Red Blood Cells Derived from Whole Blood Treated with Riboflavin and UV Light Maintain Adequate Cell Quality through 21 Days of Storage.

BACKGROUND: The Mirasol system for whole blood (WB) is a non-toxic, non-mutagenic pathogen reduction technology (PRT) that treats WB units with riboflavin (vitamin B2) and ultraviolet (UV) light to alter nucleic acids, thereby reducing pathogen infectivity and inactivating white blood cells. This study evaluates the quality of red blood cells (RBCs) derived from WB treated with the Mirasol system. STUDY DESIGN AND METHODS: Paired units of WB were collected from 61 healthy donors. One unit per donor was treated with riboflavin and UV light and the other was used as an untreated control. RBCs were processed from the WB units and stored in AS-3 at 1-6°C for 21 days and sampled for in vitro analyses of RBC quality parameters. RESULTS: Several statistically significant differences were observed between test and control units, but values were overall within normal clinical ranges. After leukoreduction, the residual leukocyte count and RBC recovery met FDA requirements. The RBC units derived from treated WB maintained haemolysis below 1% through 21 days of storage. CONCLUSION: RBCs derived from WB treated with the Mirasol system meet accepted FDA guidelines for RBC quality through 21 days of storage at 1-6°C.

Reduction of Leishmania donovani infectivity in whole blood using riboflavin and ultraviolet light.

BACKGROUND: Leishmaniasis is a vector-borne disease caused by the protozoan parasite Leishmania sp. that is transmitted by sandflies. Travelers to endemic areas, and US military personnel stationed in the Middle East, are at risk for contracting the disease. STUDY DESIGN AND METHODS: Whole blood (WB) units were spiked with human monocytes infected with L. donovani amastigotes to a final concentration of approximately 10(5) infected cells/mL. After riboflavin (RB) addition, units were exposed to 80 J/mLRBCs ultraviolet (UV) light. One pretreatment (collected after RB addition) and one posttreatment sample were collected, serially diluted in culture medium, and incubated at 22°C for up to 5 weeks. Parasite viability was determined by microscopic observation for replicating promastigote forms. RESULTS: Mirasol treatment of 3 units of L. donovani-infected WB with RB and UV light resulted in a parasite reduction of 2.3 ± 0.12 log. CONCLUSIONS: Partial reduction of L. donovani can be achieved in WB using RB and UV light. This technology may be useful when potential donors are exposed to Leishmania sp. during residence, travel, or military deployment to an endemic area.

Development of a riboflavin and ultraviolet light-based device to treat whole blood.

BACKGROUND: In the United States, blood components are commonly used for patients in need of massive transfusion after blood loss. In combat situations, when severe traumatic injuries occur far from a hospital, fresh whole blood is a valuable transfusion therapy because components may not be available. The risk of infectious or immunological complications from fresh whole blood transfusions could be mitigated by a system that reduces pathogen loads and inactivates white blood cells (WBCs). Such a system is in development and utilizes riboflavin and ultraviolet light to provide pathogen reduction and WBC inactivation. STUDY DESIGN AND METHODS: The system has been tested with in vitro and in vivo animal studies to evaluate WBC inactivation and pathogen reduction, and with in vitro studies to assess the function of the treated blood products. RESULTS: Elimination of viable WBCs with the system is equivalent to gamma-irradiation. Results have been reported for reduction of Babesia microti, Trypanosoma cruzi, HIV, and bacteria, and preliminary results for Babesia divergens are available. Treated whole blood, platelets, and plasma maintain coagulation function. Treated red blood cell components exhibit low hemolysis and high adenosine triphosphate levels at the end of storage. CONCLUSIONS: Treatment with riboflavin and ultraviolet light is a promising alternative to gamma-irradiation. Effectiveness of the system against a variety of pathogens has been established, and further studies are planned. The in vitro studies of function indicate that treated whole blood, as well as components from treated whole blood, will provide acceptable hemostasis and perform well in the next phase of in vivo studies.

Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time.

BACKGROUND: Whole blood (WB) has been used in combat since World War I as it is readily available and replaces every element of shed blood. Component therapy has become standard; however, recent military successes with WB resuscitation have revived the debate regarding wider WB use. Characterization of optimal WB storage is needed. We hypothesized that refrigeration preserves WB function and that a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light has no deleterious effect over 21 days of storage. STUDY DESIGN AND METHODS: WB units were stored for 21 days either at 4°C or 22°C. Half of each temperature group underwent PRT, yielding four final treatment groups (n = 8 each): CON 4 (WB at 4°C); CON 22 (WB at 22°C); PRT 4 (PRT WB at 4°C); and PRT 22 (PRT WB at 22°C). Testing was at baseline, Days 1-7, 10, 14, and 21. Assays included coagulation factors; platelet activation, aggregation, and adhesion; and thromboelastography (TEG). RESULTS: Prothrombin time (PT) and partial thromboplastin time increased over time; refrigeration attenuated the effects on PT (p ≤ 0.009). Aggregation decreased over time (p ≤ 0.001); losses were attenuated by refrigeration (p ≤ 0.001). Refrigeration preserved TEG parameters (p ≤ 0.001) and PRT 4 samples remained within normal limits throughout the study. Refrigeration in combination with PRT inhibited fibrinolysis (p ≤ 0.001) and microparticle formation (p ≤ 0.031). Cold storage increased shear-induced platelet aggregation and ristocetin-induced platelet agglutination (p ≥ 0.032), as well as GPIb-expressing platelets (p ≤ 0.009). CONCLUSION: The in vitro hemostatic function of WB is largely unaffected by PRT treatment and better preserved by cold storage over 21 days. Refrigerated PRT WB may be suitable for trauma resuscitation. Clinical studies are warranted.

Inactivation of Plasmodium spp. in plasma and platelet concentrates using riboflavin and ultraviolet light.

BACKGROUND: Photochemical treatment of blood products could help prevent transfusion-transmitted malaria and reduce the need for donor deferrals. In this study we evaluated the effectiveness of riboflavin and ultraviolet (UV) light against both Plasmodium falciparum, which causes the most severe form of human malaria, and Plasmodium yoelii, an in vivo murine model for malaria. STUDY DESIGN AND METHODS: Plasma and platelet (PLT) concentrates were inoculated with either P. falciparum- or P. yoelii-infected red blood cells (RBCs). Aliquots from each unit were collected after inoculation, after addition of riboflavin, and after treatment. In vitro P. falciparum growth was assessed using thin blood films of duplicate samples at 24, 48, 72, and 96 hours. P. yoelii parasitemia was followed in mice for 14 days postinoculation. RESULTS: In the in vitro studies, the mean P. falciparum parasitemia increased 12- to 19-fold in pretreatment samples, both before and after addition of riboflavin, after 96-hour culture. Few parasites were observed in Mirasol-treated units at 24 hours; those that were observed were degenerating. Through the remainder of the 96-hour culture period, cultures of treated samples were negative. In the in vivo study, mouse plasma containing P. yoelii-infected RBCs had a mean starting titer of 4.6 log mouse infectious dose 50%/mL. No infectious parasite was detected in treated samples. CONCLUSION: Treatment with riboflavin and UV light was effective at reducing viable P. falciparum in both PLT and plasma products by at least 3.2 logs. Additionally, an at least 4.4-log reduction was observed with P. yoelii.

Treatment of whole blood with riboflavin plus ultraviolet light, an alternative to gamma irradiation in the prevention of transfusion-associated graft-versus-host disease?

BACKGROUND: Exposure of blood products to gamma irradiation is currently the standard of care in the prevention of transfusion-associated graft-versus-host disease (TA-GVHD). Regulatory, technical, and clinical challenges associated with the use of gamma irradiators are driving efforts to develop alternatives. Pathogen reduction methods were initially developed to reduce the risk of microbial transmission by blood components. Through modifications of nucleic acids, these technologies interfere with the replication of both pathogens and white blood cells (WBCs). To date, systems for pathogen and WBC inactivation of products containing red blood cells are less well established than those for platelets and plasma. STUDY DESIGN AND METHODS: In this study, the in vitro and in vivo function of WBCs present in whole blood after exposure to riboflavin plus ultraviolet light (Rb-UV) was examined and compared to responses of WBCs obtained from untreated or gamma-irradiated blood by measuring proliferation, cytokine production, activation, and antigen presentation and xenogeneic (X-)GVHD responses in an in vivo mouse model. RESULTS: In vitro studies demonstrated that treatment of whole blood with Rb-UV was as effective as gamma irradiation in preventing WBC proliferation, but was more effective in preventing antigen presentation, cytokine production, and T-cell activation. Consistent with in vitro findings, treatment with Rb-UV was as effective as gamma irradiation in preventing X-GVHD, a mouse model for TA-GVHD. CONCLUSION: The ability to effectively inactivate WBCs in fresh whole blood using Rb-UV, prior to separation into components, provides the transfusion medicine community with a potential alternative to gamma irradiation.

Riboflavin and ultraviolet light reduce the infectivity of Babesia microti in whole blood.

BACKGROUND: Babesia microti is the parasite most frequently transmitted by blood transfusion in the United States. Previous work demonstrated the efficacy of riboflavin (RB) and ultraviolet (UV) light to inactivate B.microti in apheresis plasma and platelet units. In this study we investigated the effectiveness of RB and UV light to reduce the levels of B.microti in whole blood (WB). STUDY DESIGN AND METHODS: WB units were spiked with B. microti-infected hamster blood. Spearman-Karber methods were used to calculate infectivity of each sample in terms of hamster infectious dose 50% (HID50 ) value. After RB addition, the units were illuminated with 80 J/mLRBC UV light. Two samples were collected: one before illumination and one after illumination. The samples were serially diluted and dilutions injected into a group of five naive hamsters. Four weeks postinoculation (PI), blood was collected from the animals and evaluated by microscopic observation. RESULTS: One pilot study showed a good dose response in the animals and demonstrated that sample infectivity could be calculated in terms of an HID50 . Three additional replicates were performed in the same manner as the pilot study, but with fewer dilutions. Infectivity values were consistent between the experiments and were used to calculate log reduction. The posttreatment reduction of B. microti for all the experiments was more than 5 log. CONCLUSIONS: The data collected indicate that use of RB and UV is able to decrease the parasite load in WB units thus reducing the risk of transfusion-transmitted B. microti from blood components containing B. microti-infected RBCs.

Fresh whole blood use for hemorrhagic shock: preserving benefit while avoiding complications.

Transfusion support of patients with hemorrhagic shock has changed over time with the development of storage and processing methods. Transfusion medicine developed during World War I with the use of whole blood, and now in the developed world, component therapy predominates. In contrast, there is still clinical use of fresh whole blood (FWB) in the developing world, in a minority of children's hospitals, and in combat settings. Although there is a rationale for the use of FWB in massively bleeding patients compared with the use of individual components, it has rarely been analyzed in prospective randomized clinical trials. Recent retrospective studies in adult trauma and mixed critically ill patients have revived this decades-old controversial question of the value of FWB for patients with severe shock and coagulopathy or those at risk. The risks of FWB use have also been highlighted recently, which has caused some to focus on reducing these risks with alternative processing and storage methods. It is important to recognize that current processing and storage methods for components have also not been adequately explored to determine whether they affect clinical outcomes. In this article, we review potential benefits and risks of FWB use for patients with hemorrhagic shock from any cause, and how current and future processing and storage methods may affect efficacy and safety of FWB in this population. We intend this review to stimulate hypothesis generation and clinical investigation in determining when FWB may be indicated and how to optimally process and store FWB to maximize its risk-benefit ratio.

Evaluating pathogen reduction of Trypanosoma cruzi with riboflavin and ultraviolet light for whole blood.

BACKGROUND: Trypanosoma cruzi, the protozoan parasitic agent of Chagas disease, can be transmitted by blood transfusion. In 2007, most US blood banks started screening blood donations for T. cruzi, but the cost and perceived need of the test have been the subject of ongoing discussion. In this study, we evaluated the ability of the Mirasol System (CaridianBCT), which uses riboflavin (RB) and ultraviolet light to inactivate pathogens, to reduce the levels of infectious T. cruzi in whole blood (WB). STUDY DESIGN AND METHODS: WB units were inoculated with 4, 40, 400, and 4000 trypomastigotes/mL. After addition of RB and illumination at various energy levels, the samples were tested for the presence of live parasites by hemoculture. RESULTS: All preillumination samples exhibited T. cruzi growth in hemoculture, while postillumination samples from units containing 4 and 40 trypomastigotes/mL showed no signs of viable parasites after 16 weeks of culture. In contrast, at both 400 and 4000 parasites/mL, two of the three units were positive for viable parasites. CONCLUSIONS: The total log reduction observed for T. cruzi was 3.5 log or greater, but less than 4.5 log. This level of reduction is likely to be orders of magnitude higher than what would be expected in a tainted blood donation, indicating that the Mirasol System could be effective at preventing transfusion of the causative agent of Chagas disease.

In vivo viability of stored red blood cells derived from riboflavin plus ultraviolet light-treated whole blood.

BACKGROUND: A novel system using ultraviolet (UV) light and riboflavin (Mirasol System, CaridianBCT Biotechnologies) to fragment nucleic acids has been developed to treat whole blood (WB), aiming at the reduction of potential pathogen load and white blood cell inactivation. We evaluated stored red blood cell (RBC) metabolic status and viability, in vitro and in vivo, of riboflavin/UV light-treated WB (IMPROVE study). STUDY DESIGN AND METHODS: The study compared recovery and survival of RBCs obtained from nonleukoreduced WB treated using three different UV light energies (22, 33, or 44 J/mL(RBC)). After treatment, WB from 12 subjects was separated into components and tested at the beginning and end of component storage. After 42 days of storage, an aliquot of RBCs was radiolabeled and autologously reinfused into subjects for analysis of 24-hour recovery and survival of RBCs. RESULTS: Eleven subjects completed the in vivo study. No device-related adverse events were observed. By Day 42 of storage, a significant change in the concentrations of sodium and potassium was observed. Five subjects had a 24-hour RBC recovery of 75% or more with no significant differences among the energy groups. RBC t(1/2) was 24 ± 9 days for the combined three groups. Significant correlations between 24-hour RBC recovery and survival, hemolysis, adenosine triphosphate (ATP), and CO(2) levels were observed. CONCLUSIONS: This study shows that key RBC quality variables, hemolysis, and ATP concentration may be predictive of their 24-hour recovery and t(1/2) survival. These variables will now be used to assess modifications to the system including storage duration, storage temperature, and appropriate energy dose for treatment.

Design and development of a method for the reduction of infectious pathogen load and inactivation of white blood cells in whole blood products.

The use of blood components has been a staple of transfusion medicine for several decades. Technologies for the processing and handling of blood, including separation of components from whole blood, are very well developed. Relative to blood safety, methods to detect the presence of pathogens and reduce the levels of donor white blood cells from whole blood are also well established in routine practice. The advantages which exist for the handling of whole blood by these methods have, for various reasons, not extended to the field of pathogen reduction technology (PRT). PRT methods have been developed and are now in routine use in various locations for addressing single donor or pooled plasma and platelet products. Several methods have also been in experimental development for the treatment of red blood cells as a separate component. The ability to treat whole blood in a fashion that would allow a single pathogen reduction and white blood cell inactivation step, to be followed by use of the product in the form of whole blood or separation into components, would afford several benefits from both a logistical and practical standpoint. This manuscript describes development efforts using a photochemical PRT method employing riboflavin and UV-Light (Mirasol PRT).

Evaluation of the Mirasol pathogen [corrected] reduction technology system against Babesia microti in apheresis platelets and plasma.

BACKGROUND: Babesia microti is an intraerythrocytic parasite, transmitted naturally to humans by infected ixodid ticks, that causes babesiosis. In recent years, B. microti has been identified as a growing public health concern that has also emerged as a critical blood safety issue in the absence of appropriate interventions to reduce transmission by blood transfusion. Thus, we evaluated the ability of the Mirasol pathogen reduction technology (PRT; CaridianBCT), which uses riboflavin (RB) and ultraviolet (UV) light, to diminish the presence of B. microti in apheresis plasma and platelets (PLTs). STUDY DESIGN AND METHODS: Apheresis plasma and PLT units were spiked with B. microti-infected hamster blood and subsequently treated using the Mirasol PRT system. Control and experimental samples were collected at different stages during the treatment process and injected into hamsters to detect the presence of viable parasites. Four weeks postinoculation, hamster blood was tested for B. microti infection by blood smear and real-time polymerase chain reaction analysis. RESULTS: None of the blood smears from animals injected with samples from PRT-treated plasma or PLT units were positive by microscopy, while all the non-PRT-treated plasma and PLT units were demonstrably parasitemic. Parasite load reduction in hamsters ranged between 4 and 5 log in all PRT-treated units compared to untreated controls. CONCLUSION: The data indicate that the use of RB and UV light efficiently reduces the presence of viable B. microti in apheresis plasma and PLT products, thereby reducing the risk of transfusion-transmitted Babesia potentially associated with these products. Based on this observed "proof of principle," future studies will determine the efficacy of the Mirasol PRT in whole blood.

Evaluation of potential immune response and in vivo survival of riboflavin-ultraviolet light-treated red blood cells in baboons.

BACKGROUND: Pathogen reduction methods have the potential to modify blood components, resulting in immunologic reactions or compromised blood components. This study evaluated the hypothesis that there is no immune response to riboflavin-and-ultraviolet [UV]-light-treated red blood cells (RBCs), as observed by serology and by survival of RBCs in circulation. STUDY DESIGN AND METHODS: Three baboons were in each treatment group: 1) untreated (negative control), 2) quinacrine mustard (QM)-treated (positive control), and 3) riboflavin-and-UV light-treated (test group) RBCs. In the immunization phase, autologous test or control RBCs were injected subcutaneously on Days 0, 21, 42, and 49. Plasma samples from these days were tested against test or control RBCs by flow cytometry and standard serology. On Day 56, autologous (51)Cr-labeled test or control RBCs were injected. Blood samples were taken over 21 days after injection to determine RBC survival (t(1/2)). RESULTS: Untreated and riboflavin-and-UV-light-treated RBCs showed no evidence of significant immunoglobulin G (IgG) binding after incubation with autologous plasma. RBC-bound IgG was detected on QM-treated RBCs after incubation with autologous plasma. This antibody was inhibited by QM, as demonstrated by a hapten inhibition study. t(1/2) values for the untreated and riboflavin-and-UV-light-treated RBCs were 7.3 +/- 0.8 and 7.5 +/- 1.7 days, respectively; the t(1/2) value for QM-treated RBCs was 2.3 +/- 2.9 days. CONCLUSION: Treatment with riboflavin and UV light did not render RBCs immunogenic. Positive controls indicated that immunization promoted an immune response. In the (51)Cr-labeled RBC survival phase of the study, riboflavin-and-UV-light-treated RBCs exhibited behavior similar to negative control RBCs. Detrimental immunologic or functional side effects were not observed.

Toxicity testing of a novel riboflavin-based technology for pathogen reduction and white blood cell inactivation.

The Mirasol PRT System (Gambro BCT, Lakewood, CO) for platelets and plasma uses riboflavin and UV light to reduce pathogens and inactivate white blood cells in donated blood products. An extensive toxicology program, developed in accordance with International Organisation for Standardisation (ISO) 10993 guidelines, was performed for the Mirasol PRT system. Test and control articles for most of the reported studies were treated (test) or untreated (control) blood products. For some studies, pure lumichrome (the major photoproduct of riboflavin) or photolyzed riboflavin solution was used. Systemic toxicity was evaluated with in vivo animal studies in the acute and subchronic settings. Developmental toxicity was evaluated with an in vivo animal study. Genotoxicity and neoantigenicity were evaluated with in vitro and in vivo tests. Hemocompatibility and cytotoxicity were assessed with standard, in vitro assays. The pharmacokinteics, excretion, and tissue distribution of (14)C-riboflavin and its photoproducts was evaluated with an in vivo animal study. The possible presence of leachable or extractable compounds (from the disposable set) was evaluated with novel assays for measuring these compounds in blood. No treatment-related toxicity was observed in any of the studies.