was given as thrombo-prophylaxis in both groups. Use of 3% dextran-60 as a plasma substitute in blood component therapy for surgical hemorrhage of up to 50% of the calculated blood volume caused no increase in bleeding tendency or frequency of postoperative hematoma compared with whole blood replacement. Plasma protein levels were low immediately postoperatively in patients given the dextran, but from the 4th postoperative day onward there was no difference between the groups. Applied in clinical practice, this would be efficient in saving plasma for other urgent purposes.

Three per cent dextran-60 as a plasma substitute in blood component therapy. II. Comparative studies on pre- and postoperative blood volume.

Microaggregate-poor erythrocyte concentrate with 3% dextran-60 as a plasma substitute was compared with microaggregate-poor whole blood for replacement of intra-operative blood loss. Their blood volume-conserving effects were studied by sequential blood volume determination with radioactive technetium (99mTc) in 19 patients undergoing total hip arthroplasty. Pre-operatively there was no difference in blood volume between the groups. Immediately after surgery and on the 2nd postoperative day there was no difference in total blood volume. Blood component therapy with 3% dextran as a plasma substitute is an efficient principle for intra-operative blood loss replacement at hip operations.

Simple method of improving the quality of platelet concentrates and the importance of production control.

Some technical improvements of the method to prepare platelet concentrates (PC) have been developed. The contamination of the PC with red blood cells (RBC) and white blood cells (WBC) is thereby kept at a low level. A majority of routinely prepared PC did not show any visible RBC contamination which means that they contained less than 0.4 X 10(9) RBC per PC unit. None of the tested examples contained more than 1 X 10(9) RBC per PC unit. The WBC contamination was less than 0.1 X 10(9) cells per PC unit in 75 per cent of tested examples and did not exceed 0.6 X 10(9) cells per PC unit. Routine platelet counting by thrombocounter applied on samples from all PRPs was found to be a reasonably simple way to make routine PC quality control. By sufficient supervision of the details of the procedure the main yield can be maintained at about 100 X 10(9) cells per unit. By follow-up of the weekly yield any deterioration of production efficiency can easily be detected.

A simple photometric method for determination of blood loss during transurethral surgery.

A new method for determining blood loss during transurethral operations is presented. Its basic principle is photometry of blood concentrations in haemolysed irrigating fluid. At test study was run on 50 patients who underwent transurethral prostatic resection because of hyperplasia. The photometer was of a type commonly used for routine determination of a haemoglobin concentration in blood. The apparatus for the test is therefore readily available. The test is simple to perform and gives highly reliable results within a few minutes. In seven cases double sampling was done. Since the results within each pair of samples were practically identical, double sampling was considered superfluous for the rest of the case series. Visual estimation of blood loss during transurethral operations seems to be customary in most urologic units in Sweden. We found this method to be unreliable, with underestimates of about 100% in several cases.