Patogenreduktion allmänt och nu även erytrocyter. Folke Knutson KITM, Akademiska sjukhuset, Uppsala Equalis användarmöte

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1 Patogenreduktion allmänt och nu även erytrocyter Folke Knutson KITM, Akademiska sjukhuset, Uppsala Equalis användarmöte

2 Blodsäkerhet Allmänheten vill att blodtransfusioner skall vara 100% säkert Dagens blodtransfusioner är säkrare än någonsin förr Men det kommer aldrig att vara riskfritt eftersom det är en transplantation från en individ till en annan

3 Transfusions överförd bakteriell smitta I USA for single-donor platelets, for pooled platelets and 0.21 for RBC units per million Fatal events: 1.94, 2.22 and 0.13 respectively M.J Kuehnert et al Transfusion vol 41 issue

4 Current Transfusion-Associated Risks to Patients

5 När det gäller bakterier hur lätt är det att detektera?

6 Logarithm of cell numbers Growth curve for a bacterial population (c) Stationary phase Reproduction = Death (c) Decline phase Reproduction lowest Death highest 1,000, , , (a) Lag phase (b) Logarithmic (log) phase Reproduction highest Death lowest Time

7 Bacterial growth variability Organism Bacillus cereus Bacillus subtilis Candida albicans Clostridium perfringens Coynebacterium species Escherichia coli Klebsiella oxytoca Propionibacterium acnes Pseudomonas aeruginosa Staphylococcus aureus Staphylococcus epidermis Serratia marcescens Streptococcus viridans Time to detection* All organisms have different growth kinetics *Times to detection for the 10 CFU per ml innoculation experiments; values given as mean±sd h

8 Limitations of bacterial detection tests Bacterial culture schemes are not robust enough to prevent the transfusion of many infected units, due to sampling errors, false-positive and falsenegative results, slow bacterial growth rate 1 1. Beckers EAM, te Boekhorst PAW, Vermeij H, et al. Vox Sang. 2004;87(suppl 3):S2 S16.

9 Experience with bacterial detection techniques Results from the implementation of bacterial detection techniques revealed that only 46.7% of confirmed positive cultures were prevented from being administered to patients 1 Sanquin Blood Bank South West Region, Rotterdam, The Netherlands A four-year review of bacterial screening found that 48% of contaminated platelet units were transfused before they could be recalled 2 Flemish Red Cross 1. Beckers EAM. Slides presented during the Congress of the International Society of Blood Transfusion, Edinburgh, July 2003, P Claeys H, Logghe F, Vandekerckhove B, et al. Slide kit presented at ISBT 2003, P086.

10 Fallbeskrivning SHOT Apheresis donation split into 1 adult and 4 neonatal packs 1 neonatal pack time-expired therefore underwent routine post-expiry quality monitoring for ph 5.59 Sent for culture to NHSBT National Bacteriology Lab significant growth of Streptococcus pneumoniae No report of transfusion reaction received by NHSBT or hospital transfusion labs on enquiry BUT

11 Fallbeskrivning SHOT 2 3 of the 4 neonatal packs transfused to one baby on each of 3 consecutive days No adverse reaction after first pack 40 mins after transfusion of both packs 2 and 3, noted pyrexia ( C), drop in O 2 sats and periorbital oedema Infant already on antibiotics (additional antibiotic added after temp spike); no growth in blood cultures; packs not retained for culture

12 Tekniker för patogenreduktion Plasma och trombocyter Bara trombocyter Röda

13 Intercept/Amotosalen Mechanism of Action Amotosalen (S-59) UVA Illumination DNA or RNA of pathogen Docking Permanent Crosslinking

14 Mirasol/Riboflavin Mechanism of action Normal pathogen DNA Riboflavin binds to DNA Illumination reaction breaks DNA Riboflavin absorbs light in visible and UV region Photolysis through electron transfer and oxidative chemistry DNA/RNA breaks result in inability of pathogen to replicate Ennever et. al., Pediatric Res 1983; 17: 234 Ito et. al., J Biol Chem 1993; 268: 13221

15 Theraflex (Macopharma) Still in phase 1 clinical studies Exposure of platelets to UVC light alone Inactivates enveloped and some nonenveloped viruses, bacteria and leucocytes Low toxicity, cell and protein function thought to be preserved

16 Amutosalen (S-303) Mechanism of Action S-303 Physiologic ph Unreactive By-product DNA or RNA of pathogen Docking & Permanent Crosslinking

17 Undvika GVH Säkerhet eller kvalité eller säkerhet och kvalité

18 Bestrålade produkter BCSH Irradiation 1 Intrauterine transfusion (IUT) (level III evidence, grade B recommendation). 2 Exchange transfusion (ET) of red cells after IUT (level III evidence, grade B recommendation). 3 Top-up transfusion after IUT (level III evidence, grade B recommendation). 4 When the donation is from a first- or second-degree relative or a human leucocyte antigen (HLA)-selected donor (level III evidence, grade B recommendation). 5 When the child has proven or suspected immunodeficiency (level III evidence, grade B recommendation). 6 Other indications as listed in the above Guidelines.

19 Strålning vad händer i cellen Joniserad strålning ger olika typer av cellskador på DNA, t.ex. Dubbelt strängbrott Enkelt strängbrott basskador

20 Ytterligare cellskada cirka 70% av strålskador orsakas av fria syreradikaler som produceras genom radiolys av cellulära vattenmolekyler

21 INTERCEPT PI treatment inactivates T leukocytes completely with an increased efficacy margin vs. gamma irradiation. Gamma irradiation Inactivation analyzed using LDA 1,2 INTERCEPT Inactivation analyzed using LDA at 1.4J/cm 2 3 2,500 cgy 150 μm, 3 J/cm fold 3,000-fold Safety Limit (No TA-GVHD) 1 Pelszynski MM, et al. Blood. 1994;83: Luban, NL et al. Transfusion 2000, 40, Grass JA et al. Blood, 1998:91,

22 INTERCEPT treated components have effectively replaced gamma for prevention of TA-GVHD Study Number of Transfusions % Nongamma irradiated Total Number of Patients Hem-Onc Patients HSCT Patients Incidence of TA-GVHD Phase III Trials % HV1 5 5, % HV2 6 7, % 2 1, HV3 6,991 95% 3 2, Mt. Godinne 7 3, % Pediatric % Basel % Lübeck % Strasbourg 11 55, % ~8,000 ~4,400 not available 0 Lin et al. Vox Sanguinis, 2011, (sup) Poster 22

23 Vad gör INTERCEPT RBC System Reducerar risken avseende ett stort antal patogener, i vissa fall där det ännu ej finns tester Ersätter gamma strålning 23

24 Amotusalen (S-303 ) (Cerus) Use in red cells Binds to and inactivates NA, activated by ph shift Effective against intra- and extra-cellular viruses, HIV, enveloped viruses, bacteria

25 INTERCEPT RBC: Hur fungerar det S-303 är en alkylerare som går på nukleinsyran och snabbt diffunderar in i virus, bakterier, parasiter och blod celler. Den är konstruerad för att reagera snabbt och brytas ned Glutathione (GSH) används för att undertrycka sidoeffekter av effektorn på andra biologiska material Linker Effector Reaction Degradation Anchor Targeting Docking & Permanent Crosslinking (Helical regions of DNA & RNA) 25

26 Leukocytpåverkan Leukocyte inactivation evaluated with First Generation S-303 treatment system T-cells from control and S-303 treated RBCs were tested for proliferation in a limiting dilution assay 5 log of leukocyte reduction was observed The number of S-303/DNA adducts in the leukocytes was 1:29 base pairs (or 34 adducts per 1000 base pairs) 1,275 times more frequently than nucleic acid strand breaks induced by 2,500 cgy gamma irradiation (1:37,000 base pairs) Hanson D, Propst M, et al. (2001). High Titer Leukocyte inactivation in INTERCEPT Red Blood Cells (RBC), Transfusion Clinique et Biologique. 8(S1): 45s.

27 Study Design 450 ml CPD whole blood (WB) units were separated into plasma, buffy coat and SAG-M RBC after being held on cooling plates for a minimum of 2 hours post collection For each replicate, ABO matched pairs of leukocytedepleted SAG-M RBC were combined and split into units of 284±7 ml (n=11) On D0 one unit per replicate was placed at 4 C and the other was treated with the S 303 Treatment System for RBCs (S-303 RBC) On D1, the second unit of each replicate was exposed to 25 Gy of gamma irradiation (IR RBC) The units were sampled for in vitro analyses on D1, 14, 28 and 42 days of storage

28 INTERCEPT RBC: Second Generation Clinical Process RBC (SCD) Reconstitution Set Integrated Processing Set S-303 GSH SCD STEP 1 Add RBC and mix with reagents STEPS 2 & 3 Inactivate & remove STEP 4 Transfer RBC for storage 28

29 Tvättstegets betydelse Det ligger ett initialt tvättsteg i hanteringen Detta leder till ännu lägre initiala kaliumnivåer Kan detta ha betydelse för transfusioner till prematura?

30 Vilka regler för användning av strålade erytrocyter till spädbarn Europarådsguiden: 14 dagars hållbarhet efter strålning om liten volym. Vid snabb infusion eller större volym max 5 dagar efter tappning. Handbok för Blodcentraler: barnenheter kan lagras upp till 35 dagar men de flesta tillämpar 14 dagar. Efter bestrålning reduceras hållbarheten till 24 timmar.

31 Patogenreduktion istället för gammastrålning Kan det betyda att vi inte behöver stråla vid utlämning? Kan det betyda att blodcentraler som inte själva har strålningsmöjligheter kan ha ett litet lager?

32 Quality of INTERCEPT RBCs is superior to Gamma IR RBCs Day 1 Day 28 Day 42 INTERCEPT Gamma INTERCEPT Gamma INT Gamma Potassium (mm) 1.4 ± ± ± ± ± ±5.5 Hemolysis (%) ATP (µmol/g Hb) 7.97 ±1.08 Red Cell Microvesicles (n=11) 0.1 ± ± ± ± ± ± ± ± ± ± ±0.80 Not Measured Not Measured PI Process: Day 0-1 post donation Gamma Irradiation: Day 1 post donation

33 Röda Platelets and plasma Red blood cells Addition of S-59 Addition of S-303 Removal Removal UVA activation of S-59 ph activation of S-303

34 Rationale for INTERCEPT RBC System Enable full PI safety strategy for all blood components Reduce risk for a large spectrum of RBC pathogens, in some cases where testing does not exist Replacement for gamma irradiation and with improved product quality Reduced allogeneic plasma proteins compared to conventional RBCs 34

35 Transfusionsreaktioner

36 Impact of Pathogen Inactivation on Transfusion Reactions in a Regional Blood Center: EFS Alsace Before INTERCEPT After INTERCEPT Patients transfused (n) 2,050 2,069 Acute reactions (%) Patients with reactions (%) JP Cazenave et al Canadian Consensus Conference 2007

37 Acute Transfusion Reactions: Three Periods of Platelet Transfusion (JP Cazenave, C Waller) PC-PLASMA 1/1/2003 1/07/2003 PC-TSOL 5/9/2005 5/3/2006 PC-INTERCEPT 20/7/ /1/2007 Patients with ATR (n) 40/976 29/ /1122 Acute reactions (n) 40/ / /6718* Acute reactions/1000 PC Patients with reactions 4 % 3 % 2 % *Fever/chills - 7; allergy - 3; others - 11 (9 RBC immunization, 2 volume overload) No TRALI, bacterial sepsis or death. All reactions were grade 1 and 2

38 Different centers experience: significant reduction in transfusion reactions Quantitative Studies JC Osselaer et al (Mont Godinne, Belgium) 1 ~30% Reduction after 18 months in routine JP Cazenave (Strasbourg) ~70% reduction M. Angelini-Tibert (La Reunion) rate of ATR for adult and pediatric patients as low as in other INTERCEPT Studies 1 JC Osselaer et al., Blood 2005; 106(11):129a. 2 Angelini-Tibert et al., AABB 2007 (Anaheim, CA).

39 Transfusionsreaktioner, Uppsala januari-oktober 2006 januari-oktober 2007 Trombocyt antal TR, antal TR, % Trombocyt antal TR, antal TR, % transfusioner transfusioner Bestrålade ,1 Bestrålade ,8 Patogeninaktiverade Patogeninaktiverade ,5 Övriga Övriga Totalt ,1 Totalt ,6 TR= Transfusionsreaktion

40 Hemovigilance Program 40 40

41 Hemovigilance Data Show Significant Reduction of Adverse Reactions for PC Apheresis Buffy coat Pools INTERCEPT INTERCEPT 1 episode of TRALI due to high titer HLA antibodies in a multiparous apheresis donor. Cazenave, et al., 12th International Haemovigilance Seminar (I.H.S.) Dubrovnik, Croatia February 17-19th,

42 Routine Adoption of INTERCEPT Results in Elimination of Septic reactions in PC Service 1 Total Number CP Period TRS Rate TRS / CP EFS 991, /10,000 Alsace (INTERCEPT) 67,571 9/2006-9/ Cazenave Transf. Clin.et Biol.18 (2011) Excludes INTERCEPT PC

43 Storage after gamma irradiation affects in vivo oxygen delivery capacity of transfused red blood cells in preterm infants Maria Saito-Benz,1,2 William G. Murphy,3,4 Yu-Chieh Tzeng,2 Greg Atkinson,5 and Mary J. Berry1,2 In infants (n = 9) who received fresher RBCs (irradiated <10 days before transfusion), there was a sustained increase in mean crso2 up to 5 days after transfusion (3.0%; 95% CI, 0.3% to 5.7%; p = 0.04). Conversely, in infants (n = 15) who received older RBCs (irradiated 10 days before transfusion), there were negligible changes in crso2 after transfusion at any time point.

44 Slutsatser Patogen reduktion är en proaktiv metod för att minska transfusionsöverförd smitta Den ger större säkerhet när det gäller bakterier än odling Behandlingen är mer skonsam än gammastrålning och detta märks mer när det gäller en komponent som lagras längre som erytrocyter Ger initial lägre kalium nivåer Möjliggör att vi slipper ha en strålningsapparat som innehåller cesium.

45 Tankar inför framtiden Vi tänker under våren jämföra strålning med Intercept för röda när det gäller barnenheter I denna studie kommer vi kontrollera med täta provtagnings tidpunkter första 5 dagarna Även om det finns en studie som visar att det kanske går med mindre än 10 dagar känns 5 säkrare.