Characterization and first-in-human clinical dose-escalation safety evaluation of a next-gen human freeze-dried plasma

Potential military applications for a new freeze-dried plasma

Hemorrhage is a leading cause of potentially preventable death in both military and civilian trauma. Current resuscitation approaches minimize crystalloids and emphasize plasma and other blood components to achieve a balanced transfusion as early as possible after injury. Owing to the nature of military operations, military medical systems must contend with great distances, degraded infrastructure, and harsh environments, as well as combat and humanitarian assistance and disaster relief (HADR) scenarios. These factors limit both patient movement and the ability to deliver blood products to the point of need. Current projections are that future military scenarios will have longer times to reach a medical treatment facility than experienced in recent conflicts, increasing the need for logistically efficient blood products. Freeze-dried plasma (FDP) is rapidly available, easy to use, and shelf-stable at room temperature, making it easier to deliver at the point of need in challenging military environments. For the past 30 years, FDP has been available in only a few countries. Where it has been available, it has become the preferred plasma for austere or military expeditionary settings. Recently, a new FDP, OctaplasLG Powder, was approved in 17 countries worldwide and for emergency use by the Canadian and United States militaries. It is expected that FDP will soon become available to many more militaries. This review discusses the importance of plasma, reassesses the potential military uses of FDP across the range of military operations, and provides a brief discussion of OctaplasLG Powder.

An experimental comparison and user evaluation of three different dried plasma products

BACKGROUND AND OBJECTIVES

Access to blood components in pre-hospital bleeding resuscitation is challenging. Dried plasma is a logistically superior alternative, and new products are emerging. Therefore, we aimed to evaluate laboratory and practical differences in three differently produced dried plasma products.

MATERIALS AND METHODS

Single-donor lyophilized LyoPlas®, pooled-donor, lyophilized and pathogen-reduced OctaplasLG Powder®, and single-donor sprayed-dried FrontlineODP™ along with fresh plasma (in-house, pre-FrontlineODP and OctaplasLG) as controls were analysed (n = 8). Laboratory tests included measurements of various coagulation factors and thromboelastography. The practical evaluation of the dried plasma products included preparation time, time to dissolve the dried plasma and total time, together with subjective opinions from eight clinical users.

RESULTS

The coagulation factor content was within human reference ranges for all dried plasma, with approximately 10%-20% loss compared with fresh plasma. More variations were observed in the single-donor products compared with the pooled products. Clot formation analysed by thromboelastography showed normal graphs. Reconstitution time was similar, ranging from on average 7-9 min. In the user evaluation, the reconstitution time and the possibility of using a plastic bag for the transfusion were emphasized as important, the latter fulfilled by two of the products.

CONCLUSION

The study supports that dried plasma may be produced with lyophilization or spray-drying technique, as well as with the addition of pathogen reduction, with preserved coagulation capability. The products were reconstituted in acceptable time and deemed feasible for pre-hospital use by eighth test users.

Dried Plasma for Major Trauma: Past, Present, and Future

Uncontrollable bleeding is recognized as the leading cause of preventable death among trauma patients. Early transfusion of blood products, especially plasma replacing crystalloid and colloid solutions, has been shown to increase survival of severely injured patients. However, the requirements for cold storage and thawing processes prior to transfusion present significant logistical challenges in prehospital and remote areas, resulting in a considerable delay in receiving thawed or liquid plasma, even in hospitals. In contrast, freeze- or spray-dried plasma, which can be massively produced, stockpiled, and stored at room temperature, is easily carried and can be reconstituted for transfusion in minutes, provides a promising alternative. Drawn from history, this paper provides a review of different forms of dried plasma with a focus on in vitro characterization of hemostatic properties, to assess the effects of the drying process, storage conditions in dry form and after reconstitution, their distinct safety and/or efficacy profiles currently in different phases of development, and to discuss the current expectations of these products in the context of recent preclinical and clinical trials. Future research directions are presented as well.

Prehospital Freeze-Dried Plasma in Trauma: A Critical Review

Major traumatic hemorrhage is now frequently treated by early hemostatic resuscitation on hospital arrival. Prehospital hemostatic resuscitation could therefore improve outcomes for bleeding trauma patients, but there are logistical challenges. Freeze-dried plasma (FDP) offers indisputable logistical advantages over conventional blood products, such as long shelf life, stability at ambient temperature, and rapid reconstitution without specialized equipment. We sought high level, randomized, controlled evidence of FDP clinical efficacy in trauma. A structured systematic search of MEDLINE/PubMed was carried out and identified 52 relevant English language publications. Three studies involving 607 patients met our criteria: Resuscitation with Blood Products in Patients with Trauma-related Hemorrhagic Shock receiving Prehospital Care (RePHILL, n = 501); Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock (PREHO-PLYO, n = 150); and a pilot Australian trial (n = 25). RePHILL found no effect of FDP plus packed red blood cells (PRBC) concentrate transfusion versus saline on mortality. PREHO-PLYO found no effect of FDP versus saline on International Normalized Ratio (INR) at hospital arrival. The pilot trial found that study of PRBC versus PRBC plus FDP was feasible during long air transport times to an Australian trauma centre. Further research is required to determine under what conditions FDP might provide prehospital benefit to trauma patients.

Current advances in 2022: A critical review of selected topics by the Association for the Advancement of Blood and Biotherapies (AABB) Clinical Transfusion Medicine Committee

BACKGROUND

The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion.

STUDY DESIGN AND METHODS

CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded.

RESULTS

For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion.

DISCUSSION

This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool.

Novel blood derived hemostatic agents for bleeding therapy and prophylaxis

PURPOSE OF REVIEW

Hemorrhage is a major cause of preventable death in trauma and cancer. Trauma induced coagulopathy and cancer-associated endotheliopathy remain major therapeutic challenges. Early, aggressive administration of blood-derived products with hypothesized increased clotting potency has been proposed. A series of early- and late-phase clinical trials testing the safety and/or efficacy of lyophilized plasma and new forms of platelet products in humans have provided light on the future of alternative blood component therapies. This review intends to contextualize and provide a critical review of the information provided by these trials.

RECENT FINDINGS

The beneficial effect of existing freeze-dried plasma products may not be as high as initially anticipated when tested in randomized, multicenter clinical trials. A next-generation freeze dried plasma product has shown safety in an early phase clinical trial and other freeze-dried plasma and spray-dried plasma with promising preclinical profiles are embarking in first-in-human trials. New platelet additive solutions and forms of cryopreservation or lyophilization of platelets with long-term shelf-life have demonstrated feasibility and logistical advantages.

SUMMARY

Recent trials have confirmed logistical advantages of modified plasma and platelet products in the treatment or prophylaxis of bleeding. However, their postulated increased potency profile remains unconfirmed.