Chapter 7-Fractionated blood products and associated pathogen safety Flashcards
How are recombinant plasma protein products made?
Made by culturing mammalian cells transfected with nucleic acid vectors carrying the gene of interest.
The plasma protein is secreted into the culture medium, which is then harvested, purified, and formulated for therapeutic use.
What has the evolution of manufacturing processes achieved in terms of viral contamination risk?
Incremental reduction in viral contamination by eliminating plasma and albumin from production and formulation steps.
What is a first-generation recombinant product?
Products that incorporate small amounts of residual human plasma proteins, usually albumin, used during cell culture and final formulation steps.
What is a second-generation recombinant product?
Products that eliminate plasma proteins from the final formulation steps but may still use plasma during cell culture.
What is a third-generation recombinant product?
Products like Advate (rFVIII) or Niastase RT® (rFVIIa), which are made without human or animal proteins in either cell culture or final product formulation.
How do longer-acting recombinant products achieve extended half-life?
By conjugating clotting factors to polyethylene glycol (PEG) or fusing clotting factors to albumin or immunoglobulin G (IgG) constant region (Fc).
What processes ensure the safety and potency of recombinant products and incorporated into the manufacturing process.?
Specific viral inactivation/partitioning procedure
*Virus inactivation/reduction procedures like
1-solvent detergent treatment,
2-nanofiltration, or
3-heat/pasteurization
What methods are used during the manufacturing process to reduce pathogen transmission?
Name 2 other than solvent detergent method
Manufacturers use a combination of two or more complementary processes to reduce pathogen transmission.
1- Chromatography and nanofiltration
2- Heat treatment
3- Caprylate or solvent-detergent treatment
How is the effectiveness of pathogen inactivation processes validated?
By determining pathogen recovery from microbially-contaminated test samples after inactivation treatment.
What has been shown to effectively remove prion protein from plasma derivatives?
Various manufacturing steps have been shown to remove prion protein.
How does the fractionation process reduce contamination?
Reduces bacterial, viral, and probably prion contamination by using changes in pH, temperature, and ethanol concentration, which keep microbial contamination low and physically disassociate viruses from proteins.
What do chromatography and nanofiltration achieve in pathogen reduction?
They provide incremental pathogen reduction and enhance the purity of the product.
What types of heat treatment are used for pathogen inactivation?
Dry, steam, or wet (pasteurization), with specific temperature, pressure, and time pre-determined for each product to inactivate pathogens without compromising biological activity.
How does caprylate or solvent-detergent treatment work in pathogen reduction?
Effective against lipid-enveloped viruses (e.g., HIV, hepatitis B, and hepatitis C). Solvents and detergents disrupt the lipid membrane of viruses, which are then removed later in the process.
How are plasma-derived protein products made?
Made by pooling plasma from large numbers of donors (typically >10,000) and fractionating the different plasma constituents.
What was the original fractionation process used for plasma-derived protein products?
The Cohn fractionation process, introduced in the 1940s,** which** uses variations in protein concentration, ethanol concentration, ionic strength, temperature, and pH to precipitate plasma fractions.**
What modern technologies are used in the fractionation process today?
Chromatography
Monoclonal affinity columns
Nanofiltration
What are the transfusion-transmissible disease prevention steps in plasma-derived protein production?
Screening donors using sensitive serologic and nucleic acid tests for infectious agents (e.g., HIV, hepatitis B, hepatitis C).
Multiple safety steps are incorporated before, during, and after the fractionation process.
What is the estimated risk of known blood-borne infectious agents in plasma-derived products?
The risk ranges from less than one in a million to less than one in 10 million.
How safe are plasma-derived protein products in terms of infection risk in Canada?
Since the introduction of modern manufacturing practices in the 1980s and 1990s, there has been no transmission of HIV, hepatitis B, or hepatitis C via plasma protein products in Canada.
What is included in donor health screening for plasma donation?
Health assessment at the time of each donation.
Exclusion of donors with specified risk factors for blood-borne infections, including potential exposure to prion diseases (e.g., Creutzfeldt-Jacob Disease (CJD) or variant-CJD).
How are donated plasma units tested for pathogens?
Laboratory testing includes **nucleic acid **and serologic tests for HIV, hepatitis B, and hepatitis C.
Donated units that test positive are discarded
What safeguards are in place for apheresis plasma donors?
- Defined weight-dependent maximum donation volume and cumulative annual donation volume.
- **Serum protein measurement **with each donation
- protein electrophoresis every 4 months.
- Annual physical examination.
Where does most of the plasma for fractionated plasma products in Canada come from?
From foreign donors, primarily paid plasma donors from the United States.
Do plasma protein products distributed in Canada meet safety standards?
Yes, they meet :
Health Canada,
2-Council of Europe (CE), and/or United States Food and Drug Administration (FDA) licensing requirements.
Plasma protein products from paid and unpaid donors are equally safe due to strict safety protocols.
How can clinicians access unlicensed plasma protein products in Canada?
Through Health Canada’s Special Access Program, on a case-by-case basis.
What additional testing is performed by plasma fractionators during the in-process stage?
Tests for non-lipid enveloped viruses like **parvovirus B19 and hepatitis A virus (HAV), **which are more resistant to inactivation during fractionation.
How does nucleic acid testing help in identifying problematic plasma units?
It identifies plasma units with high titers of parvovirus B19 or units that test positive for HAV, which are then removed from the manufacturing process.
What testing is done at the end of the manufacturing process for plasma-derived products?
Products are tested to ensure they are sterile and pyrogen-free.
Can the potential risk of disease transmission be completely eliminated in plasma-derived products?
No, the risk cannot be completely eliminated, but Good Manufacturing Practices and validated processes ensure very high standards of purity, potency, efficacy, and safety.
What are different type of factor VIII bases on source and shelf life
1- Factor VIII recombinant (rFVIII), human –standard half-life
2- Factor VIII, plasma-derived (pd FVIII) – standard half-life
3- Factor VIII recombinant – extended half-life
4- Factor VIII/VWF plasma-derived concentrate (pd FVIII/VWF) (licensed for von Willebrand disease and hemophilia A)
5-Porcine recombinant FVIII (rpFVIII)
when to use chromomogenic essay in PT receiving Factor VIII?
Factor VIII recombinant – extended half-life for all except Elocate (Standard aPTT).
How many type of VWF available?
1- Factor VIII/VWF plasma-derived concentrate (pd FVIII/VWF)
2- Von Willebrand factor concentrate, recombinant (rVWF)
Dose calculation for factor concentrate (other than fibrinogen)?
what is the maintenance dose?
Dose calculation for fibrinogen concentrate(other than fibrinogen)?
IVR: Invitro recovery
Assays (for selected products)
1- Factor VIII recombinant (rFVIII), human –standard HL: Standard aPTT based clotting assay
2- Factor VIII, plasma-derived (pd FVIII) – standard HL: Standard aPTT based clotting assay
3- Factor VIII recombinant – extended HL: chromogenic or one-stage (no reagent preference)
4- Factor VIII/VWF plasma-derived concentrate (pd FVIII/VWF):VWF activity/ antigen; FVIII by standard aPTT based clotting assay
5-Porcine recombinant FVIII (rpFVIII): Standard aPTT based clotting assay
how many types of Factor IX are available
1-Factor IX recombinant (rFIX) – standard half-life
2- Factor IX high purity plasma derived (pd) – standard half-life
3- Factor IX recombinant – extended half-life
How to assess clotting in pt receiving factor IX?
1-Factor IX recombinant (rFIX) – standard half-life: Standard aPTT
2- Factor IX high purity plasma derived (pd) – standard half-life: Standard aPTT
3- Factor IX recombinant – extended half-life: chromogenic or one-stage other tham Alprolix (Standard aPTT)
Which coagulation concentrate do contain hepain?
(7,9,11)
Factor VII concentrate
Factor X- P Behring(hep)
Factor XI
PCC (Beriplex, Octaplex)
Antithrombin III NF®
the above should be avoided in patients with history of HIT
Factor VII concentrate [Takeda], FX®P [CSL-Behring], FXI Factor XI concentrate [BPL], FIX Immunine® VH [Takeda], PCC Beriplex® P/N [CSL Behring], PCC Octaplex® [Octapharma], Antithrombin III NF
How many type of factor XIII concentate do we have in Canada?
what is the preferred assay to evaluate the pt. ?
1- Tretten:Factor XIII Recombinant (rFXIII): Only has factor 13-A subunit. Clot solubility assay for severe deficiency screening. Specialized assays (e.g. Chromogenic) for FXIII activity level
- Contains FXIII-A subunit only, not recommended for FXIII-B subunit deficiency
**2-Corifact: Factor XIII (pd) (pd FXIII): Contains both FXIII-A and FXIII-B subunits.
Clot solubility assay for severe deficiency screening.
Specialized assays (e.g., Chromogenic) for FXIII activity level.
Prothrombin Complex Concentrate (pd) (pd PCC)
Octaplex® (hep) CBS
Beriplex® P/N(hep
What are the indications and risks associated with Prothrombin Complex Concentrate (PCC) and Activated Prothrombin Complex Concentrate (aPCC)?
- Administer as directed on package insert to prevent thrombotic complications.
- Not indicated for liver disease, DIC, or patients with active thrombotic risks.
- Heparin-induced thrombocytopenia (HIT) **contraindicates **use due to heparin presence.
- Risk of myocardial infarction and intracardiac thrombus.
*
FEIBA NF
Activated Prothrombin Complex Concentrate (pd) (pd aPCC)
What is the maximum dosage for FEIBA?
The dosage for FEIBA should not exceed 200 IU/kg/day.
No heparin added; FII, FVII, FIX and FX in relatively balanced ratio; 89–98% FVII activity attributed to FVIIa activityFEI
Which clotting factor products should be used with caution and under specialist guidance in patients with thrombosis or DIC risk factors?
FEIBA (Factor VIII inhibitor bypass activity)
Factor XI (FXI) concentrate
Recombinant Factor VIIa (rFVIIa)
Fibrinogen (pd)
1- RiaSTAP
2- Fibryga
Test: Standard clot-based assay
Ceprotin
Protein C (pd)
Human albumin added
Specialized assays for protein C activity/antigen levels
Emicizumab (Hemlibra®)
Bispecific monoclonal antibody to FIX/FIXa and FX/FXa is a non-clotting factor product manufactured by recombinant technology.
produced in Chinese hamster ovary (CHO) cells (allergy precaution: trace hamster proteins)
human-animal protein present in cell culturing but removed during manufacturing process (allergy precaution: trace bovine proteins)
Emicizumab: Two approved indications?
Two approved indications: Congenital hemophilia A with inhibitors to factor VIII
Severe congenital hemophilia A (intrinsic factor VIII level < 1%) without inhibitors: For prophylaxis in hemophilia A patients with or without inhibitors (NOT for acute bleed treatment)
Assay for a pt on Emicizumab?
Use chromogenic FVIII assay with bovine reagents for assessment of FVIII activity and FVIII inhibitor titer
* For subcutaneous injections
Hemlibra® interferes with aPTT clot-based assays (artificially shortens aPTT and increases FVIII activity)
Hemlibra® interferes with aPTT-based clotting assays, artificially shortening aPTT and increasing FVIII activity. Chromogenic assay using bovine reagents should be used for FVIII and FVIII inhibitor assessment. It does not affect PT-based clotting factor assays or thrombin time.
Does Hemlibra affect PT test?
Hemlibra® does not affect PT-based clotting factor assays or thrombin time.
Th mode of infusion for emicizumab:
Hemlibra® (emicizumab) is administered subcutaneously for bleeding prophylaxis in hemophilia A patients with or without inhibitors:
Loading dose: 3 mg/kg weekly x 4 weeks
Maintenance dose:
1.5 mg/kg weekly, or
3 mg/kg biweekly, or
6 mg/kg every 4 weeks
Note: the maintenance dose of 6 mg/kg once every 4 weeks is not recommended for patients <40 kg body weight or patients <12 years of age.
administered subcutaneously
(Mean trough (µg/mL) at week 5 following loading dose at 3 mg/kg weekly x 4 weeks)
- What precautions should patients on Hemlibra® (emicizumab) prophylaxis take regarding PCC and aPCC?
- Avoid using PCC or aPCC due to the risk of thromboembolism and thrombotic microangiopathy (TMA).
Avoid using PCC or aPCC due to the risk of thromboembolism and thrombotic microangiopathy (TMA).
If aPCC is necessary, limit the dose to 50 IU/kg/dose or 100 IU/kg/day with TMA monitoring.
Do not use PCC or aPCC for 6 months after Hemlibra discontinuation.
What is The chromatographic process used to during fractionation and purification of the clotting factors
Reduces the viral load.
What should patients with congenital coagulation deficiency receiving blood products be immunized against?
Hepatitis B virus (HBV)
Hepatitis A virus (HAV)
What is the risk of Creutzfeldt-Jakob disease (CJD) transmission from plasma-derived concentrates?
Considered a theoretical risk
Are all viruses inactivated by these procedures?
No, non-enveloped viruses such as parvovirus B19 can be resistant to viral inactivation.
When were virus-inactivated factor concentrates introduced in Canada, and what is the transmission history for HIV and HCV?
Introduced in 1985
No cases of HIV or HCV transmission from concentrates since 1987 and 1988, respectively.
Which human pathogens are virus inactivation procedures effective against in blood products?
Human immunodeficiency virus (HIV)
Hepatitis C virus (HCV)
Hepatitis B virus (HBV)
What therapy should be avoided when using PCC and aPCC (including FEIBA)?
Antifibrinolytic therapy should be avoided.
What has been reported in patients with von Willebrand Disease (VWD) treated to raise FVIII levels for surgery?
Thrombosis has been reported when FVIII levels exceed 200 IU/dL.
What is the maximum dosage for FXI concentrate?
Should not exceed 30 IU/kg per dose.
What precautions should patients on Hemlibra® (emicizumab) prophylaxis take regarding PCC and aPCC?
Avoid using PCC or aPCC due to the risk of thromboembolism and thrombotic microangiopathy (TMA).
If aPCC is necessary, limit the dose to 50 IU/kg/dose or 100 IU/kg/day with TMA monitoring.
Do not use PCC or aPCC for 6 months after Hemlibra discontinuation.
What complication can arise in patients with clotting factor deficiency and coexisting risk factors?
Development of thrombotic complications when the hemostatic mechanism is corrected.
Human/animal proteins that may be present during the manufacturing process (cell culturing or purification) or in formulation in recombinant factor concentrates
1-Solid phase mouse monoclonal antibody – for purification step
2- Concentrate of porcine protein
3–Human serum albumin in formulation No longr)
Factor concentrate: rFVIII (standard half-life)
Indications:
Monitoring:
Contraindications/Precautions:
Available Alternatives:
Indications: Hemophilia A
**Monitoring: **FVIII level
Contraindications/Precautions:
Not for VWD (contains no VWF)
Available Alternatives:
pd FVIII (standard half-life)
rFVIII (extended half-life)
Desmopressin (for responsive mild patients)
pdFVIII/VWF concentrate
Hemlibra® (for prophylaxis only)
Factor concentrate: rFVIII (extended half-life):
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications: Hemophilia A
Monitoring: FVIII level (Special assay conditions for PEGylated products: Adynovate® and Jivi®)
Contraindications/Precautions:
* Not for VWD (contains no VWF)
* Available Alternatives:
* rFVIII (standard half-life)
* pdFVIII (standard half-life)
* Desmopressin (for responsive mild patients)
* Hemlibra® (for prophylaxis only)
Factor concentrate: pd FVIII/VWF:
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **VWD, Hemophilia A
Monitoring: VWF, VWF, FVIII levels
Contraindications/Precautions:
Keep FVIII <200 IU/dL to avoid thrombosis
Available Alternatives:
rVWF (for VWD only)
Desmopressin (for responsive types of VWD)
Humate-P® ——————-Wilate
Factor concentrate: rVWF
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications: VWD
**Monitoring: **VWF, VWF, FVIII levels
Contraindications/Precautions:
Not for hemophilia A
Available Alternatives:
pd FVIII/VWF concentrate
Desmopressin (for responsive VWD patients)
Vonvendi
Factor concentrate: rPorcine FVIII
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: ** Acquired hemophilia A (with autoimmune FVIII inhibitors)
Monitoring: FVIII level
Contraindications/Precautions:
Licensed only for acquired autoantibodies/inhibitors against FVIII
Available Alternatives:
* FEIBA
* rFVIIa
Factor concentrate: rFIX (standard half-life)
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **Hemophilia B
Monitoring: FIX level
Contraindications/Precautions:
Allergic reactions possible at inhibitor development
Available Alternatives:
pd FIX (standard half-life)
rFIX (extended half-life)
Factor concentrate: rFIX (extended half-life)
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications: Hemophilia B
Monitoring: FIX level
Contraindications/Precautions:
Special assay conditions for PEGylated rFIX products (Rebinyn®)
Available Alternatives:
rFIX (standard half-life)
pd FIX (standard half-life)
Factor concentrate: pd PCC (non-activated):
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
- Indications:
- Rapid reversal of warfarin overdose
- Vitamin K deficiency
- FX deficiency, FII deficiency
Monitoring: INR, FX level, FII level
Contraindications/Precautions:
* Thrombotic risk, particularly with liver disease, DIC, or arterial/venous thrombosis
* IgA deficient donors with anti-IgA (Octaplex®)
* Heparin-induced thrombocytopenia (HIT)
Available Alternatives:
* Plasma
* Vitamin K
* Andexanet alfa (AndexXa®)
contains FII, FVII, FIX, FX+Pr C and Pr S
Factor concentrate: pd aPCC
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications:
* FVIII inhibitor (congenital or acquired)
* FIX inhibitor
* Anti-IIa DOAC (dabigatran) reversal
Monitoring:
Clinical
Contraindications/Precautions:
* May cause anamnesis with FVIII inhibitor
* Avoid with FIX, allergic reactions
* Limit dosage to 200 IU/kg/d due to thrombotic risk
Available Alternatives:
* rFVIIa, rPorcine FVIII
* Hemlibra® (prophylaxis only)
* Idarucizumab (Praxbind®)
Factor concentrate: pd Fibrinogen
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **
Congenital fibrinogen deficiency
Acquired fibrinogen deficiency
Monitoring:
Fibrinogen level
Contraindications/Precautions:
Risk of thrombosis and myocardial infarction
Available Alternatives:
Cryoprecipitate (~200 mg/bag)
** Factor concentrate: pd FVII**
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: ** FVII deficiency
Monitoring: FVII level
Contraindications/Precautions:
Patients with heparin-induced thrombocytopenia
Available Alternatives:
rFVIIa
Factor concentrate: rFVIIa
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **
FVIII inhibitor, FIX inhibitor
FVII deficiency
Glanzmann’s thrombasthenia (GT)
Monitoring:
FVII level, Clinical
Contraindications/Precautions:
Thrombosis precaution
Available Alternatives:
FEIBA, rPorcine FVIII
Platelets (for GT patients)
High-dose platelets for GT with platelet antibodies
Factor concentrate: pd FX/FIX
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications:
* FX deficiency
* FIX deficiency
Monitoring:
FX level, FIX level
Contraindications/Precautions:
Patients with heparin-induced thrombocytopenia
Available Alternatives:
pdPCC, Plasma
Standard half-life FIX (rFIX, pdFIX), Extended half-life rFIX
Factor concentrate: pd FXI
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **FXI deficiency
Monitoring:
FXI level
Contraindications/Precautions:
Limit dosage to ≤30 IU/kg to avoid thrombosis
Available Alternatives:
Plasma
Factor concentrate: rFXIII
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications:** FXIII A-subunit deficiency**
Monitoring: FXIII level
Contraindications/Precautions:
Not recommended for FXIII B-subunit deficiency
Caution in cases of fresh thrombosis
Available Alternatives:
pd FXIII, Plasma, Cryoprecipitate
Factor concentrate: pd FXIII
Indications:
Monitoring:
Contraindications/Precautions:
Available Alternatives:
**Indications: **FXIII (A- or B-subunit) deficiency
Monitoring: FXIII level
Contraindications/Precautions:
Caution with fresh thrombosis due to fibrin-stabilizing effect
Available Alternatives:
rFXIII (if FXIII A-subunit deficiency)
Plasma
Cryoprecipitate (50–75 IU FXIII per bag)
Factor concentrate: pd antithrombin (AT)
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
**Indications: **
AT deficiency in high thrombotic risk situations (e.g., surgery, see the next question,..)
Monitoring:
AT level
Contraindications/Precautions:
Patients with known history of heparin-induced thrombocytopenia
Available Alternatives:
Plasma
Some additional info on AT concentarte
Factor concentrate: Antithrombin concentrate:
* Indication
* Dosage calculation
* Maintenance
* Monitoring
Indications: Congenital antithrombin deficiency
Used with heparin for patients with heparin resistance
Prophylaxis for surgery, trauma, immobilization, thromboembolism during pregnancy and after delivery
Dosage Calculation:
Loading dose: [(Target AT level - Current AT level in IU/dL) x weight (kg) ÷ 1.4]
Maintenance dose: ~60% of loading dose every 24h to maintain peak AT level ~120 IU/dL and trough level ~80 IU/dL
Monitoring:
AT levels (target, peak, and trough levels)
No randomized clinical trials for efficacy
Factor concentrate: pd protein C
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications: Severe protein C deficiency (homozygous or double heterozygous)
Monitoring:
Protein C level
Available Alternatives:
Plasma
Some additional info on Pr C
Factor concentrate: Protein C concentrate
* Indication
* Dosage calculation
* Maintenance
* Monitoring
Indications: Congenital protein C deficiency (homozygous or compound heterozygous)
Typically presents with skin necrosis within the first two weeks of life
**Acute Treatment: **Initial dose: 100 IU/kg
Followed by 50 IU/kg every 6 hours to maintain a trough protein C level ~50 IU/dL and decrease or normalize D-dimer levels
Long-Term Prophylaxis:
Protein C replacement: 30–50 IU/kg subcutaneously or intravenously every 1-2 days
Warfarin: After full heparinization for several days to prevent skin necrosis; target INR 2.5–3.5 (or INR 1.5–2.5 with protein C replacement)
Monitoring:
D-dimer levels for evidence of coagulation activation
INR for warfarin therapy
Factor concentrate: pd C1-INH
Indications:
Monitoring:
Contraindications/Precautions:
Available Alternatives:
Indications: Hereditary Angioedema (HAE)
Monitoring: Clinical
Contraindications/Precautions:
HAEgarda® approved for prophylaxis only (not for treatment of acute attack)
Available Alternatives:
Icatibant (Firazyr®) for acute attack
Lanadelumab (TakhzyroTM) for prophylaxis
Danazol for prophylaxis
Plasma
Factor concentrate: Hemlibra®
* Indications:
* Monitoring:
* Contraindications/Precautions:
* Available Alternatives:
Indications: Prophylaxis for hemophilia A (with or without inhibitor)
Monitoring:
Clinical
Contraindications/Precautions:
Not for treatment of acute bleeds
Hemlibra interferes with aPTT-based clotting assays
Available Alternatives:
For patients without inhibitor: rFVIII, pdFVIII, EHL-rFVIII
For patients with inhibitor: rFVIIa, APCC
