The Possible Advantages of Cryoprecipitate Prepared From Fresh Frozen Plasma From Blood Stored for 24 Hours

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1 The Possible Advantages of Cryoprecipitate Prepared From Fresh Frozen Plasma From Blood Stored for 24 Hours Joseph Philip, MD, 1* Samantha Kumarage, MBBS, 1 Tathagata Chatterjee, DM, 1 Sudeep Kumar, MBBS, 1 Rajeev Mallhi, MD 1 Lab Med Spring 2014;45: DOI: /LMV1E84UCTRQQZP ABSTRACT Background: To compare the coagulation-factor profile of cryoprecipitate produced from fresh frozen plasma from whole blood (WB) stored for 24 hours at room temperature (24CP) with that of standard cryoprecipitate (CP). Methods: We collected 80 units of WB from healthy volunteers, of which 20 units were of each blood group. Each unit of blood was divided into 2 parts. One part was used for preparation and qualitycontrol evaluation of CP within 8 hours of collection; the other part was stored at room temperature for 24 hours and then subjected to CP preparation. Coagulation studies were carried out on each batch of CP after production., Factor VIII (FVII), and von Willibrand factor () were measured, and the. blood groups were determined. We used the Student s t-test to perform comparisons and considered results to be significant at P <.005. In 1964, Pool and colleagues at Stanford University published the scientific paper, High-potency antihaemophilic factor concentrate prepared from cryoglobulin precipitate, 1 describing a procedure for the preparation of cryoprecipitate (CP). CP is primarily used to treat congenital and acquired hypofibrinogenemias or dysfibrinogenemias that may occur in conditions such as massive transfusion, disseminated intravascular coagulation (DIC), Abbreviations CP, cryoprecipitate; DIC, disseminated intravascular coagulation;, von Willibrand factor;, Factor VIII; FFP, fresh frozen plasma; WB, whole blood; TRALI, transfusion-related acute lung injury; HLAs, human leukocyte antigens; PRBC, packed red blood cells; 24CP, cryoprecipitate prepared from FFP from WB and stored for 24 hours at room temperature; VIIC, Factor VIIIC Department of Immunohematology and Blood Transfusion; Armed Forces Medical College, Pune, India *To whom correspondence should be addressed. eoj_in@yahoo.com Results: Overall, all 3 clotting factors were increased in 24CP compared with CP, with a statistically significant increase in the level of. Blood group AB had significantly increased levels of fibrinogen and in 24CP compared with CP. Conclusion: Our study showed that 24CP has equal or greater levels of coagulation factors compared with CP. his indicates that our alternate approach for preparation of CP may enable more efficient use of blood collected in satellite blood collection centers and during blood drives. Keywords: 24-hour cryoprecipitate, standard cryoprecipitate, fibrinogen, Factor VIII, alternative approach, coagulation factor profile and severe hemorrhage. Although hemophilia A and von Willibrand disease are currently treated with virally inactivated products of Factor VIII () and desmopressin, respectively, CP is still used in developing countries to treat hemophilia A. 2 CP is prepared from fresh frozen plasma (FFP), which is derived from freshly collected whole blood (WB). FFP must be prepared within 8 hours of collection of WB. The bag of plasma is labeled as containing FFP and is stored at less than -18 C within 8 hours of collection. Standard CP is prepared from this FFP by slow-thawing the FFP at 1 to 6 C, until the plasma develops a slushy consistency. At that point, the blood product is centrifuged at 4 C at 5000g for 5 minutes. The supernatant is then rapidly separated, producing only 10 to 15 ml of supernatant plasma for resuspension. The product is the standard CP, which is then stored at less than 30 C for 1 year. 3 A serious shortage of plasma products such as CP exists for 2 main reasons: Spring 2014 Volume 45, Number 2 Lab Medicine 111

2 1. Many countries prepare plasma products only from male donors to avoid the risk of transfusion-related acute lung injury (TRALI); most female blood donors are sensitive to human leukocyte antigens (HLAs) after pregnancy. As a result, blood products collected from female donors are more likely to trigger TRALI in recipients because anti-hla antibodies present in donor blood may activate the neutrophils of the recipient. If this occurs, the neutrophils release toxic agents and cause damage to the pulmonary capillary endothelium, resulting in TRALI, a life-threatening complication of transfusion. 2. As the world population ages, the pool of voluntary young donors is shrinking rapidly, while demand for blood products continues to increase. To fill the gap between supply and demand, transfusion services have expanded their collections to satellite blood collection centers. However, blood collected at remote sites may not reach a blood bank within the 8-hour window for FFP. Presently, international interest has increased in producing components from blood that has been stored at room temperature for 24 hours. However, there is a lack of data on the quality of CP produced from blood stored at room temperature overnight. If the time WB can be kept at room temperature is extended without compromising the quality of the product, the inventories of all derived components will be boosted. Our study was designed to compare the quality of the CP derived from FFP that was prepared from WB kept at room temperature for 24 hours (24CP) with that of standard CP, which is prepared from FFP from WB kept at room temperature for a maximum of 8 hours after collection. Materials and Methods This study was conducted in a blood bank serving a multiethnic population, including Indo-Aryan, Dravidian, Parsi, and Sindhi; written consent was obtained from the donors and the protocol was approved by the institutional ethics committee. We collected blood from healthy donors according to standard protocols. We drew a total of 80 units (of which 20 units were from each blood group) of WB into the central bag of the triple-unit blood bags and thoroughly mixed the blood with the anticoagulants. Both satellite bags were separated and placed aside. We connected a single bag to the central bag via a sterile connecting device (SCD; Terumo Corporation, Tokyo, Japan) and weighed the WB to divide it into equal halves. The two halves were separated and labeled as 8 hours and 24 hours. This nullified the donor-dependent variables between the 2 arms of the study. Previously removed satellite bags were reconnected to the 8 hours and 24 hours bags using the SCD. We maintained bags at room temperature for either 8 hours or 24 hours, as labeled. Plasma (ie, FFP) and packed red blood cells (PRBC) were prepared according to standard protocols. 4 The FFP was extracted into a connected satellite bag via a manual expresser and stored at or below 30 C. To prepare the CP, we thawed bags at 4 C overnight and centrifuged them at 5000g for 5 minutes at 4 C. We immediately siphoned out supernatant cryo-poor plasma, leaving 10 to 15 ml of plasma containing CP. We collected 2.5 ml of products in plain test tubes. A computer-generated number was assigned to each of bag before it was sent to the laboratory for clotting-factor evaluation. We measured levels of fibrinogen,, and activity in the products via the automated STA Compact Plus analyzer (Diagnostica Stago Inc, Parsippany, NJ). Ten samples from the study arm and 10 from the control arm were randomly selected to be sent to an independent laboratory for bacterial cultures. Statistical analysis included paired 1-tail distribution and the Student s t-test using Microsoft Office Excel 2010, Student Edition (Microsoft Corporation, Redmond, WA). P <.05 was considered statistically significant. Results Mean (SD) fibrinogen concentrations in CP and 24CP preparations were (57.97) mg per unit and (96.51) mg per unit, respectively. There was a 26.4% increase in mean fibrinogen levels in the 24CP compared with those of CP (P >.99). The mean (SD) values for CP and 24CP were 81.5 (33.16) IU per unit and 95.3 (37.91) IU per unit, respectively; this represents a 16.93% increase of mean in CP compared with that of 24CP (P =.02). Mean (SD) values for CP and 24CP were 95.3 (37.91) IU per unit and (76.04) IU per unit, respectively, which represents a 111% increase in mean in 24CP compared with CP (P = 2.6) (Table 1 and Figure 1). Variations of clotting factors among the blood groups examined in the 2 arms of the study are shown in Table 2 and Figure 2. Blood Group A The mean (SD) values of analytes in CP and 24CP were as follows: The values for fibrinogen were (57.9) mg 112 Lab Medicine Spring 2014 Volume 45, Number 2

3 per unit and (118.18) IU per unit, respectively (P =.08). For, the values were 79.7 (36.4) IU per unit and 88.3 (51.9) IU per unit, respectively (P <.49); for activity, (76.74) IU per unit and (112.94) IU per unit, respectively (P =.05). Table 1. Main Quality Control Values of CP and 24CP Mean (SD) Clotting Factor CP 24CP P Value Blood Group B The mean (SD) values of analytes in CP and 24 CP were as follows: The values for fibrinogen were (69.3) mg per unit and (63.5) mg per unit, respectively (P = 2.42). For, the values were (22.09) IU per unit mg-iu/dl Figure 1 CP 24 CP Variations of quality-control values for the 2 study groups. 24CP indicates cryoprecipitate prepared from FFP from WB and stored for 24 hours at room temperature., indicates von Willibrand factor;, Factor VIII; CP, cryoprecipitate. Table 2. Variation of Clotting Factors by Blood Group mg-iu/unit (mg/unit) (57.97) (96.51) >.99 a 81.5 (33.16) 95.3 (37.91).02 a 95.3 (37.91) (76.04) 2.6 a a Not statistically significant. CP, cryoprecipitate; 24CP, cryoprecipitate prepared from fresh frozen plasma from whole blood and stored for 24 hours at room temperature;, Factor VIII;, von Willibrand factor Figure 2 (mg/unit) CP (mg/unit) 24 CP Variation of clotting factors among individual blood groups in cytoprecipitate (CP) and CP prepared from fresh frozen plasma from whole blood and stored for 24 hours at room temperature (24CP). indicates Factor VIII;, von Willibrand factor. A B AB O CP, Mean (SD) 24CP, Mean (SD) Blood Group (mg/unit) (mg/unit) A (57.90) 79.7 (36.40) (76.74) (118.18) 88.3 (51.90) (112.94) B (69.30) (29.80) 111 (28.70) (63.50) a (22.09) (57.62) AB (68.30) 89.1 (34.80) (25.30) (100.48) a (43.83) (58.60) O (50.27) (31.90) (74.07) (99.01) a (27.34) (74.73) a Statistically significant. CP, cryoprecipitate; 24CP, cryoprecipitate prepared from fresh frozen plasma from whole blood and stored for 24 hours at room temperature;, Factor VII;, von Willibrand factor. Spring 2014 Volume 45, Number 2 Lab Medicine 113

4 and (29.8) IU per unit, respectively (P =.07); for activity, (57.62) IU per unit and 111 (28.7) IU per unit, respectively (P = 6.33). Blood Group AB The mean (SD) values of analytes in CP and 24 CP were as follows: Values for fibrinogen were (100.48) mg per unit and (68.3) mg per unit, respectively (P =.02). For, the values were (43.83) IU per unit and 89.1 (34.8) IU per unit, respectively (P =.06); for activity, (58.6) IU per unit and (25.3) IU per unit, respectively (P.001). Blood Group O The mean (SD) values of analytes in CP and 24CP were as follows: For fibrinogen, the values were (50.27) mg per unit and (99.0) mg per unit, respectively (P = 9.98). For, the values were (27.34) IU per unit and (31.9) IU per unit, respectively (P =.45); for, (74.73) IU per unit and (74.07) IU per unit, respectively (P =.19). Discussion The 3 clotting factors we evaluated in the study were present in increased levels in 24CP compared with CP. The fibrinogen level was increased by 26.4% in 24CP compared with that in CP; this difference was not statistically significant (Figure 1 and Table 1). This phenomenon might be explained by more effective precipitation after the 24-hour storage period. We observed a statistically significant increase in the fibrinogen level in the AB blood group in 24CP. In the other 3 blood groups, fibrinogen levels in 24CP were also increased; however, the differences were not statistically significant (Figure 2 and Table 2). Similar studies performed by Alakech et al 7 and Yazer et al 8 revealed that the fibrinogen level was not deceased in 24CP; these results were comparable with ours. Alakech at el 7 and Yazer et al. 8 The activity of 24CP was increased to 111% of the activity recovered from CP; this increase was not statistically significant. The finding is also comparable to those of the 2 studies previously mentioned. The activity observed in the AB blood group in our study showed a statistically significant increase. is a large multimeric glycoprotein present in plasma and produced in the endothelium (in the Weibel-Palade bodies), megakaryocytes (α-granules of platelets), and subendothelial connective tissue. In an inactive state, is bound to and thereby prevents its degradation in circulation. 8 This may partially explain the significantly elevated levels of in 24CP compared with those of CP. N-glycans are part of ; they are precursors of A and B antigens. The level of expression of A and B antigens in affects the circulating plasma level of and. Thus, the AB blood group has the highest level of, followed by the B, A, and O groups. 9 The association of and, which we discussed earlier, clearly suggests that the AB blood group should be superior to the other blood groups regarding CP production. Nevertheless, we did not observe this in our study. In a study performed by Alakech at el, 7 Factor VIII activity declined by 29% in 24CP compared with FFP. However, levels of and fibrinogen, as well as activity levels, were not decreased in 24CP compared with those of CP. The results from those studies is consistent with our observations. In a study performed by Yazer et al, 8 the mean (SD) levels in CP and 24CP at the time of thawing were as follows: fibrinogen (mg/unit), (172.6) and (185.9; P =.04); Factor VIIIC (FVIIC; IU/unit), (52.3) and (70.1; P =.07); and, (118.9) and (135.1; P =.16), respectively. All units of CP and 24CP met the current minimum quality standards established by the AABB. All of the samples sent for bacterial cultures yielded negative results. In 24CP, we observed a 16.9% increase in level compared with that of CP, with P =.02, which was statistically significant (Figure 1 and Table 1). activity in all 4 blood groups in 24CP was increased compared with those of CP, but the individual differences were not statistically significant (Figure 2 and Table 2). These observations are comparable to those of 2 similar studies performed by Conclusion The results from this study have shown that qualitatively, 24CP is comparable to CP. In fact, fibrinogen, activity, and levels were increased in 24CP; the increase in was statistically significant. Our results show that 24CP has equal or increased levels of coagulation factors 114 Lab Medicine Spring 2014 Volume 45, Number 2

5 compared with CP; therefore, 24CP and CP could be equally effective in clinical use. The alternate approach for preparation of CP may enable better use of blood collected in satellite blood collection centers and during blood drives. However, because our sample size was small, it is necessary to conduct large-scale studies to validate this method for clinical efficacy. Doing so would enhance the practice of CP banking by validating an alternative method for CP preparation. LM References 1. Pool JG, Gershgold EJ, Pappenhagen AR. High-potency antihaemophilic factor concentrate prepared from cryoglobulin precipitate. Nature. 1964;203: Cruz J, Gregurek S Transfusion therapy and the role of the medical director in blood banking. In: Quinly ED. Immunohematology Principles and Practice. 3 rd ed. Philadelphia: Lippincott, Williams & Wilkins. 2010; Roback JD, Grossman BJ, Harris T, Hillyer CD. Blood collection, component preparation, and storage. In: Roback JD, ed. Technical Manual of Blood Banking. 17 th ed. Bethesda: AABB Press. 2011; Kakaiya R, Aronson CA, Julleis JJ. Whole blood collection and component processing at blood collection centers. In: John DR, ed. Technical Manual of Blood Banking. 17 th ed. Bethesda: AABB Press. 2011; Saran RK, India Directorate General of Health Services, World Health Organization. Quality assurance in blood transfusion. In: Saran RK, ed. Tranfusion Medicine: Technical Manual. 2 nd ed. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family, Government of India. 2003; Laffan M, Manning R. Investigation of haemostasis. In: Dacie and Lewis eds. Practical Haematology. 11 th ed. Churchill Livingstone. 2011: Alakech B, Miller B, Berry TH, Ambruso DR. Coagulation profile for cryoprecipitate produced from 24-hour stored whole blood. Lab Medicine. 2009;40: Yazer MH, Triulzi DJ, Hassett AC, Kiss JE. Cryoprecipitate prepared from plasma frozen within 24 hours after phlebotomy contains acceptable levels of fibrinogen and VIIIC. Transfusion. 2010;50: Carbohydrate blood groups. In: Simon TL, Snyder EL, Solheim BG, Stowell CP, Strauss RG, Petrides M, eds. Rossi s Principles of Transfusion Medicine. 4 th ed. Wiley-Blackwell. 2009;98. To read this article online, scan the QR code, ascpjournals.org/content/45/2/111. full.pdf+html Spring 2014 Volume 45, Number 2 Lab Medicine 115