|Year : 2019 | Volume
| Issue : 2 | Page : 204-207
Assessment and association of coagulation factors (FVIII and fibrinogen) with the mode of collection and storage of fresh frozen plasma
Rajendran Loganathan1, Rajendra G Kulkarni2, Rakhee Kar3, B Abhishekh2, Debdatta Basu3
1 Department of Transfusion Medicine, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry, India
2 Department of Transfusion Medicine, Jawaharlal Nehru Institute of Post Graduate Medical Education and Research, Pillaiyarkuppam, Pondicherry, India
3 Department of Pathology, Jawaharlal Nehru Institute of Post Graduate Medical Education and Research, Pillaiyarkuppam, Pondicherry, India
|Date of Submission||10-Jul-2019|
|Date of Acceptance||20-Sep-2019|
|Date of Web Publication||17-Oct-2019|
Dr. Rajendran Loganathan
Department of Transfusion Medicine, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry
Source of Support: None, Conflict of Interest: None
Background: Indian Drugs and Cosmetics Act and Rules 1945 states that 1% or 4 units/month of any components prepared and stored should meet specific quality control parameter. Currently, our blood center relies on nonancillary tests such as prothrombin time (PT)/activated PT test for quality check of fresh frozen plasma (FFP). However, the guidelines advice to check the levels of labile coagulation factors, routinely. Aim: This study was conducted to establish coagulation factor assay and assess conditions such as collection, transportation, time of preparation, and storage conditions to assess the level of clotting factors FVIII and fibrinogen in FFP and to identify the association of the levels of clotting factors FVIII and fibrinogen in FFP with its mode of collection and storage. Materials and Methods: A cross-sectional study was carried out delimiting inclusion criteria as the FFP to be prepared from whole blood collected in-house or at outdoor blood collection drives blood with varying duration of storage within 12 months; the exclusion criteria on units that were discarded reasons due to leaking in bags found positive for transfusion transmitted infections. The sample size was calculated based on logistics, budget, and convenient sampling technique. Statistical analysis was carried out using software IBM PASW statistics (SPSS) version 19.0, and independent Student's one-way analysis of variance for levels of statistical significance was considered at P < 0.05 among the parameters such as clotting factors among the different blood groups. Results: There was no significant difference observed on different modes of collection between the levels of FVIII and fibrinogen. However, the difference between FVIII levels with different time-lapse of component processing was statistically significant (P = 0.002). However, regarding fibrinogen such a difference was not a significant difference. Conclusion: Heat-labile factors were maintained as per the DGHS criteria when FFP was prepared within 4 h and stored for 6 months.
Keywords: Blood collection sites, factor VIII, fibrinogen, in-house and outdoor camps
|How to cite this article:|
Loganathan R, Kulkarni RG, Kar R, Abhishekh B, Basu D. Assessment and association of coagulation factors (FVIII and fibrinogen) with the mode of collection and storage of fresh frozen plasma. Glob J Transfus Med 2019;4:204-7
|How to cite this URL:|
Loganathan R, Kulkarni RG, Kar R, Abhishekh B, Basu D. Assessment and association of coagulation factors (FVIII and fibrinogen) with the mode of collection and storage of fresh frozen plasma. Glob J Transfus Med [serial online] 2019 [cited 2020 Apr 9];4:204-7. Available from: http://www.gjtmonline.com/text.asp?2019/4/2/204/269390
| Introduction|| |
Indian Drugs and Cosmetic Act and Rules 1945 (DCA) states that 1% or 4 units per month of any components prepared and stored should meet specific quality control parameter. Fresh frozen plasma (FFP) is used to treat coagulopathy due to multiple factor deficiencies or in therapeutic plasma exchange. DCA, National Blood Transfusion Council under National AIDS Control Organization (NACO), and the International Organizations such as AABB and European committee on blood transfusion have laid down the quality control parameters for FFP. As assessment of various factors is expensive, the most blood banks rely on prothrombin time (PT) test and activated PT test (aPTT) results as the screening approach to assess the quality of FFP. There is a decrease in the level of coagulation factors FVIII and FIX in FFP under different conditions. Currently, our blood center relies on nonancillary tests such as PT/aPTT and on the subjective feedback from clinicians as measures for quality check of FFP. However, the guidelines advice to check the levels of labile coagulation factors in routine practice., Estimation of coagulation factor levels in FFP would help us in evaluating the process of preparation and storage methods.
The present study aimed to establish the coagulation factor assay and assess the conditions which affect the factor levels such as collection, transportation, also time taken for procedure preparation, and storage conditions of FFP. The objective of the present study was to assess the level of clotting factors FVIII and fibrinogen in FFP as well as to identify the association of the levels of clotting factors FVIII and fibrinogen in FFP with its mode of collection and storage.
| Materials and Methods|| |
The present study was carried out in the department of transfusion medicine through a 20 months' period between January 2016 and August 2017. Whole blood (WB) was collected in 350-ml blood collection bag with the satellite bags. All the bags were processed to separate the blood components within 8 h of collection. The plasma components were prepared from platelet-rich plasma after separation of platelets separation by high centrifugation. The plasma units were frozen as FFP by keeping them in deep freezers at temperature <−80°C and then further stored at a temperature <−30°C. For the test purpose, 5 ml of sample was collected after thawing in a water bath at 37°C temperature and was transported in the cold chain to the coagulation laboratory of hematology section under the department of pathology, where the levels of various factors in FFP were determined using fully automated Stago Coagulometer. Fibrinogen assay was done. This cross-sectional study involving FFP units included the following inclusion and exclusion criteria: (a) Inclusion criteria: FFP prepared from WB donations at in-house and outdoor blood donation camps, with varying duration of storage within the 12 months' period; (b) Exclusion criteria: FFP units which were discarded due to various reasons such as leakage in bags or reactive on the logistics, budget, and the convenient sampling technique. Various parameters included mode of collection as WB at outdoor blood donation campsites and in house at blood bank premises, mode of transportation as to maintain cold chain at 1°C–10°C temperature, and mode of storage of separated FFP in deep freezer at −80°C and then after 24 h in deep freezer <−30°C. The WB collection time and the time of separation into FFP were noted accurately. Data regarding the levels of various coagulation factors, duration of storage, volume of the content, storage temperature, and mode of collection were collected for the analysis.
The distribution of categorical data such as blood group, Rh factor, storage duration of the bag, and mode of blood collection was expressed as proportions. The data such as factor level and volume of the bag were calculated and expressed as mean with standard deviation (SD). The comparison of the levels of clotting factors such as fibrinogen and VIII among various ABO blood groups was carried out using independent Student's one-way analysis of variance. The linear relationship between the level of coagulation factors with the storage period and volume of the FFP bag was carried out by regression analysis. Of 155 units, variable storage period for 41 (26.45%), 45 (29.03%), 44 (28.39%), and 25 (16.13%) units was 1, 4, 8, and 12 months, respectively. We had 16 units (10.32%) of FFPs, which were separated within 4 h of WB collection, and 139 (89.7%) units were separated after 4 h but within 8 h of WB. The statistical analysis was carried out at 5% level of significance, with keeping P < 0.05 to consider as significant. All the statistical analyses were done using software IBM PASW statistics (SPSS) version 19.0.
| Results|| |
A total number of 28,919 WB were collected during the period, 6508 units were collected at 191 out-door blood donation drives and 22411 units were collected in house and were processed for plasma separation. Of these, 77 units (49.68%) of plasma were from in-house collection and 78 units (50.32%) of units were from outdoor donation drives that were included in this study. The FVIII level in the FFP derived from in-house collection (mean value, 68.42 IU) was not significantly different from those made from outdoor collection drives (mean value, 75.39 IU). However, the processing time-lapse between the collection of WB and the separation into plasma showed a significant difference (P 0.002) for the level of FVIII, i.e., if the plasma separated before 4 h of blood collection (mean + SD value of 0.9 + 0.4 (IU/ml or mean + SD value of 108.73 + 44.09 (IU/unit) as compared to that on the plasma separated after a lapse of more than 4 h, (mean + SD value, 0.6 + 0.2 (IU/ml) or mean + SD value of 67.69 + 30.05 (IU/unit). The data are summarized in [Table 1].
|Table 1: Level of factor VIII in plasma separated 4 h before and after the blood collection|
Click here to view
The factor VIII levels between different intervals of the storage periods had no significant difference as to 1, 4, 8, and 12 months, with the respective mean values of FVIII being 81.31 IU, 66.57 IU, 71.71 IU, and 66.57 IU. Factor VIII levels were compared between ABO blood groups which have no significant difference as to its mean level of the FVIII being 67.54 IU, 78.84 IU, 64.54 IU, and 71.54 IU among the A, B, AB, and O groups, respectively. There was no significance difference in fibrinogen levels augmented from the blood collected in-house (255.02 IU) or from the out-door blood donation drives (264.70 IU) nor was any difference observed in time-lapse in separation process before 4 h (mean value, 279.68 IU) and that after 4 h (mean value, 257.65 IU). Likewise, there was no significant difference noticed as regards the length of storage of 1, 4, 8, and 12 months with a mean fibrinogen level of 271.88 IU, 264.96 IU, 249.36 IU, and 249.84 IU, respectively. Interestingly, all 155 units of the FFP had fibrinogen level of more than 200 mg/dL.
| Discussion|| |
FFP is a rich source of coagulation factors, but its preparation needs to have stipulated concentration of the coagulation proteins estimated as per recommendation by the national standards. As per the DGHS criteria, the ideal content of all coagulation factors should be 1.0 IU/ml and fibrinogen levels should be 200–400 mg for one unit of FFP prepared from 450 ml of WB. The QC criteria for the factor VIII are 0.7 IU/ml, while that for the fibrinogen level are 200–400 mg per unit. In the present study, various QC parameters for FFP prepared within 4 h met the stipulated QC requirement for both FVIII and fibrinogen. The level of fibrinogen in FFP prepared between 4 and 8 h also met the required criteria. As regards the site of blood collection, be it in-house or outdoor camps, QC criteria met well within the required standard for fibrinogen and nearly so for FVIII and hence was true on elongated storage of the components. For therapeutic efficacy in clinical conditions such as massive transfusion, disseminated intravascular coagulation, multiple coagulation deficiencies, and in plasma exchange, the most coagulation of more than 0.5 IU/ml is sufficient. However, the FFPs with FVIII concentration of <0.7 IU/ml are not suitable to be used for the patients with hemophilia. In the present study, the fibrinogen content of FFP units was more than 200 mg (200–400 mg) which was well within the quality requirement. On association with the ABO blood groups, the elevated level of FVIII found among the non-O groups (i.e., A, B, and AB groups) in the present study was in line with the reported literature., Sheffield et al. observed 30%–35% decrease in the yield of FVIII when delayed (held for 24 h) separation of plasma from the WB unit. In the present study, a better yield of FVIII was found when plasma was separated within 4 h of collection than that after 4 h of delayed separation as was observed by Dogra et al.
In the present study, while the fibrinogen levels met the QC criteria, the same for FVIII did not meet as exactly required criteria as laid down by DGHS or European council guidelines. This could be due to the poor storage conditions, e.g., piling up of blood units one above the other rather than keeping in the individual canister boxes that allow cold air current to the centrally stored FFP products. Other causes include maintenance breakdown, which happens frequently in our center.
The present study was basically done to assess the coagulation factor content of plasmas obtained from two different sources of collection such as in-house or outdoor collection drives since there are no baseline data available on coagulation factor content of FFPs in this demographic set up. Our study may help in establishing baseline data on coagulation factor contents in this demography. It may also help to evaluate the quality required by different Indian guidelines like that fixed up by the NACO and NABH. In India, we are moving toward 100% voluntary blood donation program, which is not possible without conducting a far-distant blood donation drives. It also becomes necessary to evaluate whether the components prepared from such blood collections actually meet the quality requirement. Besides, we do conduct camps all over the season, more so during the summer season. Since South India falls in the tropical region with extreme hot climate during months between April and June every year, the climatic factor may influence the yield of the labial coagulation factors prepared off the plasma collected during the period. While we had not addressed the parameter on a seasonal variable in our present study, we recommend it to include this parameter as an influencing factor in future studies.
The outcome of the present study may help in the preparation of raw materials for the better yield of other blood products through plasma fractionation, particularly for the Von Willebrand disease. To the best of our knowledge, the present study is first ever attempted in the Southern region of India to assess the FVIII (labial) and fibrinogen (stable) coagulation factors as included in the study. We faced a few limitations that could be maneuvered including storage of the FFP units preventing overload in the deep freezer, transportation of material using the ideal cold chain system box, and establishing testing facility right in blood center rather than depending on the faraway department.
| Conclusion|| |
In our study, heat-labile factors could be well maintained as per the criteria laid by the DGHS if the FFP was prepared within 4 h and was stored up to 6 months.
I thank technician Mr. Shankar and PhD student MissP L Ambika for their kind technical support.
Financial support and sponsorship
This study was financially supported by JIPMER intramural funding – Rs 150,000/- and Self – Rs 50,000/-.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saran R. Transfusion Medicine Technical Manual. 2nd
ed. New Delhi: Directorate General of Health Services; 2003.
Arya RC, Wander G, Gupta P. Blood component therapy: Which, when and how much. J Anaesthesiol Clin Pharmacol 2011;27:278-84.
] [Full text]
Dogra M, Sidhu M, Vasudev R, Dogra A. Comparative analysis of activity of coagulation factors V and VIII and level of fibrinogen in fresh frozen plasma and frozen plasma. Asian J Transfus Sci 2015;9:6-8.
] [Full text]
National AIDS Control Organisation. Standards for Blood Banks and Blood Transfusion Services. New Delhi: Ministry of Health and Family Welfare; 2007. p. 1-101.
Klarmann D, Eggert C, Geisen C, Becker S, Seifried E, Klingebiel T, et al.
Association of ABO (H) and I blood group system development with von Willebrand factor and factor VIII plasma levels in children and adolescents. Transfusion 2010;50:1571-80.
Preston AE, Barr A. The plasma concentration of factor VIII in the normal population. II. The effects of age, sex and blood group. Br J Haematol 1964;10:238-45.
Sheffield WP, Bhakta V, Jenkins C, Devine DV. Conversion to the buffy coat method and quality of frozen plasma derived from whole blood donations in Canada. Transfusion 2010;50:1043-9.