Plasma TRIM. Jennifer Muszynski MD March 11,

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1 Plasma TRIM Jennifer Muszynski MD March 11, 2015

2 Plasma Transfusion in the US Nearly 4 million units of plasma are transfused in the US annually. Plasma transfusion has been associated with increased risks of mortality and nosocomial infection in critical illness Immunomodulatory effects of plasma transfusion are incompletely understood

3 Plasma and Transfusion-Related Immunomodulation Transfusion-Related Acute Lung Injury Antibody-mediated TRALI associated with anti-hla, anti-hna antibodies in donated plasma Male-only donations for plasma associated with decline in TRALI rates Toy et al, Blood, 2012

4 Other immunomodulatory effects of plasma?

5 LPS-induced TNF α production (pg/ml) :1 dilution 1:1 dilution 1:3 dilution Control FFP Mixed whole blood / blood component culture Followed by LPS stimulation FFP exposure resulted in significant decrease in LPSinduced TNFα production

6 Exosomal vesicles isolated from plasma Co-cultured with CD4+ T lymphocytes Induced T cell apoptosis Suppressed T cell proliferation

7 Allogeneic fresh frozen plasma may be immunosuppressive by unknown mechanisms Potential immunomodulatory mediators: Microvesicles Bioactive lipids Antibodies Protein (cytokines, chemokines, other) DNA ncrnas (microrna)

8 FFP It s not all FFP Plasma Preparations: FFP = plasma separated from whole blood and frozen within 8 hours of collection PF24 = plasma separated from whole blood and frozen within 24 hours of collection Thawed plasma = FFP (or PF24) thawed and kept at 1-6 C for up to 5 days before transfusion Solvent-detergent plasma = pooled plasma which is filtered (0.2µm) then treated with organic solvent and detergent to disrupt lipid membranes and extract lipids (to inactivate enveloped viruses) Liquid plasma = plasma separated from whole blood within 5 days of expiration and stored at 1-6 C for up to 30 days before transfusion

9 FFP It s not all FFP 5.5 Percent of Plasma Units Transfused FFP PF24 Thawed plasma Other US DHHS 2011 National Blood Collection and Utilization Survey

10 Do different plasma preparations have different effects on immune cell function?

11 Proposal Use transfusion models to test the hypotheses that: 1. Plasma products will directly suppress immune cell function in vitro. 2. Different plasma products will have different magnitudes of immunomodulatory effects Increasing immune suppression? SD plasma FFP PF24 - fewer MV - more time in contact - less lipids with angry WBC

12 Specific Aims Aim 1 / Preliminary data: To Determine effects of FFP, PF24, thawed plasma, and SD plasma on immune cell function in vitro Aim 2: To Determine effects of FFP, PF24, thawed plasma, and SD plasma on immune function in an animal model (with collaborator from the group) Aim 3: To Determine relationships between plasma transfusion and immune function in critically ill children (multi-center study)

13 Methods Monocyte function in vitro Isolate monocytes from healthy adults Co-culture with 20% by volume plasma product for 24 hours Stimulate with LPS for 4 hours Measurements: Cytokine production (+/- LPS) TNFα, IL-1β, IL-8, IL-10 HLA-DR, TLR4 expression by flow cytometry Phagocytosis capacity by flow cytometry Bank cells for RNA

14 Methods: Lymphocyte function in vitro Isolate PBMCs from healthy adults Co-culture with 20% by volume plasma product for 24 hours Stimulate with PHA for 24 hours Measurements: Cytokine production (+/- PHA) IL-2, IL-4, INFγ, IL-10 Lymphocyte cell surface marker expression (CD4/CD8, Treg) T cell apoptosis by flow cytometry T cell proliferation Bank cells for RNA

15 Methods: Additional measurements Characterize plasma products: Microvesicle content and characterization Cytokines MicroRNA

16 Next Steps 1. Complete in vitro studies 1. Publication 2. Preliminary data for funding application 2. Identify collaborator(s) for animal studies 3. Plan multicenter clinical study - Patient population? - Feasibility? - Observational vs RCT? - Which plasma products? - Outcomes? 4. Apply for funding - NHLBI PAR , 025 Special Topics in Transfusion Medicine - R01 vs R21 depending on scope of work

17 Acknowledgements The Research Institute at NCH The Center for Clinical and Translational Research The Muszynski Laboratory Justin Bale Sanjna Shah, MD Susana Beceiro, PhD The Immune Surveillance Laboratory Lisa Hanson-Huber, Manager Jyotsna Nateri, Sr. Research Associate Lisa Steele, RN, Research Coordinator Elizabeth Ireson, Kristin Greathouse Katherine Bline, MD Joel Thompson, MD Mark W Hall, MD Transfusion Services at NCH Kathleen Nicol, MD Stephanie Townsend Mark D. Wewers, MD Phillip C. Spinella, MD K12HD Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)