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Klinische Erfahrungen mit der Pathogeninaktivierung von Thrombozytenkonzentraten
(Interceptverfahren)
Department for Blood Group Serology and Transfusion Medicine
(Interceptverfahren)
G. Leitner Klinik für Blutgruppenserologie und
Transfusionsmedizin
5. LeukocytesAdverse immune responses
and transfusion reactions
1. BacteriaIntroduced during
collection
2. Emerging/UnknownViruses
Residual risk
NAT
Department for Blood Group Serology and Transfusion Medicine
4. Known PathogensFor which no assay
is available
3. Window PeriodLimits of detection of
current assays(e.g. false negatives)
Patient
Window period
Ab/Ag(d)
NAT(d)
gain(d)
HIV 22 11 11
Department for Blood Group Serology and Transfusion Medicine
HCV 70 11 59
HBV 56 31 22
Bacterial contamination• PC (pool, apherese) 1: 2-3000*
– reaction 1: 25.000 (1:50.000)– mortality 25% (Sepsis)**
• RBC 0.03-0.3% (DL), 17,5% Ghana– reaction 1: 100 000 bis 1:1 000 000
Department for Blood Group Serology and Transfusion Medicine
– reaction 1: 100 000 bis 1:1 000 000– mortality 20% (Sepsis)**
• FFP < 0.04% (storage < minus 30°C)*Blajchman et al, 2001 **Bacterial Contamination of Blood Components: Risks, Strategies, and Regulation, Christopher D. Hillyer et al , 2003
Pathogen-inactivation• Pasteurisation (human albumin)• Heat inactivation• pH 4 inactivation• nanofiltration• solvent/detergent (SD) (plasma)• methylenblue/light (plasma)
Department for Blood Group Serology and Transfusion Medicine
• methylenblue/light (plasma)• UV-C 100 - 280 nm• mirasol (vitamin B2)/Caridian BCT
– plasma and platelets• intercept (psoralen) / Cerus
– Plasma and platelets
Helinx Compounds
Department for Blood Group Serology and Transfusion Medicine
• Amotosalen HCl platelet and plasma inactivation (S-59)
• S-303 für RBC
Naturally occurring psoralens
•The average daily dietary
intake of natural
psoralens is ~1300 µg
•The amount of 8-
methoxypsoralen in an
Department for Blood Group Serology and Transfusion Medicine
Average human psoralen intake = 1–2 mg/day
methoxypsoralen in an
average stalk of celery
(90 g) is ~60 µg compared with 50 µg in a platelet transfusion
Highly specific mechanism of Action
Amotosalen
(S-59)
UVA Illumination
Department for Blood Group Serology and Transfusion Medicine
Targeting
Intercalation Crosslinking
Helical region of single- or
double-stranded
DNA or RNA
Multiple crosslinks block
strand separation no
replication,
no transcriptionWollowitz Seminars in Hematology 2001;38:4-11
INTERCEPT Platelet System
Department for Blood Group Serology and Transfusion Medicine
• 7
Amotosalen Chemistry During Processing
After UVA
Department for Blood Group Serology and Transfusion Medicine
After CAD
Efficacy and Safety for Platelets Evaluated in 11 Clinical Studies (1,108 Patients)
EU Studies
Buffy Coat
Count Increments
(n=103)
Thrombocytopenic Patients (n=1074)
Bleeding Time
(n=32)
Grade 2 Bleeding
US Studies
Healthy Subjects (n=34)
Recovery and Survival
Without CAD
(n=24)
Safety, Tolerability &
PK With CAD
(n=10)
Department for Blood Group Serology and Transfusion Medicine
Buffy Coat
7-Day Storage Pilot
Count Increments
(n=20)
Apheresis
Count Increments
Integrated Set
(n=43)
Buffy Coat
Count Increments
Integrated Set
(n=20)
Grade 2 Bleeding
(n=645)
Recovery and Survival
γγγγ-Irradiation - With CAD
(n=15)
Recovery and Survival
With CAD
(n=16)
Buffy Coat
7-Day Storage
Count Increments
(n=211)
Van Rhenen et al: Blood 2003;101:2426-2433
McCullough et al: Blood 2004; 104:1534-1541
Lozano et al: Br J Haematol, e-pub, 2011
11
# of Patients
Receiving
INTERCEPT
Alsace 36 Month HV
Study# INTERCEPT
Transfusions
Study Design /
Endpoints
~6000~42,000 Routine Use, unblinded, AE
HV 1 327416,631 Routine Use, unblinded, AE
Mont Godinne 36 Month HV 7958030 Routine Use, unblinded, AE
SPRINT 3182678 Randomized,
Blinded, Bleeding
Gent -Pediatric 83500 Open label,
unblinded, ATR/AE
INTERCEPT Clinical Study Experience
Department for Blood Group Serology and Transfusion Medicine
Pediatric 83500 unblinded, ATR/AE
Lubeck 52560 Open label, unblinded, ATR/AE
Basel 46551 Open label, unblinded, ATR/AE
Euro-SPRITE 52390 Randomized,
blinded, CCI
HOVON ~67*~350* Randomized, unblinded, CCI
TESSI 101101 Randomized,
blinded, 7 day CCI
* Based upon interim analysis of HOVON Study.
INTERCEPT(n=318)
Control(n=327)
p-Value
Primary Endpoint
Patients with Grade 2 bleeding (%) 58.5 57.5 P<0.001
SPRINT : controlled, randomized, double-blindHemostasis Endpoints
McCullough J, et al. Blood. 2004;104:1534–41.
Department for Blood Group Serology and Transfusion Medicine
Secondary Hemostasis Endpoints
Patients with Grade 3 or 4 bleeding (%) 4.1 6.1 P<0.001
Number of bleeding sites with Grade 2 bleeding
1.1 1.0 NS
Proportion of patients with maximum Grade 2 bleeding (%)
54 52 NS
INTERCEPTControl
0.6
0.8
1.0P
ropo
rtio
n of
pat
ient
s w
ithG
rade
2 b
leed
ing
McCullough et al. Blood. 2004;104:1534.
SPRINT Phase III Platelet Trial:Time to Onset of Grade 2 Bleeding
Department for Blood Group Serology and Transfusion Medicine
Similar median time to onset = 8 days (p=0.78)
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 320.0
0.2
0.4
Pro
port
ion
of p
atie
nts
with
Gra
de 2
ble
edin
g
Study day
INTERCEPT Platelet Hemovigilance
Study No. Transfusions
No. Countries
No. Sites
Location
HV1 5,106 4 5 Montgodinne, Madrid RC, Bergen, Tronheim, Pescara
HV2 7,437 3 7 Montgodinne, Erasme, St Jan Brugge, Strasbourg, St Etienne, Rennes, Valladolid
Department for Blood Group Serology and Transfusion Medicine
HV3 (closed) 6,632 9 13 Lübeck, La Reunion, Uppsala, Rennes, St Etienne, Prague, Barcelona, Madrid BTC, Bergen, Iceland BTC, Basel, Lisbon, Rome, Ljubjana
France HV-system(2006-2011)
104,148 1 national
CHKV epidemic 1,950* 1 1 Ile de La Reunion
Total: 125,273
No Unexpected Adverse Events
Transfusion Patient
Total 18,641 3,861
Any AE 181 (0.97%) 136 (3.5%)
Department for Blood Group Serology and Transfusion Medicine
Related AE (ATR) 125 (0.67%) 94 (2.4%)
Any SAE 19 (0.10%) 18 (0.5%)
SAE (probably related ATR)
1 (0.005%) 1 (0.03%)
16
INTERCEPT treatment has effectively replaced gamma-irradiationfor prevention of TA-GVHD
StudyNumber of
Transfusions
% Non-gamma
irradiated
Total Number of Patients
Hem-Onc Patients
HSCT Patients
Incidence of TA-GVHD
Phase III Trials 4 575 100% 87 82 28 0
HV1 5 5,106 97.3% 1 651 378 47 0
HV2 6 7,437 98.9% 2 1,400 748 121 0
Lin et al. Vox Sanguinis, 2011, (sup) Poster
Department for Blood Group Serology and Transfusion Medicine 17
HV3 6,991 95% 3 2,062 974 310 0
Mt. Godinne 7 3,645 100% 186 186 186 0
Pediatric 8 500 100% 83 48 10 0
Basel 9 551 100% 46 38 15 0
Lübeck 10 560 100% 52 52 17 0
Strasbourg 11 55,104 100% ~8,000 ~4,400 not available 0
1. Volume loss: 5%, platelet loss: 9-12% (16%)
during INTERCEPT treatment
2. pH loss due to treatment (> 6.4)
3. pH stable during storage
Summary / Validation 2010
Department for Blood Group Serology and Transfusion Medicine
3. pH stable during storage
4. Swirling is seen in all PCs during storage
5. Glucose runs out in some PCs from day 5
6. 100% sterility
Amicus Crescendo Fenwal
Software
Trima AccelTerumo(BCT)
Software
Department for Blood Group Serology and Transfusion Medicine
Software 2.51, 2.52, 3.1
Software 5.1; 5.2; 6.0
Start: 29.3.2012
Spenden 3126
Hergestellte TK 6443
Doppel TK (Plt ≥ 5.0 x10^11) 54%
Department for Blood Group Serology and Transfusion Medicine
Doppel TK (Plt ≥ 5.0 x10^11) 54%
Triple TK (Plt ≥7.2 ≤ 8.0 x 10^11 ) 27%
Außerhalb der Spezifikation 0,62% = 20
Außerhalb der Spezifikationen (aSZF)
Grenze - Volumen Erlaubte Abweichung Erlaubtes Volumen
255 ml - 6,37 ml 248 ml
420 ml + 10,5 ml 431 ml
Abweichungsregel minus 2.5%; plus 2.5%
Department for Blood Group Serology and Transfusion Medicine
420 ml + 10,5 ml 431 ml
Grenze - Yield Erlaubte Abweichung Erlaubter Yield
2.5 x 1011 - 0,06 2.44 x 1011 = 2.4 x1011
8.0 x 1011 + 0.2 8.2 x 1011
Konsequenzen
Intercept Tks
• 7 Tage Lagerung• kein CMV
a SZF (n = 20)
• 5 Tage Lagerung• CMV nach bestimmt
Department for Blood Group Serology and Transfusion Medicine
• kein CMV• kein
• CMV nach bestimmt• gamma
Ergebnisse der Qualitätskontrolle
• n = 235 Tk
• Volumen vor/nach IBS• Zellzahl vor/nach IBS
Department for Blood Group Serology and Transfusion Medicine
• Zellzahl vor/nach IBS
Vor ICB- nach ICB
5
6
7
8
9
vor
Department for Blood Group Serology and Transfusion Medicine
0
1
2
3
4
5vornach
7
8
Vor – und Nachwert% 13.8 (4.5)
Hist 9-12%16%
15
20
25%
6
X 1
011
Department for Blood Group Serology and Transfusion Medicine
Amicus Trima
3
4
5
Amicus Trima
5
10
24.02.2013 14:54:35 PI.WST
X 1
0
mL 28.8 (9.3)
% 6.5 (2.6)
400
450
Verlust - Volumen
13% plt
Department for Blood Group Serology and Transfusion Medicine
vor nach
250
300
350 13% plt
20,00
25,00
30,00
35,00
Threshold 20% Verlust
Department for Blood Group Serology and Transfusion Medicine
0,00
5,00
10,00
15,00
20,00
0 50 100 150 200 250
Reihe1
7.2%
Verlust (n = 235)
yield Plt 0.87 x 1011
(± 0.82)
% 13.8 (± 4.5)
Thrombozyten
Department for Blood Group Serology and Transfusion Medicine
(± 4.5)
n>threshold 17 (7.2%)
historisch 9-12% (16%)
ausgangswert
Thrombozytenbedarf 2003 - 2012
5000
6000
7000
8000
Department for Blood Group Serology and Transfusion Medicine
0
1000
2000
3000
4000
1 2 3 4 5 6 7 8 9 10
Reihe1
TransfusionserfolgSA
n = 30
AKHn = 30
Plt G/L vor 16.9 (6.1) 15.4 (9.6)
Plt G/L nach 50.4 (21.1) 31.1 (20.4)
Department for Blood Group Serology and Transfusion Medicine
Plt G/L nach 50.4 (21.1) 31.1 (20.4)
Anstieg errechnet 68.1 (32.9) 45.6 (12.4)
Anstieg gemessen 33.5 (21.0) 15.7 (12.4)
% Anstieg 51.4 (27.7) 36.4 (30.0)
CCI 15.0 CCI 10.4
CCI nach IBS
10
15
20
25
30
20
25
AKH
Department for Blood Group Serology and Transfusion Medicine
0
5
10
0
5
10
15
20
SA
CCIp < 0.0001; U-Test (Mann-Whitney)
30
40
2005 Dr.Witt/SA
-20
-10
0
10
20
0 1
ICB J=1 N=0
CC
I (G
/l)
14,27 ± 10,77
Non Intercept
8,96 ± 8,54
Intercept
15±7.4
ROTEM• inactivated • normal
19 Plt
Thrombo 36 G/l
19 Plt 22 Plt
36 Plt 100 Plt
Hämovigilanz Transfusionsbedarf6 AE /6000 Tk (0.1%) Transfusionsintervall
Vor IBS (n=48) 2.1(±2)Related AE
(ATR)125 (0.67%)
Department for Blood Group Serology and Transfusion Medicine
Nach IBS (n=68) 3.4 (±2)SAE
(probably related ATR)
1 (0.005%)
18.641Transfusionen
Studiendaten
300
350
4000
1
ICB J=1 N=0
0
50
100
150
200
250
J N
Unerwünschte Transfusionsnebenw irkung (J/N)
Häu
figke
it
EuroSprite Sprint
ICB n=103
Contr1n=103
ICB n=645
Contr n=645
Plt x 10^11 (mean) 3.7 4.0 3.9 4.3
• POOL • Apherese
Plt x 10^11 (mean) 3.7 4.0 3.9 4.3
Total plt dose 22.3 21.2 29.4 24.1
n transf 7.5 5.6 8.4 6.2
interval 3 3.4 1.9 2.4
1 (24) h CCI 28 (16) 36 (25) 12 (13) 34 (22)
Ich danke für Ihre Aufmerksamkeit
Department for Blood Group Serology and Transfusion Medicine