Component Therapy

DE LA SALLE HEALTH SCIENCE INSTITUTE

COLLEGE OF MEDICAL LABORATORY SCIENCE
Dasmarinas City, Cavite

Jion P. Dimson, RMT

 Transfusion Medicine
• Transfusion medicine is divided between blood centers
and transfusion services.
– Blood centers recruit and collect blood from donors
and manufacture and distribute blood components.
– Transfusion services perform pretransfusion
compatibility testing, select and issue blood
components for patients, and provide medical
support for blood transfusion.
Component Therapy

• Transfusion of the SPECIFIC

component needed by the patient
• Primarily intended to treat:
– inadequate oxygen-carrying capacity due
to anemia or blood loss
– inadequate coagulation proteins to provide
adequate hemostasis
Objective
• To provide adequate supply of blood
• To provide appropriate blood
• To ensure that blood and blood
components have optimal benefit to
patient
Blood component preparation
• Centrifugation
• Sedimentation
• Filtration
• Fractionation
Cohn Ethanol Fractionation
• Developed by Edwin Cohn in 1940
• Sequential precipitation of specific
proteins by ethanol and pH
• fractions are harvested by centrifugation
or filtration
• antiviral effects: physical partitioning
and anti-viral activity of ethanol
BLOOD COMPONENTS
WHOLE BLOOD (WB)
• Unprocessed blood containing all cellular and plasma
components
• Platelets and WBCs are present but are NOT active
• Coagulation factors (VIII & V) are labile and significantly
decrease after 2 days
• Immediate effect: increase in Hematocrit by 1-3% and
Hemoglobin by 1 g
• Store @ 1-6°C
– CPD/ACD/CP2D (21 days)
– CPDA-1 (35 days)
– Heparin 2 days
– Irradiated Blood (28 Days after irradiation or the original
outdate, whichever comes first)
The use of WB has been
decreased for the ff.. reasons:
• WB is more likely a carrier of
transfusion transmitted diseases (e.g.
hepatitis)
• Frequency of shortage of quality blood
• Blood products have a greater shelf life
• Blood products can be infused
regardless of blood type
• MOST PATIENTS REQUIRE ONLY A
PARTICULAR COMPONENT
MODIFIED WHOLE BLOOD
• Either extracting 50 ml of plasma for the
preparation of platelet concentrate
• OR 10-15 ml of plasma for
cryoprecipitate
• Indication: Increase oxygen-carrying
capacity and intravascular volume
PACKED RED BLOOD
CELLS (pRBC)
• May be prepared by sedimentation or
centrifugation
• 250 ml of plasma extracted leaving the RBC
with a hematocrit of 65-80%
• The immediate effect of 1 unit of pRBC is to
raise the hematocrit by 3% (similar to WB)
• storage the same as WB (closed system)
• under open system, storage is at 1-6°C for 24
hours or 4 hours at room temp.
Additives
• To remove as much plasma as possible
leaving a hematocrit of 90%
• Enhances RBC survival and function
• 100 ml of additive consists of:
– adenine
– extra glucose
– mannitol (red cell stabilizing agent)
• Extend expiry date to 42 days
• yield a final hematocrit of 60%
• must be combined with the RBC within 72
hours after phlebotomy
FROZEN RBC
• High glycerol (40% w/v final concentration) RBC is
stored 10 years @ -65 C or colder
• Low glycerol (14-17.5% w/v) employs liquid
nitrogen @ -120 to -196 C for 10 years
• Thawed and washed (decreasing osmolality of
NSS) prior to transfusion to remove glycerol
• Shelf life after deglycerolization is 24 hours @ 1-
6°C or 14 days under close method
• Agglomeration employs deglycerolization using
LISS
• Mainly used to maintain an inventory of rare
antigen-negative units
LEUKOCYTE-REDUCED
RBC
• Reduced WBC count in the unit less than 5 x 106 per bag
• retain 80-85% of rbc
• store @ 1-6 C for 24 hours under open system and the same
as the original in a closed system
• Leukoreduction prevents the following:
– Febrile nonhemolytic transfusion reactions
– Immunization to leukocyte (particularly HLA) antigens with
subsequent refractoriness to platelet transfusions
– Transmission of leukocyte-associated viruses
• Leukoreduction has NOT been shown to prevent
posttransfusion graft-versus-host disease and is not
used for this purpose
 LEUKOCYTE-REDUCED
Platelets
• WBC reduced to 8.3 × 105 for whole
blood–derived PC
Methods of Leukocyte
Reduction
• Blood bags are inverted and centrifuged
• Washing (NOT an effective method)
• Spin cool technique
• Filtration
– During component manufacture
(prestorage leukocyte reduction) - more
effective
– During transfusion (poststorage leukocyte
reduction)
Why reduce the leukocytes?
• Leukocytes may cause febrile non-hemolytic
transfusion reactions (FNHTR) and
transfusion related acute lung injury (TRALI)
• In stored blood, granulocytes fragment and
release cytokines
• May transmit infectious agents like CMV,
EBV, HTLV-1
Washed RBCs
• Not effective in reducing WBCs
• For patients (with Anti-IgA) that may react
with plasma proteins containing IgA
• Reactions may be allergic, febrile or
anaphylactic
• Stored at 1-6C and must be transfused
within 24 hours of washing
• Washed platelets must be transfused within 4
hours of washing
NEOCYTES
• Young RBC
• Prepared by differential centrifugation or
apheresis (young cells are large and buoyant
while older cells are smaller and dense)
• Indications: used in patients with severe
chronic anemia; thalassemia
Irradiated RBCs
• Indicated for the prevention of TA-
GVHD
• Blood is exposed to an ionizing
radiation (gamma or X-rays) source to
destroy lymphocytes
• Shelf-life 28 days after irradiation or the
original outdate whichever comes first
REJUVENATION OF RBC's
• Addition of pyruvate, inosine, glucose,
phosphate with or without adenine
• Performed 3 days after RBC expiration or to
fresh RBC
• Increase 2,3 DPG (2,3 BPG) levels and post
transfusion survival of RBC
• After rejuvenation, may be washed and
transfused within 24 hours or may be frozen
by glycerolization
PLATELET CONCENTRATE
(PC)
• Prepared from WB within 6-8 hours after
phlebotomy by centrifugation or by apheresis
• It is typically necessary to pool five or more
PCs (random donor) to obtain a therapeutic
dose for a typical adult patient. (transfuse
within 4 hours!)
• One apheresis platelet unit will typically
provide a therapeutic dose for an adult
patient.
Platelet Indications
• To correct severe thrombocytopenia
• To bleeding patient in surgery or trauma cases
with platelet count of 75,000
• Thrombocytopathy (qualitative abnormal platelet
dysfunction)
• Chemotherapy (decreased production - <20,000)
• DIC (increased destruction - <50,000)
• Massive transfusion (platelet dilution - <50,000)

• A unit of PC should increase the platelet count

5,000-10,000 in a typical 70 kg man
Platelet Refractory State
(PRS)
• Defined as a post transfusion corrected count
increment (CCI) is less than 5,000
measured one (1) hour after transfusion of
PC

CCI = absolute platelet count increment/ ul x body surface area (m2)

number of platelet units transfused x 0.55
Common Causes of PRS
• Immune causes
– HLA or platelet-specific antibodies
• Nonimmune clinical causes
– Bleeding, splenomegaly, disseminated
intravascular coagulation [DIC], medications
• Product-specific causes (ABO incompatibility
• Older products (give lower increments),
• Poor storage conditions
• NOTE: Leukocyte reduction prevent both
alloimmunization and platelet refractoriness
Shelf Life of Platelets
• 5 days @ room temperature (20-24°C) under
closed system or 2 days at 4°C with constant
agitation
– agitation may be stopped for a maximum of 24
hours
• 6 hours under open system
• Pooled platelets must be transfused within 4
hours
• pH should be maintained at least pH 6.2 or
higher at the end of storage
Standards
• For random donor platelet concentrates, each
unit should have at least 5.5 x 1010 platelets
per bag
• For platelet concentrates prepared by
Apheresis, each unit should have at least 3.0
x 1011 per bag

• 1 unit should produce an increment 5,000-

10,000 to platelet count of the patient
FRESH FROZEN PLASMA
(FFP)
• By-product of pRBC and platelet concentrate
• Labile factors V and VIII deteriorates rapidly in stored
plasma, hence the need to freeze
• Composed of 90% water, 6-8% proteins and a small % of
carbohydrates and lipids
• 1 unit should contain 150-250 ml of plasma, approx.. 400 mg
of fibrinogen and about 1 unit activity/ml of clotting factors
• Storage: 1 year @ -18 C or colder
• Indication: Patient with multiple coagulation deficiencies
• Must be prepared from whole blood and stored at -18C within
8 hours of collection
 FRESH FROZEN PLASMA
(FFP)
• Before transfusion, both FFP and FP24 are thawed
at 37° C and must be transfused within 24 hours.
• Thawed plasma not used within 24 hours may be
relabeled as “Thawed Plasma.”
• Thawed plasma can be kept at refrigerator
temperatures for up to 5 days, while adequate
levels of factors V and VIII are maintained
FP24
• Plasma frozen within 24 hours after
phlebotomy (FP24)
CRYOPRECIPITATED
ANTIHEMOPHILIC FACTOR
• Cold insoluble portion of plasma remaining
after FFP has been thawed at refrigerator
temperatures
• Prepared from 1 unit of WB
• 1 unit should contain
– Factor VIII (80 IU)
– Fibrinogen (150-250 mg)
– vWF (40-70%)
– Factor XIII (20-30%)
– Fibronectin
Preparation of the
Cryoprecipitate
• FFP (200 ml) is slowly thawed at 1-6 C
usually overnight, leaving a small whole
precipitate
• The component is centrifuged
• Supernatant is expressed leaving 10-15 ml of
cryoprecipitate
• Refrozen @ -18 C or colder (if closed system
is used)
• Prior to use, it is thawed @ 37 C and may be
stored @ 1-6 C for 6 hours
Indications for Cryoprecipitate
• Cryoprecipitated antihemophilic factor was a
major advance in the treatment of hemophilia
A before the development of safe purified
clotting factor concentrates. Currently, cryo is
used mainly as a source of fibrinogen.
GRANULOCYTE
CONCENTRATE
• Collected only by apheresis
• 1 unit should have >1.0 x 1010 granulocytes
and >2.0 x 1011 lymphocytes and platelets
• Indicated for patients with sepsis
unresponsive to antibiotics and for severe
neutropenia (<500 PMN/ul)
• Shelf life of 24 hours @ room temp without
agitation after collection
 Special Components
• Cryoprecipitate-reduced plasma (cryopoor plasma)
– the supernatant remaining from the production of
cryoprecipitate. Retains normal levels of the vWF-cleaving
metalloprotease ADAMTS 13
– May be used for treatment of patients with thrombotic
thrombocytopenic purpura
• Hematopoietic Progenitor Cells (HPCs)
– Prepared from mononuclear cells harvested during apheresis
• Lymphocytes
– Prepared from mononuclear cells
– Used for induction of graft-versus-tumor effect (donor
lymphocyte infusion)
BLOOD PRODUCTS
FACTOR VIII CONCETRATE
• Lyophilized products prepared by Cohn
ethanol fractionation of pooled donor plasma
• Reconstituted with 25 ml of sterile diluent
• Shelf life: 2 years @ 2-8 C
• Indication: Component of choice for vW
disease and for moderate to severe
congenital Factor VIII deficiency (Hemophilia
A)
PATHOGEN REDUCTION
• Applicable to blood derivatives such as albumin, coagulation
factor concentrates, and immunoglobulins
• Heating @ 60 C for over 24 hours
• Pasteurization
– pressurized steam @ 60 C for 10 hours
– isolated by monoclonal factor VIII antibody affinity column
and then eluted
• Solvent/Detergent Exposure (S/D)
– Dolvent: tri(n-butyl) phosphate
– Detergent: sodium cholate, Tween 80 or Triton X-100
– Inactivates viruses with lipid envelop
– Ineffective against nonlipid-enveloped viruses
– Destroys cell membranes hence not applicable to cellular
blood components
 PATHOGEN REDUCTION
• Intercept®
– Uses PSORALEN compound which
intercalates between bases of RNA and DNA
and when exposed to UV light forms covalent
cross-links that prevents replication
• Mirasol®
– Uses RIBOFLAVIN which causes strand
cleavage of nucleic acids when activated by UV
light
FACTOR IX CONCENTRATE
• Lyophilized products prepared by Cohn
ethanol fractionation of pooled donor plasma
• contains Factor II, VII, IX, X
• may contain activated coagulation factors
• Shelf life: 2 years @ 2-8 C
Factor IX is administered in
patients with:
• Factor IX deficiency (Hemophilia B/Christmas
Disease
• Congenital Factor VII and X deficiency
• Factor VIII deficient patients with significant
inhibitor activity
Precaution in administration of
factor IX concentrate
• May cause DIC in patient with liver disease
who are not producing adequate amounts of
antithrombins
ANTI-INHIBITOR
COAGULATION COMPLEX
(AICC)
• Also known as Factor VIII Inhibitor Bypass
Activity (FEIBA)
• Lyophilized product from pooled plasma using
fractionation
• Contains: Vitamin K-dependent factors (II, VII,
IX, X) and their precursors and kinin-
generating proteins
• Indication: It is used to stop bleeding
episodes in patient with high levels of Factor
VIII inhibitor
PPF (Plasma Protein Fraction)
and Albumin
• Colloid derivatives made from pooled plasma
by Cohn ethanol fractionation
• Viral inactivation
– Pasteurization @ 60 C for 10 hours; inactivates
coagulation factor
 PPF vs.. Albumin
• PPF • Albumin
– 83% albumin – 96% albumin
– 17% alpha and beta – 4% alpha globulins
globulins – 250-500 ml in volume
– contains bradykinin – Shelf life:
– 250-500 ml in volume • 3 years @ 20-24 C
– Shelf life: • 5 years @ 1-6 C
• 3 years @ 20-24 C
• 5 years @ 1-6 C

• Neither contains gamma globulins, no ABO

grouping and compatibility test is required
Indications

• Plasma expanders (hypovolemia and shock)

• Used to raise the blood pressure in
therapeutic plasma exchange, dialysis, shock
and other hypotensive situation
IMMUNE SERUM GLOBULIN
(ISG)
• a solution or lyophilized preparation
containing immunoglobulins
• prepared by fractionation
• available in intramuscular (IM) and
intravenous (IV) form
• also contain IgA, IgM and other plasma
proteins
ISG is used for replacement of
gammaglobulins in cases of:
• Agammaglobulinemia
• Common Variable Immunodeficiency (CVID)
• Wiskott-Aldrich Syndrome
• Severe Combined Immunodeficiency

• Half-life in the blood stream is 18-32 days