Treatment of refractoriness to platelet transfusion by protein A column therapy

Protein a Carrying Monosize PMMA Microbeads for the Removal of HlgG from Human Plasma

Protein A-incorporated polymethylmethacrylate (PMMA) microbeads were investigated for specific removal of HlgG from human plasma. The microbeads were prepared by a phase inversion polymerization, and activated by periodate oxidation. Protein A was then incorporated by covalent binding onto these microbeads through hydroxyl groups coming from the stabilizer. The amount of incorporated protein A was controlled by the initial concentrations of protein A in the immobilization medium and pH. The maximum protein A immobilization of 0.615 mg protein A/g PMMA, was observed at a pH of 9.5 corresponding to an initial protein A concentration of 0.1 mg/ml. There was no HlgG adsorption onto the plain PMMA microbeads, while high HlgG adsorptions of up to 32 mg HlgG/g PMMA were achieved with human plasma.

SIMULATION OF SOLID–LIQUID SUSPENSION AND SCALE-UP OF AGAROSE GEL ACTIVATION REACTOR

Agarose gel activation reaction, which is of great importance in preparing the carrier of the column packing material for blood purification, would be significantly influenced by the configuration and parameter of reactor. In order to optimize the structure design of the reactor and operating parameters of the process, the characteristics of suspension system composed of agarose gel, NaOH, water, 3-allyl bromide, and activated alumina were simulated numerically utilizing an Eulerian multiphase flow model and multi-reference frame (MRF) approach. The effect of impeller configuration was studied with three typical impellers, including Rushton disk turbine (DT), pitched blade downflow turbine (PBTD45), and pitched blade upflow turbine (PBTU45). The results showed that the optimum solid suspension was obtained using PBTD45 impeller with a diameter of 100[Formula: see text]mm and critical suspension speed of 570[Formula: see text]rpm in a 20[Formula: see text]L stirred reactor. In addition, the critical suspension speeds using the three impellers were calculated and the errors were all within the engineering allowance. Finally, the feasibility of scale-up design for agarose gel activation reactor was preliminarily discussed. The results would be useful to the optimization and scale-up of relevant reactor design.

Protein A Immobilized Poly(Methylmethacrylate-Co-Hydroxyethylmethacrylate) Microbeads for IgG Adsorption

Poly(methylmethacrylate- co-2-hydroxyethylmethacrylate) microbeads in the size range of 1.5-2.0μm were prepared by a phase inversion polymerization. The hydroxyl groups were activated by periodate oxidation, and the active ligand, i.e., protein A was immobilized via a spacer-arm, i.e., hexamethylene diamine (HDMA) by using a cross-linker, i.e., glutaraldehyde and protein A. The optimal concentration obtained for modifications are as follows: sodium periodate concentration: 0.467 × 10−2mmol/mL; HMDA concentration: 3.5 × 10−2mmol/mL; and glutaraldehyde concentration: 0.7 × 10−6mmol/mL. Yields of immobilization of protein A onto the plain and periodate oxidized microbeads were found very close, and were in the range of 0.01-0.02 mg protein A/g microbeads. The optimal conditions for immobilization are as follows: the initial protein A concentration: 0.1 mg/mL; temperature: 25°C; pH: 9.5; and immobilization time:120 min. Incorporation of protein A at these conditions resulted in 0.825 mg protein A/g microbeads. The HIgG adsorption onto these protein A incorporated microbeads was 41 mg HIgG/g microbeads.

Rituximab, plasma exchange and intravenous immunoglobulins as a new treatment strategy for severe HLA alloimmune platelet refractoriness

Platelet refractoriness (PR) due to HLA alloimmunization is a common and serious complication of patients receiving long-term packed red blood cell and platelet transfusions. Although most alloimmunized patients will respond to HLA-matched platelets, 20-50% of patients will remain refractory even to matched platelets. Several measures have been reported to overcome this complication, such as intravenous immunoglobulins (IVIG), plasma exchange (PE), protein A column therapy, or rituximab. We report a woman with acute myeloid leukemia secondary to myelodysplastic syndrome who was diagnosed with PR because of HLA alloimmunization. Due to difficulties in finding HLA-compatible platelet donors by cross-reactive groups in our panel of HLA-typed platelet donors, the patient received treatment with rituximab, PEs and IVIG. With this treatment strategy, the presence of HLA antibodies decreased from a panel-reactive antibody (PRA) of 89-0%. This allowed the performance of hematopoietic progenitor cell transplantation with random donor platelets. Rituximab, PE, and IVIG may be an option to overcome severe PR due to poly-specific HLA alloimmunization.

Platelet transfusions

Ever since platelet transfusions were shown to reduce mortality from haemorrhage in patients with acute leukaemia in the 1950s, the use of this therapy has steadily grown to become an essential part of the treatment of cancer, haematological malignancies, marrow failure, and haematopoietic stem cell transplantation. Today, more than 1.5 million platelet products are transfused in the USA each year, 2.9 million products in Europe. However, platelet transfusion can transmit infections and trigger serious immune reactions and they can be rendered ineffective by alloimmunisation. There are several types of platelet components and all can be modified to reduce the chances of many of the complications of platelet transfusion. Transfusion practices, including indications for transfusion, dose of platelets transfused, and methods of treating alloimmunised recipients vary between countries, and even within countries. We review commonly used platelet components, product modifications, transfusion practices, and adverse consequences of platelet transfusions.

Correcting immune imbalance: the use of Prosorba column treatment for immune disorders

The treatment of selected refractory autoimmune diseases has been complemented by the use of Protein A (Prosorba column) immunoadsorption. US Food and Drug Administration-approved clinical applications include idiopathic thrombocytopenia purpura (ITP) and rheumatoid arthritis (RA). Other common off label uses include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Less common experimental uses in diseases in which efficacy has been reported include autoimmune CNS syndromes, peripheral neuropathies, autoimmune pancytopenia, hemolytic anemia and solid organ transplant rejection. Prosorba column treatment is generally well tolerated but a small proportion of treated patients experience chills, fever, tremor, hypotension and rash. The mechanism of action suggested for the efficacy of the column is the restoration of normal immune balance and normal tolerance. Observations in ITP has suggested that column treatment stimulates a rise in anti-idiotype antibody directed against antiplatelet antibodies, effecting a decrease in pathogenic antiplatelet antibodies and immune complexes.

Plasmapheresis in immune hematology: review of clinical outcome data with respect to evidence-based medicine and clinical experience

The objective of this paper is to assess the role of plasmapheresis in immune hematology by reviewing published clinical outcome data and narrative review articles. This information will be used to define evidence levels for appraisal of the efficacy and rank of plasmapheresis among other management options. This evidence-based strategy conforms to the concepts of the American Society of Hematology (ASH). as put forward in 1996 in the context of immune thrombocytopenia (ITP) treatment. The term 'experimental' is used to describe indications where the only scientific evidence of the efficacy of plasmapheresis consists of pathophysiological reasoning and empiric clinical findings. We reviewed the available literature on the use of plasmapheresis in autoimmune hemolytic anemia (AIHA), hemolytic disease of the newborn (HDN), autoimmune thrombocytopenic purpura (AITP), heparin-induced thrombocytopenia type II (HIT II), post-transfusion purpura (PTP), refractoriness to platelet transfusion (RPT), coagulation factor inhibitor (CFI) and catastrophic antiphospholipid syndrome (CAS). Plasmapheresis completes the spectrum of management options as it eliminates physically circulating free antibodies involved in the pathogenesis of these immune hematological syndromes. Because of the paucity of data, evidence levels had to be defined based on the findings of uncontrolled case series and the opinions of independent experts. In many cases, randomized clinical trials were not feasible because the syndromes are so rare. When defined as an 'experimental indication', plasmapheresis has a firm scientific basis, but larger scale clinical experience with the method is still lacking. In these cases, the detection and monitoring of symptomatic disease-related circulating free antibodies or immune complexes is a mandatory prerequisite for the use of plasmapheresis. The therapeutic benefit of plasmapheresis is substantiated by the level V of evidence of its efficacy in treatment of HDN, HIV-associated AITP, induction of tolerance in CFI and in CAS. The goal of future studies should be to establish a firmer base of scientific evidence for indications classified as experimental by setting up case series large enough for proper assessment of plasmapheresis alone or combination with other treatment measures. This goal can only be achieved through multiinstitutional cooperation.

Background and indications for protein A-based extracorporeal immunoadsorption

Protein A (SPA), a major cell wall component of Staphylococcus aureus, has occupied numerous investigators from its discovery in the late fifties. Its availability and avid binding to human immunoglobulins have led to extensive usage for diagnostic and research purposes. Today, SPA-based extracorporeal immunoadsorption relies on two rather different systems, namely, SPA-silica (Prosorba), and SPA-Sepharose (Immunosorba). Both systems are approved by the Food and Drug Administration for the core indications of rheumatoid arthritis and idiopathic thrombocytopenic purpura (SPA-silica) or hemophilia with inhibitors (SPA-Sepharose). Off label indications include immune disorders with a conceivable connection between autoantibody titers and disease activity, like forms of glomerulonephritis, systemic lupus erythematodes, myasthenia, and the Guillain-Barré syndrome as well as alloantibody formation in the context of e.g., transplantation. This review summarizes historical developments and important properties of SPA. Indications for extracorporeal therapy are discussed on the basis of available information and personal experience.

Protein A-immobilized microporous polyhydroxyethylmethacrylate affinity membranes for selective sorption of human-immunoglobulin-G from human plasma

Microporous membranes made of poly(2-hydroxyethylmethacrylate) [poly(HEMA)] carrying protein A were used for selective sorption of human-IgG from human plasma. Poly(HEMA) membranes were prepared by a photo-polymerization technique, and activated by cyanogen bromide (CNBr) in an alkaline medium (pH 11.5). Bioligand protein A was then immobilized by covalent binding onto these CNBr-activated membranes. The amount of immobilized protein A was controlled by changing pH and the initial concentrations of CNBr and protein A. The non-specific adsorption of protein A on the plain poly(HEMA) membranes was 2.9 microg cm(-2). Maximum protein A immobilization was observed at pH 9.5. Up to 186 microg cm(-2) was immobilized on the CNBr-activated poly(HEMA) membranes. The maximum adsorption of human-IgG on the protein A-immobilized poly(HEMA) membranes was observed at pH 8.0. The non-specific adsorption of human-IgG onto the plain poly(HEMA) membranes was low (about 4.4 microg cm(-2)). Higher human-IgG adsorption values (up to 394 microg cm(-2)) were obtained in which the protein A-immobilized poly(HEMA) membranes were used. Much higher amounts of human-IgG (up to 489 microg cm(-2)) were adsorbed from human plasma. Up to 91% of the adsorbed human-IgG was desorbed by using 0.1 M aminoacetic acid as elution agent. The adsorption-desorption cycle was repeated ten times using the same polymeric membranes. There was no remarkable reduction in the adsorption capacity of the protein A-immobilized poly(HEMA) membranes.

Protein A immobilization and HIgG adsorption onto porous/nonporous and swellable HEMA-incorporated polyEGDMA microspheres

Both non swellable and swellable poly(EGDMA/HEMA) microbeads were produced by suspension copolymerization. These microbeads were modified by immobilization of a spacer-arm (hexamethylene diamine (HMDA)) and protein A. The optimal values for modifications were as follows: sodium periodate concentration, 1.0 mgml(-1); HMDA concentration, 4 mgml(-1); and glutaraldehyde concentration, 0.070 microgml(-1). Adsorption of protein A onto the plain and periodate oxidized poly(EGDMA/HEMA) microbeads were very close to each other, and were 0.01-0.02 mg protein A on the 1-g Microbeads I and II, respectively. Protein A immobilization on poly(EGDMA/HEMA) microbeads were studied at different temperatures, times, and pHs using single protein solution containing different amounts of proteins. The optimal values for immobilization were as follows: the initial protein A concentration, 0.1 mgml(-1); temperature, 25 degrees C; pH, 9.5; and immobilization time, 120 min. Incorporation of protein A resulted in 1.420 and 1.825 mg protein A on the 1-g Microbeads I and II, respectively. HIgG adsorption capacity on the protein A-incorporated poly(EGDMA/HEMA) microbeads is 27 and 35 mg HIgGg(-1) polymer for Microbeads I and II, respectively.

Therapeutic plasma exchange and cytapheresis in pediatric patients

Pediatric therapeutic apheresis is reviewed including what it is, how it is performed and indications for its use. Pediatric patients are special, and the unique needs for replacement fluids and attention to access, anticoagulation, volume shifts and hypothermia are stressed. While all indications cannot be addressed, the procedures most commonly performed are reviewed. These include erythrocytapheresis, leukaphereses and plasma exchanges. A table details the strength of evidence supporting the use of apheresis procedures for many of these indications.

Reticuloendothelial "activation" noted after splenectomy for ITP and presence of a post-poliomyelitis asymmetry

A radiocolloid study was carried out, after splenectomy, in a 75-year-old man who had idiopathic thrombocytopenic purpura. The patient, who did not have an increase in platelet counts after spleen removal or after platelet infusions, showed radiocolloid accumulation in the lungs and in the bone marrow. This suggested some "activation" of reticuloendothelial cells, perhaps by circulating immune complexes. The left femur (site of an episode of poliomyelitis many years previously) had less radiocolloid uptake than the right.

Protein a Carrying PMMA Microbeads: Adsorption of Cholesterol and HlgG from Human Plasma

Cholesterol and HlgG adsorbed from human plasma obtained from a hypercholesterolemia patient, onto protein A-immobilized polymethyl-methacrylate uniform microbeads carrying different amounts of protein A (0.264-1.682 mg protein A/g PMMA, or 0.66-4.2 mg protein A/m2PMMA) were investigated in batchwise experiments. There was no interaction between protein A molecules and cholesterol when cholesterol aqueous solutions were used. However, there was significant cholesterol and HlgG adsorption from the plasma obtained from a patient with hypercholesterolemia. The maximum amounts of cholesterol and HlgG adsorbed were 3.96 μmol cholesterol/g PMMA (5.4 mg cholesterol/g PMMA) and 0.242 μmol IgG/g PMMA (35.4 mg IgG/g PMMA).

Immune modulation associated with extracorporeal immunoadsorption treatments utilizing protein A/silica columns

The Prosorba column is designed for the removal of IgG and IgG containing immune complexes from plasma. Clinical studies employing patients presenting with idiopathic thrombocytopenic purpura (ITP) indicate that this new form of therapy is effective in approximately 40% of treated patients. Responding patients exhibit a significant increase in platelet numbers associated with decreases in antiplatelet antibody and immune complexes suggesting the induction of immune modulation. Preliminary studies indicate that ITP patients presenting with antiplatelet IgG antibody are those most likely to respond. In addition, this subgroup of ITP patients also exhibit elevated levels of antiidiotypic IgG antibody, which may contribute to an exacerbation of the autoimmune process due to antigen mimicry of the platelet autoantigen. Interestingly, antiidiotypic IgG antibody levels appear to decrease in association with antiplatelet IgG autoantibody levels suggesting that removal of immune complexes composed of IgG autoantibody and platelet autoantigen and/or antiidiotypic IgG antibody may be related to the observed clinical responses. Additional studies with alloimmune patients refractory to platelet transfusion suggest that transfused platelet retention time may be increased as a consequence of immunoadsorption therapy. This clinical response appears to be related to decreases in IgG alloantibody, again suggesting the induction of immune modulation. Alloimmune thrombocytopenic patients also appear to present with elevated levels of antiidiotypic IgG antibody which may contribute to an exacerbation of the alloimmune process due to antigen mimicry of platelet alloantigen(s). Preliminary studies indicate that both IgG alloantibody and corresponding antiidiotypic IgG antibody levels appear to decrease during immunoadsorption therapy, which suggests that removal of these antibodies, possibly in the form of immune complexes, may be related to clinical responses. Finally, studies in rheumatoid arthritis patients suggest that immunoadsorption therapy may be of clinical benefit in this autoimmune disorder. Consistent with the results observed above, preliminary studies in patients responding to immunoadsorption treatments again suggest that there is a concomitant decrease in idiotypic IgG (rheumatoid factor) and antiidiotypic IgG antibodies levels during therapy.

Transfusion and stem cell support in cancer treatment

Intensification of therapeutic regimens, improved patient survival, and advances in cytokine and cellular therapies have led to increasingly complex requirements for transfusion and stem cell support in cancer treatment. This article focuses on current and evolving issues in red blood cell, platelet, and granulocyte transfusion support, as well as measures to avoid increasingly important complications of transfusion therapy, such as alloimmunization, graft-versus-host disease, cytomegalovirus infection, and immunomodulation. Issues concerning current applications of hematopoietic stem cell transplantation and future prospects also are discussed.

Modulation of idiotypic and antiidiotypic immunoglobulin G responses in an alloimmune thrombocytopenic patient associated with extracorporeal protein A immunoadsorption

In the present case study, a patient with Non-Hodgkin. Lymphoma underwent combination chemotherapy resulting in severe pancytopenia requiring transfusion support with blood products. The patient became refractory to random donor platelet transfusions and subsequently received five immunoadsorption treatments. The patient's clinical response to immunoadsorption therapy was assessed by monitoring platelet transfusion recovery and survival. In addition, changes in antibody responses were assessed. Early during the course of immunoadsorption therapy, antiplatelet immunoglobulin G (IgG) alloantibody was detected. There was a decline in antiplatelet IgG alloantibody levels by the last immunoadsorption treatment associated with increases to platelet correct count increments after completion of immunoadsorption therapy. In addition, elevated levels of antiidiotypic IgG antibody detected early during the course of therapy were significantly reduced by the last immunoadsorption treatment. This case study suggests that specific alloimmune idiotypic IgG antibody and corresponding antiidiotypic IgG antibody responses may be modulated in association with extracorporeal immunoadsorption employing protein A/silica columns.

Protein A immobilized polyhydroxyethylmethacrylate beads for affinity sorption of human immunoglobulin G

Protein A immobilized polyhydroxyethylmethacrylate (PHEMA) microbeads were investigated for the specific removal of HIgG from aqueous solutions and from human plasma. PHEMA microbeads were prepared by a suspension polymerization technique and activated by CNBr in an alkaline medium (pH 11.5). Protein A was then immobilized by covalent binding onto these microbeads. The amount of immobilized protein A was controlled by changing pH and the initial concentrations of CNBr and protein A. The maximum protein A immobilization was observed at pH 9.5. Up to 3.5 mg protein A/g PHEMA was immobilized on the CNBr activated PHEMA microbeads. The maximum HIgG adsorption on the protein A immobilized PHEMA microbeads was observed at pH 8.0. The non-specific HIgG adsorption onto the plain PHEMA microbeads was low (about 0.167 mg of HIgG/g PHEMA). Higher adsorption values (up to 6.0 mg of HIgG/g PHEMA) were obtained in which the protein A immobilized PHEMA microbeads were used. Much higher amounts of HIgG (up to 24.0 mg of HIgG/g PHEMA) were adsorbed from human plasma.

Protein A immunoadsorption treatment in hematology: an overview

Staphylococcal protein A efficiently binds immunoglobulins and circulating immune complexes (CIC) and provides an effective medium to remove immunoglobulins and CICs from plasma while sparing albumin and most coagulation proteins. Although it activates the complement system its clinical use abrogates the need for plasma expanders necessitated by plasma exchange. Despite anecdotal reports of utility in several hematologic syndromes, publications of clinical trials are available only for autoimmune thrombocytopenic purpura (AITP) and refractoriness to platelet transfusions (RFT) associated with alloimmunization. In the former situation Snyder et al. (Blood 79:2237-2245, 1992) reported on 72 patients with AITP all of whom had failed at least two previous therapies including splenectomy in 68%. Forty-six percent achieved improved platelet counts following treatment. The response was durable (8-26 mo) in all but 10%. Spleen-intact patients could not be differentiated from those who had been splenectomized. Both responders and nonresponders showed significant decreases in CIC and platelet-directed immunoglobulin (PDIG), but responders achieved near-normal levels. The beneficial response of these factors, particularly in spleen-intact patients, warrants a prospective study. In our studies at the University of Minnesota twelve patients with thrombocytopenia secondary to bone marrow failure who were refractory to platelet transfusion were treated with protein A immunoadsorption. Ten had demonstrable antiplatelet Abs (Anti-HLA, HPA, ABO). Seven of 12 demonstrated improved platelet counts and post-transfusion corrected count increments after treatment. This was associated with decreased platelet utilization and clinical bleeding. A prospective controlled clinical trial is justified.