Pathogeninaktivierung - Rotes Kreuz · Pharmakokinetik Toxizität Toxizität Akut Mehrfachanwendung...
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Transcript of Pathogeninaktivierung - Rotes Kreuz · Pharmakokinetik Toxizität Toxizität Akut Mehrfachanwendung...
www.roteskreuz.at
Blutsicherheit
� Spenderauswahl
� Spendertestung
� Klinische Indikation
� Produktion
� PI
� QM
� Hämovigilanz
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Blutspendewesen
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Infektionsrisken
� Diagnostisches Fenster
� Bekannte Viren ohne Testung
� Unbekannte (emerging) Viren
� Bakterien
� Protozoen
� Jeder Erreger, der während der asymptomatischen Phase der Infektion, im Blut vorkommt, kann via Transfusion übertragen werden
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Blutspendewesen
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Testung (BSZ W,N,B)
� 1950 AB0, RH, Ery-Ak, Lues
� 01. 1973 AuSH Ag
� 02. 1979 HBs Ag
� 07. 1985 HIV Ak
� 01. 1989 ALT
� 07. 1990 HCV Ak
� 04. 1995 Neopterin
� 02. 1999 NAT – HBV, HCV, HIV
� 06. 2003 NAT – Parvo B19
� 10. 2003 NAT - HAV
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Blutspendewesen
www.roteskreuz.at
Restrisiko 2009
� HCV, HIV 1 : 5.000.000
� HBV 1 : 500.000
(okkulte HBV Infektionen)
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Blutspendewesen
www.roteskreuz.at
Pathogeninaktivierung - PI
� Fensterperiode – Viren mit Test
� Unbekannte Viren
� Bakterien
� Protozoen
� Leukozyten (TA GvHD)
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Blutspendewesen
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Leukozyten
� Zell-assoziierte Viren (CMV, EBV, ...)
� Febrile Transfusionsreaktionen NHFTR
� HLA / HNA Alloimmunisierung
� Transfusions-assoziierte Immunmodulation
� TA GvHD
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Blutspendewesen
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Pathogeninaktivierung
� Wirksamkeit
� Klinik
� Pharmakokinetik
� Toxizität
Toxizität� Akut
� Mehrfachanwendung
� Subchronisch
� Reproduktiv
� Genotoxizität
� Carcinogenität
� Phototoxizität
� Venenirritation
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Blutspendewesen
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Prion-removal capacity ...(Thyer J et al, Vox Sang 2006; 91: 292-300)
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Blutspendewesen
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PI – stabile Blutprodukte
� Pasteurisierung (60°C, 10 h)
� Erhitzen (trocken, feucht)
� S/D (solvent-detergent)
� Nanofiltration
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Blutspendewesen
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PI - FFP
� Pool S/D inaktiviert „Octaplas“
� Einzelspender Quarantäne
PI durch Amotosalen
PI durch Methylenblau
PI durch Riboflavin
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Blutspendewesen
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S/D FFP versus Einzelspender-FFP
FFPFFPFFPFFP S/D FFPS/D FFPS/D FFPS/D FFP QuarantQuarantQuarantQuarantääääne FFPne FFPne FFPne FFP PI Einzelspender PI Einzelspender PI Einzelspender PI Einzelspender FFPFFPFFPFFP
Standardisierung (Volumen, Proteine, Zellgehalt, ...)
Hoch Gering Gering
Umhüllte Viren Sicher Okkulte HBV Sicher
Nicht-umh. VirenB19, HAV
NAT Nicht getestet Relativ sicher
„Emerging“ Viren Pool Einzelspender Relativ sicher
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Blutspendewesen
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PI - labile ProdukteThrombocyten
� Hauptproblem: bakterielle Infektion
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Blutspendewesen
Division of Division of Division of Division of Blood Group Blood Group Blood Group Blood Group
Blajchman MA et al, Transfus Med Rev 2005; 19: 259-272
Division of Division of Division of Division of Blood Group Blood Group Blood Group Blood Group
REDUCTION OF SEPTIC TRANSFUSION REACTIONS WITHOUT BACTERIA DETECTION
(Andreu et al, ISBT Science Series 2008; 3: 124-132 )
• Reduction of initial bacterial contamination– Hygiene, skin desinfection– Diversion of the first 35 ml– Postdonation information– Donor selection
• Reduction of bacterial growth– Practice for delivery– Universal leukodepletion– Storage of whole blood before processing (2 – 20 h)
• Improvement of knowledge and practice on bacterial contamination
– Management of possible bacterial infection– Research on bacterial contamination
Bacterial screening of apheresis platelets (ARC 2004-2006)
Division of Division of Division of Division of Blood Group Blood Group Blood Group Blood Group
Eder AE et al, Eder AE et al, Eder AE et al, Eder AE et al, Transfusion Transfusion Transfusion Transfusion 2007; 47: 11342007; 47: 11342007; 47: 11342007; 47: 1134----1142114211421142
Division of Division of Division of Division of Blood Group Blood Group Blood Group Blood Group
te Boekhorst PAW et al, Transfusion 2005; 45: 514-519
Screening platelet concentrates for bacterial contamination: low numbers of bacteria and slow growth in contaminated units mandate
an alternative approach to product safety
Murphy WG et al, Vox Sanguinis 2008; 95: 13-19
Conclusions:Screening platelet concentrates for bacterial contamination using the most sensitive method available has a sensitivity of less than 40% because of the low numbers of bacteria in the initial contamination. Effective resolution of this problem will require a pathogen-inactivation technique.
Division of Division of Division of Division of Blood Group Blood Group Blood Group Blood Group
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PI – labile Blutprodukte:Thrombocyten
� Verhinderung der DNA Replikation: Photosensitizer + Licht
� Verhinderung der DNA Replikation:
UVC (254nm) Behandlung
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Blutspendewesen
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
Nucleic Acids Must “UnZip”During Pathogen Replication
Strand SeparationDNA / RNA Replication ofNucleic Acids and Pathogen
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
DNA or RNAof pathogen
Amotosalen Mechanism of Action
Amotosalen
Docking Permanent Crosslinking
UVA Illumination
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for
Pooling Container
Leukodepletion Filter
Whole BloodSeparation
INTERCEPT Blood System for Platelets Buffy Coat Preparation
Pooling and Addition of InterSol Solution
Centrifugationto Pellet Red
Blood Cell
Separationof Platelets
Buffy Coat Platelets
InterSol Solution
1 2 3 4
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
INTERCEPT Blood SystemAmicus Platelet Preparation
Amicus enables theAmicus enables theautomatic collection ofautomatic collection ofone or more therapeutic dose(s)one or more therapeutic dose(s)of SDP in 35% plasmaof SDP in 35% plasmaand 65% InterSol Solution.and 65% InterSol Solution.
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
WithinWithinone day
of collectionof collection
INTERCEPT Blood System for Platelets Process Timeline
11 22 33
IlluminateIlluminateStart ProcessingStart Processing Removal & StorageRemoval & Storage
3 J/cm3 J/cm 22
forfor~3-6 minutes
Incubate plateletsIncubate plateletson the CAD for a minimum of on the CAD for a minimum of
4 hours: SDP6 hours: buffy coat platelets
1. UV light only: reversible inactivation
� UV light alone breaks chemical bonds in the
nucleic acids of pathogens
2. UV light + riboflavin: irreversible inactivation
� Riboflavin molecules form complexes with nucleic acids
� UV light from the Mirasol Illuminator activates the
riboflavin molecule in the complex
� Photoactivated riboflavin induces a chemical alteration to
the functional groups (such as guanine bases) of nucleic
acids making pathogens unable to replicate
The Mirasol PRT System inactivates disease-causing agents by
altering their nucleic acids in two primary ways:1
Mirasol PRT System Primary Modes of Action
1 Kumar et al 2004
Reduction of activepathogen load
Typicalperformance
References
VirusesVirusesVirusesViruses(enveloped, non(enveloped, non(enveloped, non(enveloped, non----enveloped; enveloped; enveloped; enveloped; intracellular, extracellular)intracellular, extracellular)intracellular, extracellular)intracellular, extracellular)
~2–6 log(99.0–99.9999%)
Ruane, et al., 2004; Goodrich, et al., 2006a,b;CaridianBCT data on file.
BacteriaBacteriaBacteriaBacteria(Gram +, Gram (Gram +, Gram (Gram +, Gram (Gram +, Gram ----))))
~2–5 log(99.0–99.999%)
Ruane, et al., 2004; Goodrich, et al., 2006b; CaridianBCT data on file.
ParasitesParasitesParasitesParasites ≥ 3.0 to ≥ 5.0(≥ 99.9% to ≥ 99.999%)
Cardo, et al., 2006; Cardo, et al., 2007; Rentas, et al., 2007; Tonnetti, et al., 2007;
Sullivan, et al., 2008.
Mirasol PRT System Performance
Inactivation of whiteblood cells
Typicalperformance
References
White blood cell inactivationWhite blood cell inactivationWhite blood cell inactivationWhite blood cell inactivation ≥ 6.0(>99.9999%)
Fast, et al., 2006a. (in-vitro)
Cytokine production and Cytokine production and Cytokine production and Cytokine production and expressionexpressionexpressionexpression
prevented Fast, et al., 2006a. (in-vitro)
GraftGraftGraftGraft----versusversusversusversus----Host DiseaseHost DiseaseHost DiseaseHost Disease prevented Fast, et al., 2006b. (animal model)
Alloimmunization & Alloimmunization & Alloimmunization & Alloimmunization & transplant rejectiontransplant rejectiontransplant rejectiontransplant rejection
prevented Asano, et al., 2007. (animal study)
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UVC Behandlung (Mohr H et al, Transfusion 2009; 49: 1956-1963)
� Beutel 19 x 38 cm
� Thrombocyten: in 350 ml (109 / ml)
� Bestrahlung mit UVC (254 nm)
� Agitation (100 rpm, horizontal)
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Blutspendewesen
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PI bei Thrombocyten
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Blutspendewesen
Stramer et al, Transfusion 2009; 49: August Suppl 1S – 29S
www.roteskreuz.at
Amotosalen: Apherese- und BC-Thrombocyten
� CCI nach 1 und nach 24h geringer als bei nicht behandelten Thrombocyten
� Hämostaseologische Funktion nicht verändert
� Keine unerwünschte Nebenwirkungen
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Blutspendewesen
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
Red Cell Processing
SS--303303
Collected RedCollected RedCells withCells with
Additive SolutionAdditive Solution
MixingMixingContainerContainer
ReactionReactionContainerContainer
FinalFinalStorageStorage
ContainerContainer
CADCAD
Copyright 2001 – Cerus Corporation
Blood Donation Center for Vienna, Lower Austria and Burgenland,
Austrian Red CrossDepartment for Blood Group
Collected red blood Collected red blood cells with additive cells with additive
solution;solution;LeukodepletedLeukodepleted
INTERCEPT Blood System for Red Blood Cells
Proposed Process Timeline
11 22 33
TreatmentTreatmentStart ProcessingStart Processing Removal andRemoval andStorageStorage
IncubateIncubatered blood cells red blood cells
and Sand S --303303at 19at 19--2525°°C forC for
12 hours
RemoveRemoveresidualresidual
compoundcompoundat 19at 19--2525°°C forC for
8 hours
SS--303303
CADCAD
ReconstituteReconstituteSS--303 and mix303 and mix
with red blood cellswith red blood cells
------- Development of an automated process is on-go ing -------
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PI of RBC (S-303, Inactine, ...)
Treated red cells demonstrated acceptable recovery and comparablTreated red cells demonstrated acceptable recovery and comparablTreated red cells demonstrated acceptable recovery and comparablTreated red cells demonstrated acceptable recovery and comparable e e e lifelifelifelife----span to conventional red cellsspan to conventional red cellsspan to conventional red cellsspan to conventional red cells
Repeated transfusions of autologous treated red cells did not prRepeated transfusions of autologous treated red cells did not prRepeated transfusions of autologous treated red cells did not prRepeated transfusions of autologous treated red cells did not provoke ovoke ovoke ovoke autoautoautoauto----antibody formationantibody formationantibody formationantibody formation
PostPostPostPost----transfusion recovery after repeated transfusions of autologous transfusion recovery after repeated transfusions of autologous transfusion recovery after repeated transfusions of autologous transfusion recovery after repeated transfusions of autologous treated red cells was comparable to that of untreated red cells treated red cells was comparable to that of untreated red cells treated red cells was comparable to that of untreated red cells treated red cells was comparable to that of untreated red cells and to and to and to and to that of single exposures of treated red cellsthat of single exposures of treated red cellsthat of single exposures of treated red cellsthat of single exposures of treated red cells
Full unit transfusions of treated red cells were well toleratedFull unit transfusions of treated red cells were well toleratedFull unit transfusions of treated red cells were well toleratedFull unit transfusions of treated red cells were well tolerated
? Production of antibodies against treated RBC? Production of antibodies against treated RBC? Production of antibodies against treated RBC? Production of antibodies against treated RBC
41
Blutspendewesen