|Year : 2021 | Volume
| Issue : 1 | Page : 54-60
Harvesting COVID convalescent plasma using latest-generation apheresis systems: Analyzing factors associated with donor, machine, and manufactured product
Sudipta Sekhar Das, Rathindra Nath Biswas, Subrata Sen
Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
|Date of Submission||25-Nov-2020|
|Date of Decision||22-Jan-2021|
|Date of Acceptance||17-Mar-2021|
|Date of Web Publication||29-May-2021|
Dr. Sudipta Sekhar Das
Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Objectives: Transfusion of COVID convalescent plasma (CCP) has been found to be a useful and logistically feasible therapeutic strategy in COVID-19. Appropriate guidelines describing donor eligibility criteria, CCP collection and storage, and clinical transfusion of CCP have been described. In this study, we discussed the collection of CCP by plasmapheresis, quality of product obtained, and donor adverse reactions associated with CCP collection. Methods: This observational study included 209 screened eligible donors and 186 procedures of plasmapheresis for the collection of CCP. Donor selection and CCP collection were done as per the guidelines described by regulatory bodies. Statistical analysis was done using the SPSS statistical package. Results: The median age of the eligible donors was 42 years, with a male preponderance. The mean anti-severe acute respiratory syndrome coronavirus 2 immunoglobulin G value (S/Co) was 11.8 in eligible donors. The total mean whole blood volume processed to collect the targeted plasma volume, mean utilization of anticoagulant, and mean time needed to complete the procedure were significantly more in the Spectra Optia cell separator (P < 0.05). Quality of the plasma separated by Trima Accel and Spectra Optia was found to be comparable. A total of 9 (5.1%) donors experienced adverse events during or after plasmapheresis. Conclusion: Plasmapheresis using new-generation automated cell separators has the potential to generate CCP of optimized quality and potency. More emphasis is needed on the quality control of CCP with regard to the establishment of defined quality markers and their allowable limits. Appropriate donor vigilance, donor selection, and equipment management during the procedure may significantly prevent adverse events related to plasmapheresis.
Keywords: Cell separator, COVID-19, COVID convalescent plasma, plasmapheresis, quality control
|How to cite this article:|
Das SS, Biswas RN, Sen S. Harvesting COVID convalescent plasma using latest-generation apheresis systems: Analyzing factors associated with donor, machine, and manufactured product. Glob J Transfus Med 2021;6:54-60
|How to cite this URL:|
Das SS, Biswas RN, Sen S. Harvesting COVID convalescent plasma using latest-generation apheresis systems: Analyzing factors associated with donor, machine, and manufactured product. Glob J Transfus Med [serial online] 2021 [cited 2021 Jun 25];6:54-60. Available from: https://www.gjtmonline.com/text.asp?2021/6/1/54/317119
| Introduction|| |
The novel coronavirus disease-2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a contagious respiratory disease and is now a worldwide pandemic. India has become the epicenter of COVID-19 outbreak, making it the second most affected country in the world. Till date, there is no proven effective therapy for COVID-19 and a number of treatment options are on clinical trial.
The immune response induced by SARS-CoV-2 results in the production of potential antibodies which are capable of neutralizing the virus. Passive transfusion of COVID convalescent plasma (CCP) that contains these anti-SARS-CoV-2 antibodies has proven to be a useful and logistically feasible therapeutic strategy. Various research studies and meta-analyses on COVID-19 have shown significant reduction in mortality and morbidity following CCP therapy.,,, The efficacy of CCP depends on proper donor selection, good plasma manufacturing practice, optimum plasma quality, and appropriate dosing and timing of therapy.,,,, In India, CCP has been approved by the Indian Council of Medical Research (ICMR), Government of India, as an investigational therapy for the treatment of indicated COVID-19 patients. Appropriate guidelines describing donor eligibility criteria, CCP collection and storage, and clinical transfusion of CCP have been officially published by the Indian national regulatory authorities such as the Central Drugs Standard Control Organization in conjunction with the ICMR.,
Ours is a tertiary care hospital with dedicated COVID-19 facilities. The blood center which is an inherent part of the hospital obtains requisitions of CCP from clinicians for the treatment of COVID-19. In this study, authors discussed the collection of CCP by plasmapheresis, quality of product obtained, and donor adverse reactions associated with CCP collection.
| Materials and Methods|| |
This prospective observational study was conducted in the hospital blood center from June 2020 to October 2020 after obtaining ethical approval from the institutional ethics committee (approval number ECR/373/Inst/WB/2013/RR-19, dated May 14, 2020).
Donor eligibility and selection
Donor eligibility criteria for CCP donation were followed in accordance with the Drug and Cosmetics Act 1940 and Rules 1945 therein for plasmapheresis and guidelines published by the Indian national authorities for the clinical trial of CCP in COVID-19 patients.,, We accepted only those donors who had complete resolution of symptoms at least 28 days before CCP donation., All prospective donors were registered and screened for demographic profile, COVID-19 status, medical and drug histories, and other mandatory selection parameters. Donors who qualified the initial screening were subjected to laboratory screening as per the guidelines described for donating CCP., Donors were accepted for plasmapheresis only when all these laboratory values were within acceptable limits. Donor details such as demography, laboratory, and serological values were obtained from blood center software and departmental CCP donor register.
Donor laboratory investigation
Approximately 10 mL whole blood (WB) sample was collected from each donor and distributed in 2 EDTA vials and 2 clotted vials for the following laboratory investigations.
- Hematological parameters such as hemoglobin (Hb), hematocrit (Hct), WBC count, and platelets (PLT) were measured using a calibrated automated cell counter (iCount 3CP, IRIS Healthcare Technologies Private Limited, India)
- Blood group confirmation and antibody screening using automated solid-phase assay (NEO Iris, Immucor, USA)
- Serum protein using automated chemistry analyzer (Abbott Architect ci8200, Abbott Laboratories, USA)
- Qualitative detection of anti-SARS-CoV-2 immunoglobulin G (IgG) directed against domain S1 and S2 of the SARS-CoV-2 spike protein using automated VITROS ECiQ Immunodiagnostic System based on enhanced chemiluminescence technology following validated test protocols and controls (Ortho Clinical Diagnostics, USA)
- Transfusion transmitted pathogens:
- Mandatory serology: Anti-HIV 1 and 2, anti-hepatitis-C virus (HCV), and HBsAg tests were performed by the automated VITROS ECiQ Immunodiagnostic System (Ortho Clinical Diagnostics, UK). Treponema pallidum antibodies for syphilis were done by rapid qualitative, immunochromatographic method (Medsource Ozone Biomedicals Pvt. Ltd., Haryana, India). Malarial antigens for Plasmodium falciparum and Plasmodium vivax were tested by rapid qualitative, chromatographic immunoassay (MicroGene Diagnostic Systems [P] Ltd., Thane, India)
- Nucleic acid testing (NAT): NAT for HIV, HBC, and HCV was performed using the automated cobasTaqScreen MPX v2.0 assays based on polymerase chain reaction technology (Roche Molecular Systems, Inc., USA).
Plasmapheresis for COVID convalescent plasma collection
All plasmapheresis procedures were performed by the same apheresis team after taking informed consent and using the latest-generation cell separators mentioned below.
- Spectra Optia cell separator (version 11.3, Terumo BCT, Lakewood, USA)
- Trima Accel cell separator (version 6.0, Terumo BCT, Lakewood, USA).
All procedures were performed following the manufacturer's instructions and departmental standard operating procedure (SOP) using recommended apheresis kits. The end point of each procedure was based on the target plasma volume of 500 mL. Donor demography such as age, gender, weight, height, body surface area (BSA), and total blood volume (TBV); laboratory details such as blood group, Hb, Hct, WBC, PLT, serum protein, and anti-SARS-CoV-2 IgG antibody, and details of plasmapheresis procedure such as TBV processed, anticoagulant volume (acid-citrate-dextrose-A), procedure time, and blood flow rate were recorded for each procedure. All donors were administered prophylactic oral calcium (1000 mg) and explained the details of procedure before starting it. Donor adverse reactions if any were managed and documented following departmental SOP. For all donors undergoing plasmapheresis, aliquot of serum samples was collected and stored at −80°C for future neutralizing antibody titer test.,
Quality control of COVID convalescent plasma
As no defined quality control (QC) criteria for CCP were available in the literature, therefore, we adopted the QC criteria of plasma component described by the European Council. In addition to quality parameters such as visual appearance of product, product volume, transfusion transmitted infectious markers, and residual cells discussed by the Council, we added anti-SARS-CoV-2 IgG antibody value (S/Co) as a quality parameter and measured antibody value in the products. QC was performed on alternate CCP products after thawing them on the day of transfusion. Approximately 1 mL sample from each bag was collected in a test tube after thoroughly stripping the segment to ensure a representative product of the bag. Each sample was subjected to the measurement of QC parameters.
Statistical analysis was done using the SPSS Statistical Package (IBM, 2015, Armonk, New York, USA). All values were captured in the MS office excel sheet and statistically analyzed. Quantitative variables were calculated as mean ± standard deviation or N (%) and analyzed using the paired Student's t-test. A P < 0.05 was considered statistically significant. Factors with P < 0.05 such as anticoagulant used, plasmapheresis procedure time, and WB volume processed were statistically analyzed through multivariate logistic regression to identify the independent factor that may affect the collection of CCP by plasmapheresis. All results were reported in terms of odds ratio and corresponding 95% lower control limit and 95% upper control limit.
| Results|| |
The present study included 209 voluntary donors who were screened for CCP donation and 186 procedures of plasmapheresis for the collection of CCP. [Table 1] describes the demographic and laboratory values of screened 209 voluntary CCP donors. The median age of the eligible donors was 42 years, with a male preponderance (male:female = 7:1). The mean weight and BSA of the CCP donors were 68.2 ± 7.4 kg (range: 56–79) and 1.63 ± 0.37 m2 (range: 1.64–1.69), respectively. However, the mean Hb and PLT count were observed to be 14.1 ± 3.4 g/dL (range: 12.6–16.2) and 183.9 ± 49.1 × 106/mL (range: 152–259), respectively; the mean anti-SARS-CoV-2 IgG value (S/Co) was calculated to be 11.8 ± 6.2 (range: 7.6–21.2). The prevalence of “B” blood group donors was 45% followed by “O” group (33.8%).
|Table 1: Demographic and laboratory values of eligible Covid convalescent plasma donors (n=209)|
Click here to view
Out of 209 eligible donors, 186 (89%) underwent plasmapheresis for the collection of CCP. The rest 23 eligible donors were either lost or could not report the blood center due to various reasons. Eighty-four procedures were performed using Spectra Optia and 102 using Trima Accel cell separators. The mean anticoagulant use in Trima Accel and Spectra Optia was 253.1 ± 40.3 mL (range: 138–345) and 274.5 ± 35.7 mL (range: 172–359), respectively. The mean procedure time in Spectra Optia (52.8 ± 10.1 min, range: 34–70) was found more than the Trima Accel (48.3 ± 9.8 min, range: 32–69). The mean WB processed in Trima Accel and Spectra Optia was 2270.2 ± 336.2 mL (range: 1714–3187) and 2444.3 ± 338.7 mL (range: 1701–3095), respectively [Table 2]. A multivariate logistic regression of these significant factors such as anticoagulant used, procedure time, and WB volume processed was not found to be affecting the collection of CCP independently [Table 3].
|Table 2: Details of plasmapheresis procedures for Covid convalescent plasma collection (n=186)|
Click here to view
|Table 3: Multivariate logistic regression analysis to identify independent significant factors for collection of coronavirus disease convalescent plasma by plasmapheresis|
Click here to view
[Table 4] depicts the quality of CCP obtained from both machines. Quality of the plasma separated by Trima Accel and Spectra Optia was found to be comparable. The mean volume of product processed by Trima Accel was 490.3 ± 5.5 mL (range: 479–499) and Spectra Optia was 489.9 ± 7.2 mL (range: 468–502) (P = 0.796). Quality parameters such as anti-SARS-CoV-2 IgG (S/Co) and residual cell content were analyzed in 46 and 39 random samples collected by Trima Accel and Spectra Optia, respectively. The mean anti-SARS-CoV-2 IgG antibody level (S/Co value) in CCP separated by Trima Accel and Spectra Optia was 13.2 ± 3.6 (range: 7.6–19.7) and 12.7 ± 4.1 (range: 7.9–21.2), respectively, which was observed to be comparable statistically (P = 0.661). Residuals blood cells in all plasma products were within the recommended limits as described by international guidelines. The mean residual leukocytes, red cells, and PLT were found to be 0.12 ± 0.06 × 109/L, 4.98 ± 2.13 × 109/L, and 43.6 ± 11.4 × 109/L, respectively, in the CCP products.
|Table 4: Quality control of Covid convalescent plasma collected by plasmapheresis|
Click here to view
A total of 9 (5.1%) donors experienced adverse events during or after plasmapheresis [See [Table 5]]. While citrate toxicity was observed in three donors, hematoma and vasovagal reactions were found in 4 and 2 donors, respectively. Plasmapheresis-associated adverse events were observed with both the cell separators.
|Table 5: Donor adverse events in Covid convalescent plasma collection by plasmapheresis (n=186)|
Click here to view
| Discussion|| |
The ongoing SARS-CoV-2 pandemic has significantly disrupted the global healthcare facilities. With various studies and researches describing the beneficial effect of CCP in the management of COVID-19, the emphases on CCP collection and utilization have increased in the last few months., Studies describing collection of CCP by plasmapheresis from eligible donors and QC of the obtained products are sparse in the literature.
The median age of the screened donors in the present study was 44 years, with a male preponderance. Previous authors investigated that clinical features and prognosis of COVID-19 vary among patients of different ages and younger patients showed lighter clinical manifestations and low severity. Further, age-dependent gender dimorphism for COVID-19 was demonstrated in which the females have higher susceptibility but lower severity and fatality.
Evidence suggests that CCP collected from survivors of COVID-19 contains receptor binding domain-specific antibodies with potent antiviral activity. Overall mean serum anti-SARS-CoV-2 IgG (S/Co) in the present study was 11.8. The 28-day symptom-free period before CCP donation ensures total clearance of the virus from the individual and optimized production of anti-SARS-CoV-2 IgG in the blood circulation. Anti-SARS-CoV-2 IgG antibodies were identifiable from day 7 onward, peaking at the 4th week, and thereby maintained at a high level for few weeks. However, we failed to perform anti-SARS-CoV-2 neutralizing antibody titer due to lack of expertise and infrastructures.
We observed that most eligible donors belonged to “B” group (45%) followed by “O” (33.8%). Due to small sample size, we could not determine the blood group association with COVID-19. However, previous authors studied such association and found variable results.,
CCP collection or plasmapheresis in the present study was performed using approved apheresis equipment or cell separators in a licensed blood center by dedicated and trained team. The target volume for all procedures as depicted in national guidelines was 500 mL, which ensured both donor safety and dose adequacy., Both equipment used in the present study consistently provided optimized plasma products, irrespective of their variations in inherent working programs. The total mean WB volume processed to collect the targeted plasma volume, mean utilization of anticoagulant, and mean time needed to complete the procedure were observed significantly more in the Spectra Optia cell separator. A multivariate logistic regression of these significant factors was not found to be affecting the collection of CCP by plasmapheresis independently. These findings may be incidental because donor factors such as weight, height, total donor blood volume, hematological values, and venous access determine the volume of WB to be processed to obtain the target yield. The time of apheresis procedure and volume of anticoagulant usage in turn depend on the volume of WB processed.,,
A thorough literature search could not provide any peer-reviewed scientific data on the QC of CCP collected by plasmapheresis. The current study enlisted few relevant quality parameters describing the quality of CCP. Both the equipment provided product of optimized quality as shown in [Table 3]. We observed that 98.9% of the total procedures could provide a CCP volume of ≥480 mL. This ensured that COVID-19 patients receive an initial dose of 200 mL, followed by additional dose of 200 mL within 24 h as described., Due to inadequate inventory of CCP in the blood center, all patients received the identical aliquot of plasma on the next day. Here, we like to report that QC was performed only on the first CCP aliquot issued to the patient. However, all the products were nonreactive for the mandatory infectious markers: no leakage, discoloration, or visible clots were observed in any of the CCP aliquots. Mean anti-SARS-CoV-2 IgG level and residual cell content in the products obtained by both the equipment were comparable. In 94.7% of plasma products, the residual cell content was within the maximum allowable limits described in quality guidelines. Infectious markers as QC parameters were included as per the European Council guidelines. Anti-SARS-CoV-2 IgG level was estimated in the thawed CCP products to ascertain the quality during their storage. With this ongoing COVID-19 pandemic, more appropriate, stringent, and mandatory QC markers may be implemented to ensure optimized CCP quality, their safety, and potency.
Like other apheresis procedures, plasmapheresis is a safe procedure without significant complications; however, at times, symptoms due to citrate toxicity and other adverse events may cause discomfort to the donors. Early recognition of adverse events and preventing their occurrences are important to encourage donor retention. Donor adverse events such as mild citrate toxicity, hematoma, and vasovagal reactions were observed in 9 donors (5.11%) and were comparable in both the machines. Despite administering prophylactic oral calcium (1000 mg), citrate toxicity was observed in three donors. Such mild reactions may be expected because 20% of donors experience citrate-related side effects, despite prophylactic oral calcium due to various causes related to inappropriate calcium metabolism, suboptimal calcium dose, or associated hypomagnesemia.,, Hematoma due to vascular injury was observed in four CCP donors. Although donor inattentiveness, excessive arm movement, or high return rate in a case of thin vein may cause vascular injury, majority of such injury can be prevented by good vein selection and skilled phlebotomist.
| Conclusion|| |
Donor screening and selection in CCP donation should be performed meticulously following guidelines established by the national and international bodies. We also conclude that plasmapheresis using new-generation automated cell separators has the potential to generate CCP of optimized quality and potency. More emphasis is needed on the QC of CCP with regard to establishment of defined quality markers and their allowable limits. Appropriate donor vigilance, donor selection, and equipment management during procedure may significantly prevent adverse events related to plasmapheresis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al
. Genomic characterisation and epidemiology of 2019 novel coronavirus: Implications for virus origins and receptor binding. Lancet 2020;395:565-74.
Home | Ministry of Health and Family Welfare GOI. COVID-19 India as on; 2020. Available from: https://www.mohfw.gov.in/
. [Last accessed on 2020 Jul 25].
Cai X, Ren M, Chen F, Li L, Lei H, Wang X. Blood transfusion during the COVID-19 outbreak. Blood Transfus 2020;18:79-82.
Meher BR, Padhy BM, Das S, Mohanty RR, Agrawal K. Effectiveness of convalescent plasma therapy in the treatment of moderate to severe COVID 19 patients: A systematic review and meta-analysis. J Assoc Physicians India 2020;68:35-43.
Duan K, Liu B, Li C, Zhang H, Yu T, Qu J, et al
. Effectiveness of convalescent plasma therapy in severe COVID-19 patients. Proc Natl Acad Sci U S A 2020;117:9490-6.
Chen L, Xiong J, Bao L, Shi Y. Convalescent plasma as a potential therapy for COVID-19. Lancet Infect Dis 2020;20:398-400.
Shen C, Wang Z, Zhao F, Yang Y, Li J, Yuan J, et al
. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA 2020;323:1582-9.
ICMR, Govt. of India. Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease. Available from: https://www.icmr.gov.in/ctechdocad.html
. [Last accessed on 2020 Apr 21].
Woelfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Mueller MA, et al
. Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. Med Rxiv 2020;[Prepress]. [doi: 10.1101/2020.03.05.20030502].
Zhao J, Yuan Q, Wang H, Liu W, Liao X, Su Y, et al
. Antibody responses to SARS-CoV-2 in patients with novel coronavirus disease 2019. Clin Infect Dis 2020;71:2027-34.
Malik V. Drugs and Cosmetics Act, 1940 and Rules 1945 there in Amended Up to the 31s
t December, 2016, Eastern Book Company, India.
Keitel S. Guide to the Preparation, Use and Quality Assurance of Blood Components. 18th
ed. Strasbourg, France: Council of Europe Publishing; 2015.
Liu Y, Mao B, Liang S, Yang JW, Lu HW, Chai YH, et al.
Association between age and clinical characteristics and outcomes of COVID-19. Eur Respir J 2020;55:1-4.
Qian J, Zhao L, Ye RZ, Li XJ, Liu YL. Age-dependent gender differences in COVID-19 in Mainland China: Comparative study. Clin Infect Dis 2020;71:2488-94.
Robbiani DF, Gaebler C, Muecksch F, Lorenzi JC, Wang Z, Cho A, et al
. Convergent antibody responses to SARS-CoV-2 in convalescent individuals. Nature 2020;584:437-42.
Liu X, Wang J, Xu X, Liao G, Chen Y, Hu CH. Patterns of IgG and IgM antibody response in COVID-19 patients. Emerg Microbes Infect 2020;9:1269-74.
Zhao J, Yang Y, Huang H, Li D, Gu D, Lu X, et al
. Relationship between the ABO blood group and the COVID-19 susceptibility. Med Rxiv. 2020;[Prepress]. [doi: 10.1101/2020.03.11.20031096].
Latz CA, DeCarlo C, Boitano L, Png CY, Patell R, Conrad MF, et al
. Blood type and outcomes in patients with COVID-19. Ann Hematol 2020;99:2113-8.
Chaudhary R, Das SS, Khetan D, Sinha P. Effect of donor variables on yield in single donor plateletpheresis by continuous flow cell separator. Transfus Apher Sci 2006;34:157-61.
Beyan C, Cetin T, Kaptan K, Nevruz O. Effect of plateletpheresis on complete blood count values using three different cell separator systems in healthy donors. Transfus Apher Sci 2003;29:45-7.
Das SS, Chaudhary R, Verma SK, Ojha S, Khetan D. Pre and post donation hematological values in healthy donors undergoing plateletpheresis with five different systems. Blood Transfus 2009;7:188-92.
Dogra K, Fulzele P, Rout D, Chaurasia R, Coshic P, Chatterjee K. Adverse events during apheresis procedures: Audit at a tertiary hospital. Indian J Hematol Blood Transfus 2017;33:106-8.
Bolan CD, Greer SE, Cecco SA, Oblitas JM, Rehak NN, Leitman SF. Comprehensive analysis of citrate effects during plateletpheresis in normal donors. Transfusion 2001;41:1165-71.
Das SS, Chaudhary R, Khetan D, Shukla JS, Agarwal P, Mishra RB. Calcium and magnesium levels during automated plateletpheresis in normal donors. Transfus Med 2005;15:233-6.
Solanki A, Agarwal P. Comprehensive analysis of changes in clinically significant divalent serum cation levels during automated plateletpheresis in healthy donors in a tertiary care center in North India. Asian J Transfus Sci 2015;9:124-8.
] [Full text]
Das SS, Sen S, Zaman RU, Biswas RN. Plateletpheresis in the era of automation: Optimizing donor safety and product quality using modern apheresis instruments. Indian J Hematol Blood Transfus 2021;37:134-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]