Refractory hemolytic uremic syndrome improved by plasmapheresis using cryosupernatant fraction as a replacement fluid: A case report

A 52-year-old woman who had had 6 months of chemotherapy using mitomycin C and cisplatin for cervical cancer presented with hemolytic uremic syndrome. Conventional plasmapheresis using whole-plasma fraction was ineffective. However, plasmapheresis using the cryosupernatant fraction dramatically improved symptoms of hemolytic anemia and thrombocytopenia in this case. The activity of factor VIII in the cryosupernatant fraction of plasma as a replacement fluid decreased after removal of cryoprecipitate, indicating effective removal of von Willebrand factor. The pathogenesis of her hemolytic uremic syndrome may have been associated with von Willebrand factor multimers contained in the cryoprecipitate of plasma. Similar use of the cryosupernatant fraction of plasma could not be found in other reports of cases of hemolytic uremic syndrome. Plasmapheresis using the cryosupernatant fraction of plasma may improve refractory hemolytic uremic syndrome.     

Development of large-scale manufacturing of adipose-derived stromal cells for clinical applications using bioreactors and human platelet lysate

In vitro expanded adipose-derived stromal cells (ASCs) are a useful resource for tissue regeneration. Translation of small-scale autologous cell production into a large-scale, allogeneic production process for clinical applications necessitates well-chosen raw materials and cell culture platform. We compare the use of clinical-grade human platelet lysate (hPL) and fetal bovine serum (FBS) as growth supplements for ASC expansion in the automated, closed hollow fibre quantum cell expansion system (bioreactor). Stromal vascular fractions were isolated from human subcutaneous abdominal fat. In average, 95?×?10⁶ cells were suspended in 10% FBS or 5% hPL medium, and loaded into a bioreactor coated with cryoprecipitate. ASCs (P0) were harvested, and 30?×?10⁶ ASCs were reloaded for continued expansion (P1). Feeding rate and time of harvest was guided by metabolic monitoring. Viability, sterility, purity, differentiation capacity, and genomic stability of ASCs P1 were determined. Cultivation of SVF in hPL medium for in average nine days, yielded 546?×?10⁶ ASCs compared to 111?×?10⁶ ASCs, after 17?days in FBS medium. ASCs P1 yields were in average 605?×?10⁶ ASCs (PD [population doublings]: 4.65) after six days in hPL medium, compared to 119?×?10⁶ ASCs (PD: 2.45) in FBS medium, after 21?days. ASCs fulfilled ISCT criteria and demonstrated genomic stability and sterility. The use of hPL as a growth supplement for ASCs expansion in the quantum cell expansion system provides an efficient expansion process compared to the use of FBS, while maintaining cell quality appropriate for clinical use. The described process is an obvious choice for manufacturing of large-scale allogeneic ASC products.     

An economic model of haemophilia in Mexico

A model was developed to assess the lifetime costs and outcomes associated with haemophilia in Mexico. A retrospective chart review of 182 type A haemophiliacs was conducted for patients aged 0-34 years receiving one of three treatments: (i) cryoprecipitate at clinic; (ii) concentrate at home; or (iii) concentrate at clinic. Patients treated at home experienced 30% less joint damage, used 13-54% less factor VIII, had four times fewer clinic visits, and utilized half as many hospital days than those treated at a clinic. For cryoprecipitate at clinic patients, the annual incidence rates of HCV and HIV were calculated to be 3.6% and 1.4% respectively. The life expectancy for patients receiving cryoprecipitate and those receiving concentrate was estimated to be 49 years and 69 years respectively, with 58% of cryoprecipitate patients predicted to die of AIDS before age 69. Across the lifespan, the average annual cost of care was US$11,677 (MN$110,464) for cryoprecipitate at clinic patients, US$10,104 (M$95,580) for concentrate at home patients and US$18,819 (MN$178,027) for concentrate at clinic patients. Using a 5% discount rate, the incremental lifetime cost per year of life added for treatment with concentrate at home compared with cryoprecipitate at a clinic was US$738 (MN$6981). Rank order stability analysis demonstrated that the model was most sensitive to the cost of fVIII. These results indicate that treatment with concentrate at home compared with cryoprecipitate at a clinic substantially improves clinical outcomes at reduced annual cost levels.     

Bacteriological study of autologous cryoprecipitate-derived fibrin glue as the operative sealant

Fibrin glue (FG) is frequently used to seal and cover the anastomoses in many operations such as cardiovascular surgery or orthopaedic surgery. However, in case of gastrointestinal surgery, anastomoses are potentially contaminated, and FG may promote bacterial growth, increasing the risk of leakage. The purpose of this study was to examine the effect of cryoprecipitate-derived FG (CryoFG) on bacterial growth. Bacterial growth on the CryoFG and on the commercial FG (Beriplast P) was evaluated and compared with that on control medium. In addition, the complement activities were evaluated by heat inactivation or addition of guinea-pig complement to the experimental settings. The CryoFG inhibited the growth of Escherichia coli, whereas the commercial FG had no effect. Heat inactivation of the CryoFG inhibited the bactericidal effect of CryoFG. Addition of guinea-pig complement to the heat-inactivated CryoFG could almost restore the bactericidal activity, suggesting the important role of complement. This study showed that the CryoFG preserved the complement activity, which inhibited the in vitro growth of E. coli. Therefore, we concluded that the application of the CryoFG for gastrointestinal surgical anastomoses not only would be safe but also has the advantage of reducing bacterial infection.     

Immune tolerance in a haemophilia A patient with high inhibitor using locally prepared lyophilized cryoprecipitate

The immune tolerance in a 12-year-old haemophilia A patient was carried out at the Faculty of Medicine, Ramathibodi Hospital, Bangkok in 1998. His inhibitor titres ranged from 10 to 3450 Bethesda units (BU). He suffered from serious bleeding episodes requiring prolonged hospitalization and the disarticulation of the left knee joint. After obtaining informed consent, locally prepared lyophilized cryoprecipitate (LC), heat treated at 60 degrees C for 25 h, was given in a dose of 13 units kg-1 body weight of factor VIII three times per week. His inhibitor was increased from 15 to 580 BU within the first 4 weeks of immune tolerance. Finally, it was decreased to 40 BU in the 36th week. The only adverse effect was seroconversion of anti-hepatitis C virus after receiving 108 bottles of LC for 36 weeks. In conclusion, the locally prepared LC was able to control the bleeding episodes in a haemophilia A patient with high inhibitor. To our knowledge, this is the first reported case in Thailand.     

Cryoprecipitate prepared from plasma virally inactivated by the solvent detergent method

There remains a small risk of viral transmission from single-donor blood components such as fresh frozen plasma (FFP) and cryoprecipitate which have not been subjected to a viral inactivation procedure. It is now possible to subject pooled FFP to viral inactivation by the solvent detergent (SD) treatment method, but with some loss of coagulation factors. To establish whether cryoprecipitate prepared from SD plasma would be suitable for the treatment of hypofibrinogenaemia and von Willebrand's disease (VWD), control and SD cryoprecipitate were assayed for factor VIII, von Willebrand factor (VWF) and fibrinogen content. In SD cryoprecipitate, levels of VWF activity and antigen were only 36% and 37% of control values respectively, whereas fibrinogen was 72%. The highest molecular weight multimers of VWF:Ag were absent from both SD plasma and SD cryoprecipitate. SD cryoprecipitate would thus be unsuitable for treating VWD, but would provide an alternative to untreated individual donor units of cryoprecipitate for the treatment of hypofibrinogenaemic states.     

Disarticulation of a knee joint in a haemophiliac with high inhibitor titre

Summary. Disarticulation of a knee joint in an 8-year-old haemophilia A patient with high inhibitor of 3450 Bethesda units (BU) is described. He had an infected compound fracture of the tibia and fibula. Surgery was successfully performed after extensive plasma exchange; administration of immunosuppressive agents such as cyclophosphamide, methylprednisolone, intravenous immunoglobulin and cyclosporine were combined with a loading dose of 100 units kg^-1 of factor VIII concentrate, followed by continuous infusion of 16 units kg^-1 h^-1 of factor VIII in the form of factor VIII concentrate and cryoprecipitate for 7 days and decreased to 8 units kg^-1 h^-1 in the form of cryoprecipitate for 19 more days. During the 1st to 7th post-operative days, the lowest factor VIII inhibitor was 18 BU and the factor VIII level ranged from < 1–2.1 IU dL^-1. On the 9th and 13th post-operative day, although the inhibitor rose to 330 and 2700 BU, respectively, there was no serious bleeding. The suture was removed on the 21st post-operative day. The inhibitor spontaneously decreased to 550, 232 and 14 BU at 1, 7 and 10 months, respectively.