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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 38-43

Clinical outcome of platelet transfusion using platelet-rich plasma-derived platelets and buffy coat-removed platelets in patients with dengue fever – A comparison


1 Department of Transfusion Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
2 Department of Transfusion Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Date of Submission21-Jan-2019
Date of Decision03-Feb-2020
Date of Acceptance20-Feb-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Jyothis Purushothaman
Department of Transfusion Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_9_20

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  Abstract 


Background and Objectives: Platelet transfusions are widely used to treat thrombocytopenia of various etiology. There are two different methods of preparation of platelet concentrate from whole blood: one is platelet-rich plasma method (PRP) and the buffy coat removed (BCR) method. This study aimed to compare the clinical outcome of patients with dengue fever transfused with platelets prepared by PRP method and BCR method. Methodology: A total of 100 patients with thrombocytopenia due to dengue fever were enrolled in the study, with fifty patients in each group. The outcome of patients transfused with PRP-derived platelets and BCR platelets was compared on the basis of absolute and corrected count increment (CCI), percent platelet recovery, and incidence of posttransfusion reactions. Results: The mean absolute count increment in patients who received BCR-platelet concentrate (BCR-PC) was 23,900/μl ± 7022.56/μl. The mean absolute count increment in patients who received PRP-derived PC was 18,910/μl ± 7482.42/μl. The difference was statistically significant with P = 0.001. The mean CCI of PRP group was 12,847 ± 5146.76 and in the BCR group, it was 12,897 ± 4266.82, and this difference was not statistically significant (P = 0.957). None of the patients transfused with BCR platelets reported a transfusion reaction, whereas one out of fifty (2%) patients transfused with PRP platelets had febrile nonhemolytic transfusion reaction. Conclusion: On the basis of count increment, CCI, percent platelet recovery, and incidence of posttransfusion reactions, BCR platelet transfusions showed a better outcome than PRP platelet transfusions.

Keywords: Absolute count increment, buffy coat-removed platelet concentrate, corrected count increment, dengue fever, febrile nonhemolytic transfusion reaction, platelet-rich plasma-derived platelet concentrate, thrombocytopenia


How to cite this article:
Purushothaman J, Innah SJ. Clinical outcome of platelet transfusion using platelet-rich plasma-derived platelets and buffy coat-removed platelets in patients with dengue fever – A comparison. Glob J Transfus Med 2020;5:38-43

How to cite this URL:
Purushothaman J, Innah SJ. Clinical outcome of platelet transfusion using platelet-rich plasma-derived platelets and buffy coat-removed platelets in patients with dengue fever – A comparison. Glob J Transfus Med [serial online] 2020 [cited 2020 Oct 27];5:38-43. Available from: https://www.gjtmonline.com/text.asp?2020/5/1/38/282752




  Introduction Top


Platelets play a vital role in maintaining normal hemostasis in response to vascular injury. Patients with decreased number of circulating platelets or functionally abnormal platelets are at increased risk of bleeding.[1] The only source of viable platelets was freshly drawn whole blood before the invention of platelet concentrates (PCs).[2] The current platelet transfusion therapy was made possible as a result of the development of gas-permeable plastic containers which facilitate the collection, separation, and storage of platelets from whole blood. Currently, PCs are used extensively to support patients with thrombocytopenia due to various causes.[3],[4],[5]

Platelets used in transfusion therapy can be prepared either by centrifuging whole blood obtained from a single blood donation or by apheresis using automated cell separators. The advantage of separating platelets from the whole blood is that it will limit the number of red and white blood cells (WBCs) and the amount of plasma volume transfusing to the patient and it will also increase the yield of platelets to maximum. As platelets are stored at room temperature, separating them from other blood cells allows platelets to be stored under their optimal conditions because red blood cells and plasma require low temperatures for their storage and platelets lose their viability at low temperatures.[6]

There are two different methods of preparation of platelet concentrate from whole blood: platelet-rich plasma (PRP) and the buffy coat (BC) methods.[7]

PRP method includes a two-step centrifugation in which platelets are collected as pellets on second centrifugation, and there is reversible aggregation of platelets which may be due to the activation of platelets during close contact between platelets in the pellet. Another disadvantage of this method is chances of mechanical damage to the platelet as platelets hit a hard surface upon centrifugation.[8],[9] Even though platelet aggregation and damage can be minimized by leaving the product undisturbed for 1 h prior to resuspension, the activation of platelets may result in the release of granular contents such as cytokines and other factors that may cause febrile nonhemolytic transfusion reactions (FNHTRs) during transfusion.[9] The yield of platelets in PRP method is approximately 5.0–7.5 × 1010 platelets per bag that is about 60%–75% of the platelets found in the whole blood unit before separation. In BC method where platelets reside in the BC layer, there is a lesser degree of platelet activation as platelets accumulate on the red cell interface upon centrifugation.[9],[10]

In the United States, most of the PCs are prepared by the PRP method, whereas the BC method is preferred in Europe.[11] In India most blood banks are doing PRP method for preparation of platelet concentrates due to lack of automation mainly due to financial constraints, an accurate statistical data regarding this is not available.

A large number of studies are done comparing thein vitro activation of platelets and release of granular contents such as P-selectins, cytokines, and tumor necrosis factor-alpha among BCR platelets and PRP-derived platelets, which can lead to FNHTR, but whether these changes will lead to significant clinical effects in patients receiving transfusion has not been evaluated in any of these studies.

Aims and Objectives

The aim of this study is to compare the clinical outcome of patients with dengue fever and thrombocytopenia transfused with platelets prepared by PRP method and BCR method.


  Materials and Methods Top


This study was conducted in the department of transfusion medicine and general medicine in a tertiary care hospital over a period of 2 years. The outcome of patients transfused with random donor platelets prepared by two different methods, i.e., PRP method and BCR method, was compared on the basis of platelet count increment and incidence of posttransfusion reaction. A total of 100 patients, 50 in each group, were selected for the study and the sample size was adequate.

Inclusion criteria

Patients with dengue fever and thrombocytopenia admitted in the department of general medicine who received platelet transfusion were enrolled in the study.

Exclusion criteria

Patients who received platelet transfusion for causes other than dengue fever were excluded from the study.

Methodology

This is a comparative study. The data of patients who received platelet transfusions were collected in a prospective manner. For this study Buffy Coat Removed platelet concentrates were prepared along with PRP derived platelet concentrates. Patients were randomly given BCR platelets alone or PRP-derived platelets alone. Along with the platelet units, a pro forma was also issued to be filled and attached with the patient records. Patients' age, gender, height, weight, diagnosis, platelet count before transfusion, platelet count 1 h after transfusion, and incidence of any posttransfusion reaction were taken into consideration. The data were analyzed using appropriate statistical methods.

Blood collected from healthy, voluntary, or replacement blood donors was used to prepare either PRP-derived or BCR platelet concentrate. Blood was collected in 450-ml triple bags (CPD-SAGM-2 Terumo Penpol, Terumo Penpol Private Limited, Thiruvananthapuram, Kerala, India) with a diversion pouch for preparing PRP-derived platelets. Blood was also collected in top and bottom quadruple bags with a diversion pouch for the preparation of BCR platelets. Those units required more than 15 min to draw was not taken for the preparation of platelets. Platelets were separated within 8 h after the collection of the unit of whole blood.

Preparation of platelets by platelet-rich plasma method

Whole blood collected in 450-ml triple bags (CPD-SAGM-2 Terumo Penpol) from healthy donors was centrifuged in Cryofuge 6000i (Heraeus, Cryofuge 6000i, Thermo Fisher Scientific, Bremen, Germany) at a centrifugal force of 2000 ×g for 3 min at 22°C, light spin. PRP obtained as supernatant was then transferred into the bag indented for storage of platelets using a manual plasma extractor. The PRP bag was again centrifuged at 5000 ×g for 5 min at 22°C, heavy spin. Platelet-poor plasma obtained as supernatant was expressed out into the second transfer bag. Platelets collected down as pellets were suspended in 40–70 ml of plasma. The volume of the bags was checked using an electronic weighing machine. The platelet bag was left stationary with the labeled side down for 1 h at room temperature and was stored in a platelet incubator with continuous agitation at 22°C.

Preparation of platelets by buffy coat-removed method

Whole blood was collected in 450-ml top and bottom quadruple bags (CPD-SAGM, Compoflex quadruple system, Fresenius Kabi) and was centrifuged at 5000 ×g for 7 min at 22°C. Subsequently, three layers were formed depending on the specific gravity of each component. The top-most layer comprised of platelet-poor supernatant plasma, BC layer containing approximately 90% of platelets, 70% of WBCs, 10% of red cells formed the middle layer, and the bottom layer was formed by packed red cells. The components were separated using an automated plasma expresser. Red cell sediment in the bottom was then separated into the transfer bag indented for it. The supernatant platelet-poor plasma was separated into one of the top bags. The BC layer along with some red cells and leukocytes in the primary bag was hung for 3 h. After 3 h, the bag was again centrifuged at low centrifugal force (2000 ×g force) for 3 min at 22°C. The resultant supernatant which contained platelets along with 60–70 ml plasma was separated using an automated separator into the transfer bag indented for it. The final product was stored in a platelet incubator with continuous agitation at 22°C.

Quality control parameters[12] of all platelet bags which crossed 5 days of storage were screened based on volume, pH, swirling, platelet count, and bacterial culture reports. The number of platelets per bag of fifty PRP platelets and fifty BCR platelets was compared in a parallel study. The number of platelets per bag was detected using an automated cell counter. The average platelet count obtained in each group from this study was taken as the number of platelets transfused for calculating corrected count increment (CCI) in the corresponding group in the main study.

PCs were transfused within 10 min of issue of the product from the blood bank under the guidance of a registered doctor. Transfusion monitoring form and the pro forma were filled and attached along with the patients' record from the ward. A 1 h posttransfusion platelet count was done for all patients.

Data obtained were entered into the master chart. The details entered were hospital number, age, gender, height, weight, diagnosis of the patient, pretransfusion platelet count, posttransfusion count, and incidence of any posttransfusion reaction in these patients. Body surface area (BSA), absolute count increment, CCI, and percent platelet recovery were calculated from these details using the formulas given below and were entered in the master chart. All results were statistically analyzed.

BSA in m2 (Mosteller formula) =



Absolute count increment = Posttransfusion platelet count − pretransfusion platelet count.





Statistical methods

Descriptive and inferential statistical analyses were carried out in the present study. Results on continuous measurements were presented as mean ± standard deviation (min–max), and results on categorical measurements were presented as number (%). Significance was assessed at 5% level of significance. Student's t-test (two tailed, independent) was used to find the significance of the study parameters on a continuous scale between the two groups (intergroup analysis) on metric parameters. Moreover, Student's t-test (two tailed, dependent) was used to find the significance of the study parameters on a continuous scale within each group. Chi-square/Fisher's exact test was used to find the significance of the study parameters on a categorical scale between two or more groups. Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0, and R environment ver. 2.11.1 (USA) were used for the analysis of data, and Microsoft Word and Excel were used to generate graphs and tables.

Ethics

Comparative analysis of 2 widely practiced methods of platelet preparation. No human subjects recruited specifically for the study.


  Results Top


This is a comparative study done prospectively over a period of 2 years. The outcome of patients transfused with PRP-derived PCs and BCR PC was compared based on absolute count increment, CCI, posttransfusion platelet recovery, and incidence of posttransfusion reactions.

A total of 100 patients were enrolled in the study, with fifty patients in each group. The study group included patients admitted in the department of general medicine with thrombocytopenia due to dengue fever.

The age group of patients in the two groups was similar with P = 0.385, and it ranged from 14 years to 80 years [Figure 1]. Gender distribution among the two groups was also similar with P = 0.839 [Table 1]. All the transfusions included in the study were ABO compatible.
Figure 1: Age distribution of the patients studied

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Table 1: Gender distribution of the patients studied

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The mean platelet count before transfusion in patients who received PRP-derived platelets and BCR-platelets was 19,040.00 ± 5117.84 and 37,940.00 ± 10,422.03, respectively. Most of the patients in both groups had a pretransfusion platelet count ≤20,000. Those patients who received transfusion even though their platelet count was more than 20,000 had severe bleeding manifestations. The mean platelet count after transfusion in patients who received PRP-derived platelets and BCR-platelets was 37,940.00 ± 10,422.03 and 41,500.00 ± 9337.77, respectively [Table 2].
Table 2: Platelet count: A comparison before and after transfusion

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The absolute count increment in patients transfused with BCR platelets was more when compared with patients transfused with PRP platelets. The mean absolute count increment in the BCR group was 23,900/μl ± 7022.56/μl. The mean absolute count increment in the PRP group was 18,910/μl ± 7482.42/μl. The difference was statistically significant with P = 0.001 [Table 3].
Table 3: Comparison of absolute count increment and corrected count increment in the two groups studied

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The mean CCIs in both groups was almost similar. The mean CCI of the PRP group was 12,847 ± 5146.76 and in the BCR group, it was 12,897 ± 4266.82, and this difference was not statistically significant (P = 0.957) [Table 3]. As CCI <5000 is significant in defining refractoriness, it was also compared among the two groups. There were no patients in BCR platelet group with a CCI <5000, whereas 6% of patients in the PRP group were with a CCI <5000.

The comparison of percent platelet recovery in the two groups showed that the mean PPR among patients transfused with PRP platelets was 36.24% ± 14.97% and the mean PRP among patients transfused with BC platelets was 36.92% ± 13.6% [Table 4]. In our study, among PRP-derived platelet group, 14% of patients were with a PPR (percent platelet recovery) <20% and 36% were with a PPR <30%. Among BCR platelet group, 6% of patients were with a PPR <20% and 30% of patients were with a PRP (percent platelet recovery) <30%.
Table 4: Comparison of percent platelet recovery in the two groups studied

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On comparing posttransfusion reaction, it was noted that none of the patient transfused with BCR platelets had FNHTR or any other transfusion reactions, while one out of the fifty (2%) patients transfused with PRP platelets had FNHTR.


  Discussion Top


In the current study, the absolute count increment in patients transfused with BCR platelets was more compared to patients transfused with PRP platelets. Higher number of platelets per bag in BCR PCs may have contributed for the increased count increment in patients transfused with BCR platelets. In a study done by Klump et al. in 1999, it was stated that platelet increment will be affected by the dose of platelet transfused.[13]

The mean CCIs in both groups was almost similar. As CCI <5000 is significant in defining refractoriness, it was also compared among the two groups. The British Committee for Standards in Hematology and Blood Transfusion Task Force had proposed a guideline in 2003; according to it, the minimum CCI is >7.5 × 109/L at 1 h and >4.5 × 109/L at 20–24 h. As refractoriness cannot be defined following a single transfusion and CCI depends on patient factors such as concomitant fever, splenomegaly, human leukocyte antigen (HLA) alloimmunization, and platelet-specific antibodies, this inference does not have much significance in the present study.

Even though the percent platelet recovery in two groups was almost similar, refractory response was more with patients transfused with PRP-derived platelets. Recovery <20% to 30% at 1 h after the transfusion indicates a refractory response.

The incidence of FNHTR in patients transfused with BCR platelets was low compared to those received PRP-derived platelets; the reason may be lesser activation and release of granular contents in BCR platelets. As platelets are collected as pellets in PRP method after final centrifugation, it will result in a large degree of release of alpha granular contents.[14] A comparative study done by Metcalfe et al. states that the extent of activation was significantly higher in PRP platelets than in BCR platelets.[15] They measured P-selectin, and it was highest in PRP-PC and lowest in BC-PC preparations.[15] The decreased leukocyte content of Buffy coat removed platelet concentrates compared to PRP derived platelet concentrates may be an yet another reason for low incidence of FNHTR in patients receiving it.[12]

A study done by Levin et al. in 2008 compared quality control variables such as pH, platelet count, volume, sterility, and residual white cell count, as well as nonroutine testing of platelets for platelet activation, metabolic changes during storage, and extent of shape change induced by adenosine. They also found that BCR platelets have less evidence of production-related damage and better platelet quality during storage.[16]

The inference of our study is that, the outcome of patients transfused with BCR-PC was better on the basis of absolute count increment, CCI, percent platelet recovery, and incidence of posttransfusion reactions compared to those transfused with PRP platelet transfusions.


  Conclusion Top


The outcome of patients transfused with BCR platelet concentrates were better on the basis of absolute count increment, CCI, percent platelet recovery, and incidence of post transfusion reactions compared to those transfused with PRP derived platelet concentrates.

Limitations

The smaller sample group in the study is a limitation in identifying the incidence and the extent of adverse effects of transfusions. This points toward the need for a future study with a larger study group.

This comparison needs to be done with other groups (nondengue) of patients as well, for better understanding of the benefits of BCR platelets versus PRP platelets.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hersh EM, Bodey GP, Nies BA, Freireich EJ. Causes of death in acute leukemia: A ten-year study of 414 patients from 1954-1963. JAMA 1965;193:105-9.  Back to cited text no. 1
    
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Minor AH, Burnett L. A method for separating and concentrating platelets from normal human blood. Blood 1952;7:693-9.  Back to cited text no. 2
    
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Wallace EL, Churchill WH, Surgenor DM, Cho GS, McGurk S. Collection and transfusion of blood and blood components in the United States, 1994. Transfusion 1998;38:625-36.  Back to cited text no. 3
    
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Meehan KR, Matias CO, Rathore SS, Sandler SG, Kallich J, LaBrecque J, et al. Platelet transfusions: Utilization and associated costs in a tertiary care hospital. Am J Hematol 2000;64:251-6.  Back to cited text no. 4
    
5.
Schiffer CA, Anderson KC, Bennett CL, Bernstein S, Elting LS, Goldsmith M, et al. Platelet transfusion for patients with cancer: Clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001;19:1519-38.  Back to cited text no. 5
    
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Murphy S, Heaton WA, Rebulla P. Platelet production in the old world-and the new. Transfusion 1996;36:751-4.  Back to cited text no. 6
    
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Slichter SJ, Harker LA. Preparation and storage of platelet concentrates. Transfusion 1976;16:8-12.  Back to cited text no. 7
    
8.
Mourad N. Studies on release of certain enzymes from certain enzymes from human platelets. Transfusion 1968;8:363-7.  Back to cited text no. 8
    
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Fijnheer R, Pietersz RN, de Korte D, Gouwerok CW, Dekker WJ, Reesink HW, et al. Platelet activation during preparation of platelet concentrates: A comparison of the platelet-rich plasma and the buffy coat methods. Transfusion 1990;30:634-8.  Back to cited text no. 9
    
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Högman CF, Eriksson L, Hedlund K, Wallvik J. The bottom and top system: A new technique for blood component preparation and storage. Vox Sang 1988;55:211-7.  Back to cited text no. 10
    
11.
Gulliksson H. Platelets from platelet-rich-plasma versus buffy-coat-derived platelets: What is the difference? Rev Bras Hematol Hemoter 2012;34:76-7.  Back to cited text no. 11
    
12.
Singh RP, Marwaha N, Malhotra P, Dash S. Quality assessment of platelet concentrates prepared by platelet rich plasma-platelet concentrate, buffy coat poor-platelet concentrate (BC-PC) and apheresis-PC methods. Asian J Transfus Sci 2009;3:86-94.  Back to cited text no. 12
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13.
Klumpp TR, Herman JH, Gaughan JP, Russo RR, Christman RA, Goldberg SL, et al. Clinical consequences of alterations in platelet transfusion dose: A prospective, randomized, double-blind trial. Transfusion 1999;39:674-81.  Back to cited text no. 13
    
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Snyder EL, Hezzey A, Katz AJ, Bock J. Occurrence of the release reaction during preparation and storage of platelet concentrates. Vox Sang 1981;41:172-7.  Back to cited text no. 14
    
15.
Metcalfe P, Williamson LM, Reutelingsperger CP, Swann I, Ouwehand WH, Goodall AH. Activation during preparation of therapeutic platelets affects deterioration during storage: A comparative flow cytometric study of different production methods. Br J Haematol 1997;98:86-95.  Back to cited text no. 15
    
16.
Levin E, Culibrk B, Gyöngyössy-Issa MI, Weiss S, Scammell K, LeFresne W, et al. Implementation of buffy coat platelet component production: Comparison to platelet-rich plasma platelet production. Transfusion 2008;48:2331-7.  Back to cited text no. 16
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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