Virus Inactivation of Fresh Frozen Plasma by a Solvent Detergent Procedure: Biological Results

In order to increase the safety of blood products, we have developed a procedure for the virus inactivation of fresh frozen plasma. Several batches have been prepared and with the first 10 batches, each of them composed of 60 litres of plasma, we have determined a set of biological parameters. Virus inactivation was realised using TnBP (1%) and Octoxynol 9 (1%). After their elimination with castor oil using chromatography on insolubilized C18 resin, glycine was added and the pH of the plasma was adjusted to 7.4. Plastic bags were aseptically filled with a mean volume of 200 ml of plasma. The mean levels of coagulation factors were all over 0.7 U/ml and their recovery from initial plasma was nearly the same as total protein except for factor VIII:C. The net loss in factor VIII:C was 16%, when including the dilution of plasma. In vivo and in vitro tests demonstrated that in the final product there were no activated factors. As in fresh frozen plasma, the protein concentration was over 50 g/l and the potassium level lower than 5 mmol/l. According to these results, virus-inactivated plasma has the same qualities of fresh frozen plasma and could now replace it.     

In Vitro Characterization of Solvent/Detergent-Treated Human Plasma and of Quarantine Fresh Frozen Plasma

Background and objectives : Plasma pools, solvent/detergent(S/D)-treated plasma produced from plasma pools, and single donor fresh frozen plasma that had been quarantined for at least 6 months (QFFP) differ in their composition regarding clotting factors, inhibitors and other important plasma proteins. There are poor data concerning stability of important clotting factors after thawing of frozen plasma units. Materials and methods : 12 plasma pools, 12 batches of S/D plasma produced from these respective plasma pools, and 12 units of QFFP were extensively analysed. The stability of fibrinogen and factors V, VII, and VIII after thawing, storage at room temperature and at +4°C was also examined. Results : We extensively analysed plasma pools before and after solvent/detergent treatment as well as quarantined single donor plasma units for parameters of coagulation and fibrinolysis. After the S/D step, all clotting factor activities and the activities of most inhibitors and other plasma proteins were in the normal range in all batches. Protein S and plasmin inhibitor activities decreased by 35% and 76%, respectively. S/D treatment partly activated factor VII (FVII). However, there were no marked increases of other markers of activated hemostasis. The interindividual variations of all proteins analysed were significantly lower in the S/D plasmas than in the single donor plasma units. An 8-hour storage lead to a marked decrease of FVIII activity, whereas there was no significant influence on fibrinogen and factors V and VII. Conclusions : There are no critical reductions of the activities of clotting factors, inhibitors, and other important plasma proteins due to S/D treatment. Efficacy and safety of S/D plasma is not hampered by reduced activities of protein S and plasmin inhibitor. Dosage calculation and the evaluation of clinical response is simplified by usage of the more standardized S/D plasma compared to QFFP.     

The Effect of Octreotide on Urine Output During Orthotopic Liver Transplantation and Early Postoperative Renal Function; A Randomized,Double-Blind,Placebo-Controlled Trial

Background

Maintenance of the adequate intraoperative renal perfusion is very important during Orthotopic Liver Transplantation (OLT) to prevent acute renal failure.

Objectives

For the first time, this study was designed to survey the effects of octreotide on urine output during anesthesia for OLT and early postoperative renal function.

Patients and Methods

In this randomized double-blind placebo controlled clinical trial, 79 of 89 patients who underwent OLT and fulfilled the study requirement were randomly allocated into two groups. In the octreotide group, the patients received octreotide infusion from the start of the operation. On the other hand, the control group patients received physiologic saline infusion instead of octreotide. The Mean Arterial Pressure (MAP), heart rate, urine output, norepinephrine usage, and dosage during the three stages of OLT, and baseline and postoperative creatinine were recorded and compared between the two groups.

Results

No significant differences were found between the two groups regarding the demographic characteristics and graft factors (P > 0.05). However, urine output and MAP during the three stages of OLT were significantly higher in the octreotide group compared to the control group (P < 0.05). Moreover, no significant difference was observed between the two groups regarding baseline as well as postoperative creatinine (P > 0.05).

Conclusions

The results demonstrated that octreotide infusion during anesthesia for OLT not only augmented the vasoconstriction effect of norepinephrine to increase MAP, but also maintained better renal perfusion and urine output during the operation.     

Virus Inactivation by Solvent/Detergent Treatment and the Manufacture of SD-Plasma

Solvent/Detergent (SD) is an extraordinarily effective means for eliminating enveloped viruses from plasma and plasma products [1]. The safety margin suggested by the rapid and complete kill of enveloped viruses observed in the laboratory has been confirmed repeatedly by groups worldwide and by thirteen years of routine clinical use encompassing an estimated 35 million doses of a wide variety of products. Throughout this time, there has not been a single documented case of enveloped virus transmission by an SD-treated product. This record of safety spawned the development of SD-treated plasma as a substitute for fresh frozen plasma (FFP) [2] and has encouraged the adoption of SD for the treatment of non-blood products such as monoclonal antibodies and those derived from recombinant DNA procedures [3]. This review summarizes the use of SD treatment, including its use in combination with other viral elimination procedures, and also summarizes Vitex's initial experience in the manufacture of SD-Plasma, recently licensed by the U.S. FDA.     

乙肝肝衰竭患者临床输注新鲜冰冻血浆治疗效果分析

目的 回顾性调查分析乙肝肝衰竭患者临床输注新鲜冰冻血浆（fresh frozen plasma,FFP）的资料,了解输注FFP对于改善预后的疗效。方法 查阅2009-12/2013-07在四川省人民医院住院的88例乙肝肝衰竭患者,观察时间为4周,根据观察期间是否输注FFP分为2组,对照组31例未输注FFP,治疗组57例输注FFP,比较2组患者住院4周后和入院时的终末期肝病模型（Model for end-stage liver disease,MELD）评分,分析是否输注FFP和血浆用量对预后的影响,综合评估患者临床转归。结果 对照组MELD评分差值1.74±12.12,治疗组MELD评分差值-0.46±8.03,2组比较差异无统计学意义（t’=-0.91,P〉0.05）。治疗组的血浆用量和MELD评分差值使用直线相关分析,直线相关系数r=0.11 P〉0.05,无直线相关关系。结论 输注FFP不能改善乙肝肝衰竭患者的预后,不推荐预防性应用。     

Effects of Early Resistance Training After Liver Transplantation Procedures: A Randomized Controlled Pilot Trial

Background:Exercise interventions improve muscle performance and functionality when applied more than 6 months after liver transplantation, but no studies have reported on earlier exercise interventions. Hence, we assessed the effects of early resistance training on functional outcomes in adult liver recipients.Methods:The study included 30 liver transplantation patients (53.2 ± 12.4 years) randomly assigned to a training group (n = 15) or a control group (n = 15). Data collected preoperatively and 4 and 8 weeks post-surgery were analyzed, including peripheral and respiratory muscle strength, exercise capacity, physical performance, and fatigue. An 8-week physiotherapy program was applied (training group: standard physiotherapy + resistance training; control group: standard physiotherapy) for 2 sessions/day, 5 days/week.Results:Baseline data showed a homogeneous distribution in the between-group comparisons. In the within-group analysis; EG showed higher improvements in physical performance (TG: P = .001, CG: P = .048) and fatigue perception (TG: P = .001; CG: P = .006), than the CG. The TG showed eight-week improvements in exercise capacity, peripheral muscle strength, and maximal inspiratory pressure (P = .001), and maximal expiratory pressure (P = .047), while CG remained unchanged (P > .05). In the between-group analysis; the improvements indicated significant differences in deltoid strength and fatigue perception, in favor of the TG (P < .05). A change of 0.9 kg in peripheral muscle strength and >37.8 m in 6-min walk distance (6MWD) was determined, representing clinically significant improvement in liver recipients.Conclusion:Early resistance training may improve muscle strength, exercise capacity, physical performance, and fatigue perception in liver recipients, when added to standard physiotherapy. The estimated minimal clinically important differences are meaningful to clinicians in setting liver transplanted patient-specific goals.     

Effect of Ursodeoxycholic Acid Administration after Liver Transplantation on Serum Liver Tests and Biliary Complications: A Randomized Clinical Trial

Background/Aims: Endogenous hydrophobic bile acids are suspected to be one of the pathogenetic factors of biliary complications after orthotopic liver transplantation (OLT). This study was designed to investigate the effects of hydrophilic ursodeoxycholic acid (UDCA) administration early after OLT on serum liver tests and the incidence of biliary complications. Methods: 112 adult patients undergoing OLT from donation after cardiac death (DCD) were randomized to UDCA (13-15 mg/kg/day for 4 weeks; 56 patients) or placebo (56 patients). Serum liver tests and serum bile acids of all patients and biliary bile acids in patients with T-tube drainage were determined during the 4 weeks after OLT. Biliary complications as well as patient and graft survival were analyzed during a mean follow-up of 41.6 months. Results: UDCA treatment decreased ALT, AST and GGT (p < 0.05) during the 4 weeks after OLT and the incidence of biliary sludge and casts within the 1st year (p < 0.05). However, no differences in the incidence of other biliary complications as well as 1-, 3- and 5-year graft and patient survival were observed. Conclusions: UDCA administration early after DCD-OLT improves serum liver tests and decreases the incidence of biliary sludge and casts within the 1st postoperative year but does not affect overall outcome up to 5 years after OLT.     

Successful Treatment of Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura with Fresh Frozen Plasma and Plasma Exchange

ABSTRACT. Four patients with hemolytic uremic syndrome (HUS) and seven with thrombotic thrombocytopenic purpura (TTP) were treated with infusions of fresh frozen plasma (FFP). In one patient with HUS and Ave patients with TTP this treatment was combined with plasma exchange (PE). The additional treatment varied; corticosteroids, antiplatelet drugs, heparin and blood exchange. All but one patient recovered completely in spite of severe illness with uremia, oliguria and/or cerebral symptoms during the acute phase. The results were surprisingly good in comparison with other published series. The success must in the first place be attributed to early diagnosis and to the infusions of FFP. PE seemed to potentiate the effect of FFP.     

Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial

BackgroundHigh volume plasma-exchange (HVPE) improves survival in patients with acute liver failure (ALF), but apprehension regarding volume overload and worsening of cerebral edema remain.MethodsIn an open-label randomized controlled trial, 40 consecutive patients of ALF were randomized 1:1 to either standard medical treatment (SMT) or SMT with standard-volume plasma-exchange (SVPE). SVPE was performed using centrifugal apheresis [target volume of 1.5 to 2.0 plasma volumes per session] until desired response was achieved. Cerebral edema was assessed by brain imaging. Results were analyzed in an intention-to-treat analysis. Primary outcome was 21-day transplant-free survival. The levels of cytokines, damage-associated molecular patterns (DAMPs) and endotoxins were analyzed at baseline and day 5.ResultsALF patients [aged 31.5 ± 12.2 years, 60% male, 78% viral, 83% hyperacute, 70% with SIRS were included. At day 5, SVPE [mean sessions 2.15 ± 1.42, median plasma volume replaced 5.049 L] compared to SMT alone, resulted in higher lactate clearance (p = .02), amelioration of SIRS (84% vs. 26%; P = .02), reduction in ammonia levels [(221.5 ± 96.9) vs.(439 ± 385.6) μg/dl, P = .02) and SOFA scores [9.9(±3.3) vs. 14.6(±4.8); P = .001]. There were no treatment related deaths. SVPE was associated with a higher 21-day transplant free-survival [75% vs. 45%; P = .04, HR 0.30, 95%CI 0.01-0.88]. A significant decrease in levels of pro-inflammatory cytokines and an increase in anti-inflammatory cytokines along with a decrease in endotoxin and DAMPs was seen with SVPE.ConclusionIn ALF patients with cerebral edema, SVPE is safe and effective and improves survival possibly by a reduction in cytokine storm and ammonia. ClinicalTrial.gov (identifier: NCT02718079)     

Solvent/Detergent Treatment of Human Plasma - A Very Robust Method for Virus Inactivation. Validated Virus Safety of OCTAPLAS®

OCTAPLAS® is a cell-free standardized blood group specific human coagulation active plasma for transfusion. The viral safety is mainly based on the treatment with solvent/detergent. SD is known to irreversibly inactivate the lipid enveloped viruses including HTV 1+2, HBV and HCV and has been recommended both by European guidelines and the FDA. The potential limitation of each inactivation method should be validated according to the current EU-guidelines CPMP/BWP/268/95 and CPMP/BWP/269/95. Our studies demonstrate that the SD method inactivates lipid enveloped viruses within a few minutes to below the limit of detection. The concentration of the SD reagents as well as several other process parameters chosen for the virus inactivation step of plasma pools of different protein and lipid composition result in a high safety margin towards the clinically relevant viruses.     

Effects of Orthotopic Liver Transplantation on the Corrected QT Interval in Patients with End-Stage Liver Disease

Autonomic dysfunction is a recognized complication of end-stage liver disease (ESLD) associated with a poor prognosis. The corrected QT interval (QTc) on electrocardiogram is a marker of autonomic function. A few small studies have suggested that QTc may normalize with the return of liver function after orthotopic liver transplantation. We sought to determine how transplantation affects the QTc in patients with ESLD. The QTc from the pretransplantation evaluation of 46 patients with ESLD was compared with the QTc at 4-month posttransplantation follow-up. Other factors that can influence autonomic function also were evaluated. Most patients with ESLD (54%) showed a prolonged QTc (440 msec) at the pretransplantation evaluation (451± 45 msec) that improved to within the normal range at posttransplantation follow-up (418± 18 msec; P < 0.001). There was no relationship between QTc prolongation and Child–Turcotte–Pugh score, Model for End-Stage Liver Disease score, diabetes mellitus, age, or etiology of liver disease. Most patients with ESLD and a prolonged QTc will have a significant improvement in QTc after transplantation; however, 6.5% of patients in our study had a worsening of QTc after transplantation.     

Comparison of Fresh Frozen Plasma with a Standardized Serum Protein Solution Following Therapeutic Plasma Exchange in Patients with Autoimmune Disease: A Prospective Controlled Clinical Trial

abstract: The aim of the study was the comparison of the influence of fresh frozen plasma (FFP) (Freiburg, Germany) and Biseko, Biotest Pharma GmbH (Dreieich, Germany), as a plasma substitute (a standardized, virus inactivated human serum protein solution) on the coagulation factors, inhibitors, proteins, and complement factors in the plasma of autoimmune disease patients following membrane plasma separation. Patients (n = 24) with autoimmune disease were randomized to receive either FFP or Biseko for membrane plasma separation therapy. During each plasma exchange, 100% of the plasma volume was replaced by the respective substitute. Plasma exchange volume was performed once daily for 3 days. Target test parameters of the coagulation system were fibrinogen, fibrinopeptide A, factor VIII (FVIIIC), von Willebrand factor antigen (vWFAg), partial thromboplastin time (PTT), thromboplastin time (Quick value), and antithrombin (AT III). The immunoglobulins were IgG, IgA, and IgM and C‐reactive protein (CRP). The thrombocytes were platelet factor 4 (PF4), and complement factors were C3 and C4. Biseko was well tolerated with 1 mild adverse drug reaction (ADR) (n = 1) while FFP gave rise to ADR on 7 occasions (n = 4). Statistically significant differences in the 2 groups were observed for fibrinogen, PTT, Quick value, and AT III. From the clinical point of view, all fluctuations and differences in parameter levels remained clinically silent. The differences had no clinical consequences. Reflecting on a potential decrease in the risk of infections in comparison to FFP therapy and the lower rate of adverse drug reactions, it is possible to postulate an advantage of Biseko for plasma exchange therapy.     

Effect of Whole Blood Storage on Factor VIII Recovery in Fresh Frozen Plasma and Cryoprecipitate

Depending on logistics, whole blood has to be stored for several hours after collection. If storage time exceeds 8 h, storage has to be at 1–6 °C to comply with FDA regulations. In the Netherlands, however, whole blood is also stored for 12–15 h at 20–24 °C using butane-1,4-diol cooling devices. We compared these two storage methods for factor VIII recovery in plasma and cryoprecipitate. At laboratory scale a significantly higher factor VIII recovery was found in plasma prepared from whole blood stored at ambient temperature; in cryoprecipitate this was confirmed but differences were not significant. However, as a result of inefficient cooling in routine procedure, no significantly different factor VIII recoveries were found in plasma prepared from whole blood stored at either of the two temperatures. From our study we conclude that overnight storage of whole blood at ambient temperature using butane-1,4-diol cooling devices has to be favoured.     

A Double Blind Randomized Clinical Trial of Remote Ischemic Conditioning in Live Donor Renal Transplantation

Ischemic conditioning involves the delivery of short cycles of reversible ischemic injury in order to induce protection against subsequent more prolonged ischemia. This randomized controlled trial was designed to determine the safety and efficacy of remote ischemic conditioning (RC) in live donor kidney transplantation.This prospective randomized clinical trial, 80 patients undergoing live donor kidney transplantation were randomly assigned in a 1:1 ratio to either RC or to a control group. RC consisted of cycles of lower limb ischemia induced by an arterial tourniquet cuff placed around the patient''s thigh. In the RC treatment group, the cuff was inflated to 200 mm Hg or systolic pressure +25 mm Hg for 4 cycles of 5 min ischemia followed by 5 min reperfusion. In the control group, the blood pressure cuff was inflated to 25 mm Hg. Patients and medical staff were blinded to treatment allocation. The primary end-point was renal function measured by estimated glomerular filtration rate (eGFR) at 1 and 3 months posttransplant.Donor and recipient demographics were similar in both groups (P < 0.05). There were no significant differences in eGFR at 1 month (control 52 ± 14 vs RC 54 ± 17 mL/min; P = 0.686) or 3 months (control 50 ± 14 vs RC 49 ± 18 mL/min; P = 0.678) between the control and RC treatment groups. The RC technique did not cause any serious adverse effects.RC, using the protocol described here, did not improve renal function after live donor kidney transplantation.     

Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial

OBJECTIVES: To investigate whether a disease‐specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers (PUs) in institutionalized elderly patients. DESIGN: Twelve‐week follow‐up randomized controlled trial (RCT). SETTING: Four long‐term care facilities in the province of Como, Italy. PARTICIPANTS: Twenty‐eight elderly subjects with Stage II, III, and IV PUs of recent onset (<1‐month history). INTERVENTION: All 28 patients received 30 kcal/kg per day nutritional support; of these, 15 received standard nutrition (hospital diet or standard enteral formula; 16% calories from protein), whereas 13 were administered a disease‐specific nutrition treatment consisting of the standard diet plus a 400‐mL oral supplement or specific enteral formula enriched with protein (20% of the total calories), arginine, zinc, and vitamin C (P<.001 for all nutrients vs control). MEASUREMENTS: Ulcer healing was evaluated using the Pressure Ulcer Scale for Healing (PUSH; 0=complete healing, 17=greatest severity) tool and area measurement (mm² and %). RESULTS: The sampled groups were well matched for age, sex, nutritional status, oral intake, type of feeding, and ulcer severity. After 12 weeks, both groups showed significant improvement (P<.001). The treatment produced a higher rate of healing, the PUSH score revealing a significant difference at Week 12 (?6.1±2.7 vs ?3.3±2.4; P<.05) and the reduction in ulcer surface area significantly higher in the treated patients already by Week 8 (?1,140.9±669.2 mm² vs ?571.7±391.3 mm²; P<.05 and ～57% vs ～33%; P<.02). CONCLUSION: The rate of PU healing appears to accelerate when a nutrition formula enriched with protein, arginine, zinc, and vitamin C is administered, making such a formula preferable to a standardized one, but the present data require further confirmation by high‐quality RCTs conducted on a larger scale.     

Levetiracetam in the Treatment of Epileptic Seizures After Liver Transplantation

After liver transplantation, patients may develop seizures or epilepsy due to a variety of etiologies. The ideal antiepileptic drugs for these patients are those with fewer drug interactions and less hepatic toxicity. In this study, we present patients using levetiracetam to control seizures after liver transplantation.We retrospectively enrolled patients who received levetiracetam for seizure control after liver transplantation. We analyzed the etiology of liver failure that required liver transplantation, etiology of the seizures, outcomes of seizure control, and the condition of the patient after follow-up at the outpatient department. Hematological and biochemical data before and after the use of levetiracetam were also collected.Fifteen patients who received intravenous or oral levetiracetam monotherapy for seizure control after liver transplantation were enrolled into this study. All of the patients remained seizure-free during levetiracetam treatment. Two patients died during the follow-up, and the other 13 patients were alive at the end of the study period and all were seizure-free without neurological sequelae that interfered with their daily activities. No patients experienced liver failure or rejection of the donor liver due to ineffective immunosuppressant medications. The dosage of immunosuppressants did not change before and after levetiracetam treatment, and there were no changes in hematological and biochemical data before and after treatment.Levetiracetam may be a suitable antiepileptic drug for patients who undergo liver transplantation due to fewer drug interactions and a favorable safety profile.     

Inpatient Treatment of Employed Alcoholics: A Randomized Clinical Trial on Hazelden-Type and Traditional Treatment

The first randomized clinical trial on the Hazelden-type of treatment showed that this AA-oriented treatment for alcoholism can result in significant improvement in drinking behavior as compared to a more traditional form of treatment. One hundred forty-one employed alcoholics were randomized to either Hazelden-type treatment (N = 74) or to traditional-type treatment (N = 67). The treatment groups were highly comparable. The bimonthly follow-up lasted one year. According to the COPES-questionnaire (short form), the treatment at the Hazelden-type institute was significantly more involving, supportive, encouraging to spontaneity and oriented to personal problems than at the traditional-type institute. In accordance the treatment drop-out rate was 7.9% at Hazelden-type institute and 25.9% at traditional-type institute (p less than 0.02). The participation in outpatient treatment was significantly better after the Hazelden-type treatment. The proportion of those abstinent (admitted ethanol consumption, 0 g/day; gammaglutamyl transferase, and mean cell volume were normal) was higher at Hazelden-type institute during the last (8-12 months) follow-up period (26.3% vs. 9.8%, p = 0.05). Fourteen percent of the Hazeldon-type institute patients and 1.9% of the traditional-type institute patients stayed abstinent during the whole 1-year follow-up period (p less than 0.05). The differences for the corresponding rates for controlled drinking (admitted ethanol consumption less than 40 g/day, GGT, and MCV normal) were in the same direction but did not reach statistical significance. Thus the Hazelden-type treatment obtained better results in 1-year abstinence rate than a more traditional-type treatment.