From Buffy Coat Platelets to Single Donor Platelets – A Feasibility Study Dr. Sybesma, Sanquin Bloodbank Southeast, ‘s-Hertogenbosch, Netherlands St. Petersburg - June 9th - 2004 Introduction: For more than two decades conversion to apheresis Platelets is being discussed from several points of view. Because of vCJD the advisory board of Sanquin initiated a pilot study which aimed at reduction of donor exposure with Platelet concentrates obtained by aphaeresis. In the Netherlands the standard Platelet product is pooled from Buffy coats. The pilot study started in December 2002 and the aim was to contribute to the evaluation of technical, economical en logistical feasibility of collecting Double Platelet products.

Introduction  Pilot-study ● Donors, Methods  Discussion ● Results ● Conclusions  Discussion

Improvement of transfusion safety by reduction of donor exposure Variant Creutzfeldt-Jakob disease (Houston et al. 2000) Septic platelet transfusion reactions (Ness et al. 2001) Residual risk of viral infection (Soldan et al. 2003, Jackson et al. 2003) HLA - (Slichter 1998) and HPA - refractoriness TRALI Unknown agents vCJD could become a real transfusion risk. vCJD is most likely the result of infection with the agent that causes bovine spongiform encephalitis. In 1993 during the peak of bovine spongiform encephalitis (BSE) in the UK, contaminated beef entered the Dutch food chain (1) With an assumed incubation time of 5 years cases of vCJD are to be expected in the Netherlands. Transmission of iatrogenic CJD by organ transplantation was already known but through blood transfusion revealed from the sheep experiments of Houston (2). An estimated 5 % of the Dutch blood donors are exposed to BSE infected food. This was one of the reasons for the introduction of Leucodepletion of Red cell concentrates (2001) and Fresh Frozen Plasma (2003) and donor exclusion after a cumulative stay more than six month in the UK during the BSE hype.(1980-1996). Besides economical use of blood, minimizing donor exposure was one of the recommendations of the Dutch Advisory board of Sanquin concerning prevention of vCJD. Though incidence of variant Creutzfeldt-Jakob Disease onsets and deaths in the UK shows statistically significant evidence that the epidemic recently declined (3) there is still considerable concern about the possibility of transmission by blood transmission within the human species. Besides the fact that the epidemic already has reached a peak does not exclude the possibility of further peaks in the future.

Donors and methods  Technical:  Economical:  Logistical: donors selection: precount > 250, 70 kg Trima Accel, 100 procedures procedure time 70’ QC, splitting > 500  Economical: 434 Euro* pooled and single donor  Logistical: autosufficient 2500 PLT per year * nov 2002 We selected donors with an mean platelet precount more than 250.10^9 and weight more than 70 kilogram and invited them to donate. 100 procedures were performed on TRIMA Accel. Procedure time was targeted on 70’ After 3 hours product rest and movement, an 25 ml sample is used for quality controls like platelet yield (>500.10^9), product volume (350-600 ml), bacterial contamination (7 day’s), and pH All products were tested on residual leucocytes (in the collection bag < 2.10^6) with FLOWcytometer FACSC abor (Becton-Dikinson). Swirling and red coloring were judged visually. Splitting was accepted at a minimal Yield of 500.10^9 per unit and a volume of 300-650 ml. Economically: During the pilot, the price for Single Donor Platelets was agreed with local hospitals to be fixed at 434 Euro being the same for BC-PC’s. Logistical feasibility was measured by the number of donors needed to be sufficient for local demand for platelets. (annually 2500 PLT)

De machine: TRIMA ACCEL COBE Spectra: dubbele naald techniek: weinig comfortabel. Continue 2 stapsscheiding: WBC > 10^8 daarom grote LRS-kamer: snel, goede oogst TRIMA 4.0: enkele naald. Continue 2 stapsscheiding: WBC < 10^6 kleine LRS-kamer: snel, hoge oogst, TRIMA 5.0 (Accel): 1-staps scheiding: nog meer oogst per tijdseenheid (plaatjes collectie efficientie**), LRS-kamer van de Spectra WBC < 10^6, minder extra corpereel volume (< 200 ml), minder citraat naar donor, automatische aanpassing van draw en return: minder alarm.*** Na einde bewaartijd (5 dagen en 7 dagen) in vitro voldoende plaatjesfunctie* TRIMA 5.0: Donor vriendelijk: 1 staps scheiding door nieuw vormgegeven scheidingskamer (tov 4.0)/ gebruikers vriendelijk Display + product keuze mogelijkheid. Minder bloedvolume bewerkt, in minder tijd; meer opbrengst per tijd: plaatjes collectie efficientie 2 staps scheiding: 1e stap: RBC enWBC van PRP en daarna PLT van Plasma + Leucoreductie in LRS * In vitro plaatjes functie: pH, swirl, hypotone shock proef, CD62 expressie, leucoreductie 5 dagen: N=10 M. McAteer et al (lit: The International Journal of Hematology 2002; 76 (Suppl 1), 131. 7 dagen: N=5 D de Kort et al als Controlegroep Accel in T-sol en plasma (Vox Sanguinis 2002; 83 (Suppl. 2): 85. Beiden PLT geoogst met TRIMA Accel. Data omtrent parameters van PLT’s geoogst via verschillende methoden in verschillende bewaar media (ook plasma) legio: J. de Wildt- Eggen et H. Gulliksson: In vivo and vitro comparison of platelets stored in either synthetic media or plasma”Vox Sanguinis (2003) 84, 256-264 ** M McAteer et al. Transfusion 2002; 42 (9S); 37S *** Reduced speed alert: als automatische pauze 3x in 3 minuten optreedt, wordt pompsnelheid automatisch aangepast en gaat door op aangepaste snelheid. Als afname snelheid niet op gereduceerd niveau gehandhaafd kan blijven of druk neemt toe ondanks gereduceerde snelheid: dan stopt pomp en medewerkster moet actie ondernemen om procedure door te laten gaan.

TRIMA Accel TRIMA Accel is a single needle apheresis device which use a single stage separation chamber. The high processed blood volume and the high collection efficiency contributes to an overall high collection performance. An in process leucoreduction is done in a leucoreduction chamber, so no platelets are lost due of being trapped in a filter.

Donorselection Analyzing the first 100 procedures, 58 % of the donors met the selection criteria, based on PLT-precount and weight. Only 18 donors showed more deviation than 10%.

Number procedures per procedure time 69 % of the procedures took at most 70’. The average procedure time was 64.9’ (SD +/- 15.8’) Mean Double Platelet Products procedure time was 60 minutes when precount was > 250 and 85 minutes when < 225.

Donor reactions Form 289 procedures: Citrate reactions: Mild: 37, Moderate: 1, Severe: 0 Collaps: 0 Haematoma: 5 Hyperventilation: 0 Each procedure was guided by a form to registrate donorreactions like haematoma, collaps, hyperventilation Citrate reactions are categorised: mild, moderate and severe,. Mild: defined as taste of metal, Tingling perioral : measures like reducing return speed or drinking milk were sufficient Moderate: defined as tingling continues and nausea : Calcium tablet is needed, procedure has to be stopped, Severe: defined as Vomitting and cramps SHOCK?? Like you see number of donor reactions is low which can contribute to high donor satisfaction and donor loyalty.

Predicted Procedures, DPP and SDP for predicted yield (n=100) Trima Accel predicted that 90 % of the procedures would result in double platelet products (DPP). When measuring the collected products, 76 out of 90 procedures (83%) resulted in double platelet products (>500 x 10^9). 100 procedures resulted in 176 SDP; ((so overall split-rate was 76% [76x2=152+24=176]))

Evolution - Real/Target Yield This chart shows predicted yield by TRIMA at the end of each procedure versus the measured yield in the QC lab.The YSF in Trima was adapted based on the QC results of the first 100 procedures. Results improved significantly up to a level of 94 % correlation between Trima predicted yield and QC results.

Evolution of split-rate (>500x10e9) Split-rate varies in the time. After a very good start we had a significant drop between procedure 50 & 100. By verifying and improving the post-collection procedures (e.g. transport & sampling in QC lab) we were able to bring the split rated back to the original level.

Chronological trending of residual WBC levels 125 procedures. 6 transgressions of the leukoreduction limit of 1x10e6 WBC/unit This seems to be high but is influenced by bad results of the first 30 procedures. In the first 30 procedures residual white cells lie systematically higher. Leukoreduction performance within the first 30 runs was only 89.% but improved significantly in the following 95 runs resulting in a leucoreduction performance above 97 %. Data point 56. Yield was much lower than target. Donor related pasting may have been involved. Data point 113 Yield PLT just below split limit. So for 1 prduct to high WBC Data 131 TRIMA machine data file determent LRS overloading probably because of sequestration of platelets in the LRS chamber. Therefore exceding LRS chamber capacity. Multifacterial event. Clinical studies with high WBC load doesn’t result in generating leukoreduction failure.

Logistical feasibility  TRIMA: 6 procedures per day  50 weeks  190 donors  8 donations per year*  2600 SDP per year  18 % drop-out by out-dating * Lazarus et al. 2001 With the extension of the opening hours of the centre we will be able to perform 6 procedure by day by Trima. Based on a donorbase of 190 active donors , a donation frequency of 8 donations per year and the current split rates we should be able to be auto-sufficient in platelet products and deliver 2600 SDP annually. 8 donations per year will require high donor motivation. Therefore we started a donor survey on donor experience in relation to the procedure, which should give us the necessary information to further improve our processes. We also made the choise not to target more than 8 donations a year, since Lazarus schowed this could decrease the platelet count of the blood donor on the long term. We also initiated an active donor recruitment to increase our donor base upto 300 active donors Currently our average oudating is still 18 %, this is decreasing continiously due to better stock management. An extension of the maximun storage limit from 5 days upto 7 days will further decrease the outdating rate. Lazarus et al 2001 Transfusion: Significant and sustained decrease in platelet count for all donation frequentie. 9% out of 84 donors were deferred for low platelet count. Deferral strategie: <150 2 months defferal, <150 in 12 months or < 150 2 times successively: 6 mnd defferal <150 in spite of defferal for 6 mnds: 2 years defferal <100 consult medical dokter. Lazarus showed 29x10e9 decrease +/- 4,1 in frequent- donation category. Mean decrease of 40x10e9 in the frequent donor subgroup; female more than male. Conclusions: defferal policy / new apheresis donors are continuously recruited. Not 24 times a year bot once-a-month

Donor satisfaction TRIMA ACCEL enhance donor comfort. Single needle procedure, short procedure time, good alarm management, low % of donorreaction and maximal automatisation alows the nurse to spend more quality time with the donor. This should also help in keeping donor satisfaction high and maintain high donor loyalty.

Economical feasibility Pooled PLT: 434 €* Cost / procedure: 62 € manufacturing / quality controle Cost / product 62 € + Bact Alert / distribution 27 € Variable cost / product: 89 € * nov 2002 Apheresis PLT: 434 €* Cost / procedure: 269 € donorrelated / manufacturing / screening and quality control / device [1.76 product / procedure] Cost / product: 152 € + Bact Alert / distribution 27 € Variable cost / product: 179 € Donor related costs and screening (23 Euro) of Buffy Coat pooled PLT are assigned to cost for Red cell concentrates. In addition, set price of TRIMA is 137 Euro. Conclusions: High splitrates are beneficial for economical feasibility. Cost price for Apheresis Platelets are less than revenues. 3) in spite of high split-rate, there still substantial difference between cost price Single donor platelets and pooled platelets. Depending screening or donors only on AP not on BC

Economical feasibility Cost price for SDP are less than revenues High split rates are beneficial for economical feasibility Revenues for SDP are higher than for BCP Cost of SDP are higher than for BCP Distribution of secondary costs over different components influence the cost of BCP The cost of production for SDP is lower than the revenue, the high splitrates are beneficial to obtain economical feasability. Even if costs for SDP are still signifcantly higher than for BCP the revenues largely compensate the costs. The cost of BCP can be influenced by how costs for donorscreening and testing are included Yes/no in the price of the BCP.

Conclusions  Conversion is feasible economically, technically and logistically.  Adequate donor selection + high collection performence assure high split-rates in relatively short procedure time.  further research is needed on: how to keep donormotivation at high level donor recruitment and donor selection possibilities to reduce drop-out by outdating Cost / Qualy’s for pooled and apheresis PLT should be analyzed

Discussie Voor Tegen  zorginnovatie  gezondheidswinst*  Spin-off * vCJD / onbekende agens / TRALI / anti-HLA preventie / windowdonaties Tegen  inkomsten 487.500 € bbdbdbdbd

Hoe verder  voortgang invoering aferesetrombocyten  Werkgroep voorbereiding implementatie zuidoost plan van aanpak feb 2004 start september 2004 

Met dank aan Projectgroepleden Speciaal Bob en Astrid

Referenties MAR: Inzake vCJD en mogelijke maatregelen mbt bloedtransfusie / Houston art. art. P. Brown. BSE and transmission through blood The Lancet Vol 356 sept 16, 2000 art. F. Houston et al. Transmission of BSE by blood transfusion in sheep. The Lancet vol 356 sept 16, 2000. art. W.G. van Aken, A. Brand en C.L. van der Poel: Leukodepletie van bloedproducten: een maatregel ten behoeve van kwaliteit en veiligheid. NTVG 2000 27 mei;144(22) art. H.L. Zaaijer Boviene spongiforme encephalopathie en de veiligheid van voedsel NTVG 2000 27 mei;144 (22) art. H.L. Zaaijer Interpretatie van de toename van boviene spongiforme encephalopathie buiten Groot-Brittannie. NTVG 2002 20 april;146(16) art. E.A. Groes et al. Ziekte van Creutzfeldt-Jakob: diagnostiek, incidentie, preventie en behandeling. NTVG 2002 20 april;146 (16) art. R. Kersseboom et al. Het risico van de variant Creutzfeldt-Jakob in Nederland en het effect van preventieve maatregelen. NTVG 2002 20 april;146 (16) art W.G. van Aken ‘Variant van de ziekte van Creutzfeldt-Jkob en bloedtransfuzie’;rapport van de gezondheidsraad NTVG 2001 28 juli;145 (30)