আমাদের গবেষণা


Treatment Of Chronic Foot Ulcers In Patients With Diabetes Using Platelet-Rich Plasma

Reference: 

https://ijmpr.in/vol-4-issue-1



Title: Role of Platelet Rich Plasma (PRP) Therapy on Diabetic Foot Ulcer (DFU)- a study from Bangladesh

Authors:
A.B.M. Kamrul Hasan1, Md. Abdullah Al masud2, Sahnaz Karim3, Daanish Arefin Biswas4, Mst. Sabiya Afroz5, Dr. Noor Mohammad6

1Assistant Registrar, Department of Transfusion Medicine, Shaheed M Monsur Ali Medical
College Hospital, Sirajganj, Bangladesh
2Assistant Professor, Department of Transfusion Medicine, TMSS Medical College, Bogura, Bangladesh
3Professor & Head, Department of Transfusion Medicine, Dhaka Medical College, Dhaka,
Bangladesh
4Associate Professor & Head, Department of Transfusion Medicine, Sir Salimullah Medical College , Dhaka, Bangladesh
5Assistant Surgeon, Sheikh Hasina National Institute of Burn and Plastic Surgery, Dhaka,
Bangladesh
6 Assistant Registrar, Department of Haemotology, Shaheed M Monsur Ali Medical
College Hospital, Sirajganj, Bangladesh


Corresponding Author: A. B. M. Kamrul Hasan, Assistant Registrar, Department of
Transfusion Medicine, Shaheed M Monsur Ali Medical College Hospital, Sirajganj, Bangladesh,
Email: ritanuha18@gmail.com
Phone: +8801712-704840


Abstract

Introduction: Diabetic foot ulcer is a major complication of diabetes mellitus, and is the major component of the diabetic foot. This condition affects up to 15% of all patients with diabetes mellitus. 88% of all lower leg amputations are related to a diabetic foot ulcer. Growth factors from Platelet Rich Plasma (PRP) have shown enhanced wound healing. Objective: To assess the role of PRP therapy on diabetic foot infection.
Materials and Methods: This is a prospective randomized controlled study conducted at Diabetic Foot Care & PRP Center (Diagnostic & Hospital), Sirajganj & Desh PRP Centre, Bogura, Bangladesh from January to June 2022. A total of 65 (sixty-five) patients were included in our study.
Results: All the cases were diabetes patients. Among the cases male 37(56.9%) and female were 28(43.07%). In this study, the age of the patients ranged from 35 years to 75 years. The mean age was 55.0±15.44 years. The 45 – 65 years age group has the longest diabetic duration. This is statistically significant. No significant association was seen between the pre-existing medical condition and the distribution among the groups. The results of the study showed that PRP treatment was successful in 63 out of 65 cases (95.9%), with only 2 cases (3.07%) not achieving complete healing. The most common areas of treatment with significant healing were the back of the right foot (1.5%), the back of the heel of the left foot (9.5%), and the back of the right foot under the little finger (3.2%). 
Conclusion: Foot ulcers have a negative impact on the quality of life of diabetes people. According to the findings of our study, the use of PRP accelerates ulcer healing. These findings demonstrated a viable therapy for foot ulcers. There is a need for more randomized controlled trials to determine the real effectiveness of this therapy.

Keywords: Platelet rich plasma, Diabetes mellitus, Foot Ulcer.
Introduction
Diabetic foot ulcer (DFU) is a major complication of diabetes mellitus and is the major component of diabetic foot. This medical condition affects 15% of all patients with diabetes mellitus. A recent study showed that up to 88% of all lower leg amputations are related to diabetic foot ulcers [1]. A few decades ago, diabetic foot ulcers were treated by vacuum-assisted closure, high voltage pulsed current electrical stimulation and hyperbaric oxygen. Some biological therapies were used in ulcer treatment with an improvement in the time of wound healing [2]. More importantly, the cases of diabetic mellitus patients rapidly increase to 439 million by 2030. The main reason is related to the loss of balance between metalloproteinases (MMPs) and MMP inhibitors [3,4]. This status is enhanced to become serious when combined with ischemia and vascular disease. The vascular injury and ischemia reduced the oxygen and nutrients to the wound. So the wound healing mechanism cannot perform as in nondiabetic patients. Lack of oxygen and nutrients, epithelial cells in the wound cannot express essential factors for healing such as VEGF and PDGF; almost all of the cells at the wound changed metabolism and activity [4, 5]. In recent studies, growth factors from Platelet Rich Plasma (PRP) used for enhancing wound healing were compared to conventional therapies. Wound healing started with the release of local growth factors which attracted stem cells into the wound. PRP decreased cytokine release and increased capillary growth. PRP has also some antimicrobial effects against Candida albicans, MRSA and E. coli [5,6,7]. These alterations in the structure and function of cells, as well as certain substances at DFUs, slowed and disrupted the normal healing process. Therefore, when diabetes patients develop DFUs, nearly all DFUs cannot be treated, and patients must ultimately undergo lower leg amputation. DFU treatment remains a challenge.
Materials and Methods
This is a prospective randomized controlled study was conducted at the Dept. of Transfusion Medicine, Diabetic Foot Care & PRP Center (Diagnostic & Hospital), Sirajganj & Desh PRP Centre, Bogura, Bangladesh from January to June 2022. Sixty-Five (65) patients were included to our study according to the following inclusion and exclusion criteria. The inclusion criteria were patients with DM with planter foot ulcers not healed for more than 3 months, intact distal pulsation and ulcers grade 1 and grade 2 according to Wagner grading system Figure 1. The exclusion criteria were patients with liver cell failure, renal impairment, heart failure, severe cardiomyopathy, bleeding or platelet disorders, malignancies or short life expectations, peripheral vascular disease, major lower limb amputations, low immunity or corticosteroid therapy and ulcers (grade 3, grade 4 and grade 5). Full medical and surgical history taking, general assessment, vascular examination and neurological assessment were done for all patients. Laboratory investigations (pre-operative), x-ray foot, arterial duplex and culture from the ulcers were done routinely. All patients signed the consent. On an outpatient basis, debridement was done for all ulcers, optimization of the patients‟ general conditions, broad-spectrum antibiotics first then based on culture were described. The size of ulcers was recorded before treatment and every week till complete healing. Offloading for all cases by total contact cast was done. For PRP preparation 25 mL of the patient’s blood was collected. The blood was centrifuged at 2000 rpm for 5 min to obtain plasma. Then, this plasma was centrifuged at 3000 rpm for another 5 min to collect platelets at (37 Celsius). Platelets were diluted in 5 mL plasma to form PRP and the rest of the plasma is now considered as Platelet Poor Plasma (PPP). Both were activated by Calcium chloride which leads to gel formation for dressing, and PPP was stored for injection Figure 2. Ulcers were dressed with fibrin gel on the first day. After 3 days daily till the end of the first-week injection with activated PPP Was done. If after 2 weeks, still there is no healing, the procedure can be repeated again Figure 3.

Preparation of Platelet-rich plasma:

We used a PRP kit (Secquire kit SK50-20) that included sodium citrate tubes, syringes, needles and centrifuge tubes.
There were four steps to platelet collection:
⦁ blood sample collection
⦁ centrifugation
⦁ activation
⦁ platelet gel making.
The process took 30–45 minutes, from blood collection to the end infusion. Blood (30–40ml) was collected from the patient in 3.8% sodium citrate tubes. The blood was centrifuged (at 1400–1800rpm for 10–12 minutes) after which platelets were carefully removed from above the buffy coat with a sterile pipette and transferred to a new sterile tube. Platelet activation was induced by adding 20mM calcium chloride solution (CaCl2) in a ratio of 1 CaCl 2:5 PRP by volume, followed by centrifugation at 3000rpm for 10–15 minutes. Collect in between 2/3rd and 1/3rd area of the test tube and PRP ready for use. The resulting supernatant was shaken for 30 minutes to form a coagulum. This coagulum, or “platelet gel”, was used for wound treatment like ointment on wound area.
Statistical analysis: Data was collected and tabulated and statistical analysis was done with p-value recorded as a significance indicator. The significance of the changes in time for wound healing in the three groups was statistically assessed using a one-way analysis of variance, followed by Bonferroni posthoc multiple comparison by SPSS 20.0 (SPSS Inc., Chicago, IL, US). This CI, being narrow, shows more precise estimates, whereas CIs from small sample sizes tend to be wide, producing less precise results.

Results

Total 65 patients were enrolled. All the cases were diabetes patients. In this study, the age of the patients ranged from 35 years to 75 years and the maximum number of cases. Mean age of 55.0±15.44 years. Diabetic history was highest from 45 years to 65 years age group. This is statistically significant. The details of the age group are depicted in (Table 1). No significant association between the pre-existing medical condition and the distribution among the groups. Fig-6 show that male 37(56.9%) and female were 28(43.07%). Male patients were significant. Fig-7 shows the infection length and depth cm details of diabetic patients. The infection length side was highest at 6 cm and 4 cm and an average of 2 cm was on both sides.

Fig-8 shows that back heel left foot 3 month 1(1.5%), Back of middle aspect of heel 3 month 1(1.5%), Back of the foot rt side 1 month 6(9.5%), Back of the heel left foot 2 month 1 (1.5%), Back of the rt foot in under the little finger 2 month 2 (3.2%), Bellow rt heel 6 month 3(4.8), Between the front of the middle toe 4 month 2 (3.2%), Diabetic foot infection both leg 6 month 2 (3.2%), Diabetic foot infection lt leg 6 month 1(1.5%), Diabetic foot infection on 3 month 5(7.9%), Index toe 2 month 2 (3.2%), Left foot middle finger 4 month 1(1.5%), Left great toe 12 month 2 (3.2%), Left foot back side 4 month 3(4.8), Left foot back 4 month 1(1.5%), Left foot lateral part 6 month 2 (3.2%), Left foot thumb 1 month 2 (3.2%), Left foot thumb and index finger 5 month 5(7.9%), Left foot thumb upper part 8 month 4(6.3%), Middle aspect to heel 8 month 2 (3.2%), Middle aspect to right great toe 5 month 8(12.7%), Right foot of thumb 6 month 6 (9.5), Right foot thumb 15 month 4(6.3%), Rt toe amputation 8 month 6 (9.5), Sole of left foot 6 month 4(6.3%). Fig-9 show that PRP dose success rate complete healing 63 (95.9%) and treatment fall 2 (3.07%).

Results:
Total 65 patients were enrolled. All the cases were diabetes patients. In this study, the age of the patients ranged from 35 years to 75 years and the maximum numbers of cases. Mean age of 55.0±15.44 years. Diabetic history 45 years to 65 years was highest age group. This is statistically significant. The details of age group are depicted in (Table 1). No significant association between the pre-existing medical condition and the distribution among the groups. Fig-6 show that male 37(56.9%) and female were 28(43.07%). Male patients were high significant. Fig-7 shows that infection length and depth cm details of diabetic patients. Infection length side was highest 6 cm and 4 cm and average 2 cm was both sides. Fig-8 shows that back heel left foot 3 month 1(1.5%), Back of middle aspect of heel 3 month 1(1.5%), Back of the foot rt side 1 month 6(9.5%), Back of the heel left foot 2 month 1 (1.5%), Back of the rt foot in under the little finger 2 month 2 (3.2%), Bellow rt heel 6 month 3(4.8), Between the front of the middle toe 4 month 2 (3.2%), Diabetic foot infection both leg 6 month 2 (3.2%), Diabetic foot infection lt leg 6 month 1(1.5%), Diabetic foot infection on 3 month 5(7.9%), Index toe 2 month 2 (3.2%), Left foot middle finger 4 month 1(1.5%), Left great toe 12 month 2 (3.2%), Left foot back side 4 month 3(4.8), Left foot back 4 month 1(1.5%), Left foot lateral part 6 month 2 (3.2%), Left foot thumb 1 month 2 (3.2%), Left foot thumb and index finger 5 month 5(7.9%), Left foot thumb upper part 8 month 4(6.3%), Middle aspect to heel 8 month 2 (3.2%), Middle aspect to right great toe 5 month 8(12.7%), Right foot of thumb 6 month 6 (9.5), Right foot thumb 15 month 4(6.3%), Rt toe amputation 8 month 6 (9.5), Sole of left foot 6 month 4(6.3%). Fig-9 show that PRP dose success rate complete healing 63 (95.9%) and treatment fall 2 (3.07%).
Discussion
One of the most common causes of ulcers is growth factor abnormality. Platelets are considered a rich source of growth factors. PRP enhance wound healing by either the barrier effect to prevent bacterial invasion into the wound or the growth factors stimulating wound healing [4]. A total of 65 patients were enrolled. All the cases were diabetes patients. In this study, the age of the patients ranged from 35 years to 75 years and the maximum number of cases. Mean age of 55.0±15.44 years. Diabetic history from 45 years to 65 years was the highest age group. This is statistically significant. The details of the age group are depicted in (Table 1). No significant association between the pre-existing medical condition and the distribution among the groups. Fig-6 show that male 37(56.9%) and female were 28(43.07%). Male patients were highly significant. It was determined that the topical application of PRP for DFUs resulted in a statistically superior healing rate compared to patients receiving conventional wound care with low complication rates. In our study among 65 ulcers, we compared PRP and balanced moist dressing in our center for the management of chronic non-ischemic plantar diabetic foot ulcers. By the end of the 3rd week, 21 cases were healed in PRP group while in the other group, 2 ulcers only were healed. The other group was healed in the 8th week. This result was statically significant. This confirmed the authors‟ hypothesis that patients receiving this treatment results in significantly superior outcomes compared to patients receiving conventional wound management. To our knowledge, this is the first systematic review to evaluate the outcomes of the topical application of PRP versus conventional management of DFUs. Various types of PRP systems exist with variable platelet, leukocyte, and growth factor concentrations. Chronic inflammatory responses against foreign invaders are made possible by leukocytes including lymphocytes, monocytes, neutrophils, eosinophils, and basophils. Recent evidence has shown that leukocyte levels within PRP may have controversial effects on wound healing [8]. Of the studies included in the review, PerezZabala et al [9] reported using leukocyte-poor PRP with high average healing rates of 1.46 cm2/wk. Complication rates after the topical application of PRP were low. Besides the 2.2% incidence of transient wound infections and 0.3% incidence of contact dermatitis, no other adverse effects were reported. The complication rates were significantly lower compared to the 11.1% incidence of wound infection and 0.8% incidence of skin maceration among patients receiving conventional wound treatment. However, further higher-quality studies with randomized controlled trials are necessary to justify the use of PRP over more cost-effective treatment methods. Most publications apply PRP only on the wound but we apply both activated PRP and PPP. PRP enrich the wound with multiple growth factors for cell migrations and neo-angiogenesis while PPP contains nutrients for healing [10]. Fig-8 showed detailed results of different areas affected and treated. Saad et al [11] compared the results of both PRP and PPP on ulcer healing and showed that healing in PRP group was faster (P < 0.005) than PPP. Our findings mirrored those of Lone et al. [12] who used PRP to treat DFUs. They showed that 62.85% of patients developed granulation tissue by the end of the second week and 77.78% of patients reached 100% granulation at the end of the 3rd week [13]. Also, McAleer et al reported good results of PRP in chronic foot ulcers in a 57-year-old man [14]. Another study reported the synergistic effect of both autologous adipose tissue and PRP in a case study of a diabetic 65-year-old male patient who had a foot ulcer for 3 years [15]. Scimeca et al [16] published the successful result for the treatment of chronic plantar diabetic ulcers in a 49-year-old man using PRP [17]. Fig-9 shows that the PRP dose success rate of complete healing is 63 (95.9%) and treatment fall 2 (3.07%). A retrospective cohort of 599 patients with diabetic foot ulcers was published and reported complete healing in 50% of patients undergoing PRP treatment and 41% of patients not treated with PRP [18]. Future studies can improve by designing more prospective comparative trials, increasing study sizes, and standardizing clinical outcome measures such as healing rates, percentage of ulcers completely healed, and ulcer area at baseline and final follow-up. Another possible limitation of this review is that other relevant studies on this topic could have been excluded, despite conducting a systematic search.




Conclusion
Foot ulcers affect the quality of life of diabetic patients. In our study, the results confirm that the use of PRP and PPP increases the ulcer healing rate. These results provided a promising method for ulcer treatment. The future of PRP therapy is promising and still evolving. PRP is being used increasingly in fields such as dermatology, cosmetic surgery, and dentistry, as well as sports medicine and orthopedics. Further randomized controlled studies that show clinical outcome improvement in multiple parameters are necessary to evaluate the true efficacy of this treatment.

Conflict of Interest: None.
Source of Fund: Nil.
Authors’ Contribution: All authors contributed to this present study.

References:
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⦁ Ahmed M, Reffat SA, Hassan A, Eskander F. Platelet-Rich Plasma for the Treatment of Clean Diabetic Foot Ulcers. Ann Vasc Surg. 2017; 38:206–211.
⦁ Perez-Zabala E, Basterretxea A, Larrazabal A, Perez-Del-Pecho K, Rubio-Azpeitia E, Andia I. Biological approach for the management of non-healing diabetic foot ulcers. J Tissue Viability. 2016; 25:157–163.
⦁ Saad Setta H, Elshahat A, Elsherbiny K, Massoud K, Safe I. Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. 2011; 8:307–312.
⦁ Cruciani, M., Lipsky, B.A., Mengoli, C. and de Lalla, F. (2013) Granulocyte-Colony Stimulating Factors as Adjunctive Therapy for Diabetic Foot Infections. The Cochrane Database of Systematic Reviews 8, CD006810.
⦁ Saad Setta, H., Elshahat, A., Elsherbiny, K., Massoud, K. and Safe, I. (2011) PlateletRich Plasma versus Platelet-Poor Plasma in the Management of Chronic Diabetic Foot Ulcers: A Comparative Study. International Wound Journal, 8, 307-312.
⦁ Lon, A.M., Zaroo, M.I., Laway, B.A., Pala, N.A., Bashir, S.A. and Rasool, A. (2014) PRP versus Conventional Dressings in the Management of Diabetic Foot Ulcers: A Prospective Case-Control Study. Diabetic Foot & Ankle, 54, 671-678.
⦁ McAleer, J.P., Sharma, S., Kaplan, E.M. and Persich, G. (2006) Use of Autologous Platelet Concentrates in a Nonhealing Lower Extremity Wound. Advances in Skin & Wound Care, 19, 354-363.
⦁ Margolis, D.J., Kantor, J. and Santanna, J. (2001) Effectiveness of Platelet Releasate for the Treatment of Diabetic Neuropathic Foot Ulcers. Diabetes Care, 24, 483-488.
⦁ Scimeca, C.L., Bharara, M. and Fisher, K.T. (2010) Novel Use of Platelet-Rich Plasma to Augment Curative Diabetic Foot Surgery. Journal of Diabetes Science and Technology, 4, 1121-1126.
⦁ Everts, P.A., Brown Mahoney, C. and Hoffmann, J.J. (2006) Platelet-Rich Plasma Preparation Using Three Devices: Implications for Platelet Activation and Platelet Growth Factor Release. Growth Factors, 24, 165-171.
⦁ Kakagia DD, Kazakos KJ, Xarchas KC, Karanikas M, Georgiadis GS, Tripsiannis G, Manolas C. Synergistic action of protease-modulating matrix and autologous growth factors in healing of diabetic foot ulcers. A prospective randomized trial. J Diabetes Complications. 2007; 21:387–391.
⦁ Driver VR, Hanft J, Fylling CP, Beriou JM; Autologel Diabetic Foot Ulcer Study Group. A prospective, randomized, controlled trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage. 2006; 52:68–70, 72, 74 passim.
⦁ Li L, Chen D, Wang C, Yuan N, Wang Y, He L, Yang Y, Chen L, Liu G, Li X, et al. Autologous platelet-rich gel for treatment of diabetic chronic refractory cutaneous ulcers: A prospective, randomized clinical trial. Wound Repair Regen. 2015; 23:495– 505.
⦁ Saldalamacchia G, Lapice E, Cuomo V, De Feo E, D‟Agostino E, Rivellese AA, Vaccaro O. A controlled study of the use of autologous platelet gel for the treatment of diabetic foot ulcers. Nutr Metab Cardiovasc Dis. 2004; 14:395–396. 

Transfusion effect of random donor platelet and single donor platelet in thrombocytopenic patients at tertiary care hospital of M Abdur Rahim Medical College Hospital Dinajpur, Bangladesh

Abstract
Background: Platelet transfusions are typically not recommended for patients with TTP because they have been hypothesized to provoke fatal thrombotic events. Since Platelets were first identified in 1881, there has been continuous and accelerating progress in our basic understanding of platelet function. Platelet Rich Plasma-Platelet concentrate (PRP-PC) and Apheresis-PC were prepared and their therapeutic efficacy were assessed in thrombocytopenic patients.
Methods: This platelet study was done during time of ———————————at Blood bank and clinical departments after obtaining the ethical committee clearance from the same institute. Patients with different diseases with severe thrombocytopenia who require therapeutic platelet transfusion were subjects of the study. 25 patients were evaluated for therapeutic efficacy of RDP prepared by PRP method and 25 patients were evaluated for SDP. The post transfusion efficacy of transfused platelets was assessed at 1 hour and 24 hours by corrected count increment (CCI) and percentage recovery (PR). Paired ‘t’-test was used for statistical analysis and a probability of p<0.05 was used to reject null hypothesis.
Results: This study included 50 patients for transfusion episodes (25 patients each for SDP and RDP) consist of 25 SDP and 147 RDP units. It shows RDP and SDP transfusion in various diseases. Ideally the platelet dose to be transfused needs to be calculated according to weight of patient. The mean weight of the patients who received SDP and RDP were 54.06±6.0 kg and 53.9±8.08 kg (mean±SD) and ranged from 37-62 kg, and 35-67 kg respectively. The mean platelet dose of SDP (n=25) and RDP (n=25) was 2.86±1.05 x 1011 and 2.36±0.54 x 1011 respectively. The mean platelet increments of SDP at 1 hour and 24 hours were 38±18.1 x 103/μl and 37.3±20.7x 103/μl. The mean platelet increments of RDP at 1 hour and 24 hours were 28.5±11.4 x 103/μl and 26 ±11.6 x 103/μl. The mean CCI of SDP at 1hour and 24 hours were 21.4 ±7.3 x 103/μl and 20.8±7.4 x 103/μl respectively. The mean CCI of RDP at 1hour and 24 hours were 18.5±6.3x 103/μl and 17.4±7.6 x 103/μl respectively.
Conclusions: Post-transfusion increments were significantly higher in patients who received SDP as compared to RDP, but the CCI and PR were comparable in both groups of patients.
Keywords: Corrected count increment, Random donor platelet, Single donor platelet.

Introduction
Platelet transfusions are not usually recommended for patients with TTP because they are believed to cause fatal thrombotic events. Since platelets were first identified in 1881, there has been continuous and increasing progress in the understanding of platelet function. [1] Platelets are enucleated, discoid cells. In a patient weighing 70 kg, this can increase the platelet count by 30,000–60,000/μl. [1, 2] Transfused platelets have a short life span and should be re-administered within 3–4 days if administered prophylactically. Suboptimal increases may occur due to non-immune destruction or immune refractoriness. Despite their relatively small size, platelets play a vital role in maintaining hemostasis. The first successful attempt to increase platelet counts in thrombocytopenic patients by whole blood transfusion was reported by Duke in 1910. Platelets from individual donors are more effective than platelets from random donors. One unit of platelets from an individual donor is equivalent to 6-8 units of platelets from a random donor. Platelets from individual donors are obtained through a more efficient component separation system, so they are less likely to contain other components such as red blood cells. Two types of platelet concentrates are available for transfusion. The first is a by-product of regular blood donations. Random donor platelets (RDP) include platelet-rich plasma platelet concentrates (PRP-PC) and buffy coat platelet concentrates (BC-PC). The second is single donor platelets (SDP-apheresis-PC), which can be obtained from platelet-depleted volunteer donors using an automated cell separator. The initial recommended dose for an adult is 6 units of pooled random donor platelets or one apheresis unit; For pediatrics, the dose is 5-10mL/kg. This dose will usually increase the platelet count by approximately 25K-35K/microliter. Platelet transfusions are the primary therapy for thrombocytopenia due to various causes. Superiority of SDP over RDP transfusions is largely assumed, but unproven. Now a day, there has been an increasing trend toward using SDP by Apheresis as an alternative to pooled RDP for platelet transfusion therapy.[2,3] The use of SDP is preferred over RDP as it represents fewer donor exposures and, therefore, lowers risk of virus transmission, alloimmunization, and transfusion-associated septic reactions and “better” platelet quality.

Methods
This platelet study was done during time of ———————————at Blood bank and clinical department after obtaining the ethical committee clearance from the same institute. Patients with different diseases with severe thrombocytopenia who require therapeutic platelet transfusion were subjects of the study. 25 patients were evaluated for therapeutic efficacy of RDP prepared by PRP method and 25 patients were evaluated for SDP. Patient with idiopathic thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP) are excluded from the study. During this period, total number of 50 Single Donor Platelet apheresis procedure were done on Baxter CS 3000 plus with AMS cell separator (Fenwal, USA) and com.tec cell separator (Fresenius Kabi, Germany) using closed system apheresis kits and studied with respect to details of voluntary blood donors, patients and test procedures.
All data were expressed as mean±SD. We performed statistical comparison by using paired ‘t’-test for multiple groups. A probability of P<0.05 (two sided) was used to consider the difference as significant and to reject null hypothesis. Windows SPSS version 23 software was used to do all statistical analysis.

Results
This study included 50 patients for transfusion episodes (25 patients each for SDP and RDP) consist of 25 SDP and 147 RDP units. Table 1 show majorities of RDP transfusion were done for hematological malignancy and SDP for dengue fever. It shows RDP and SDP transfusion in various diseases. Ideally the platelet dose to be transfused needs to be calculated according to weight of patient. The mean weight of the patients who received SDP and RDP were 54.06±6.0 kg and 53.9±8.08 kg (mean±SD) and ranged from 37-62 kg, and 35-67 kg respectively. The dose of RDP was calculated by 10 ml/kg body weight of the patients. The mean platelet dose of SDP and RDP were 2.86±1.05×1011 and 2.36±0.54×1011 (mean±SD) and ranged from 1.7-4.6× 1011 and 1.1-4×1011 respectively.

All SDP transfusions were ABO identical and RDP transfusions were ABO compatible whenever possible but also given other group. On analyzing the parameters in total numbers of patients for each platelet preparation, it was observed that the dosage available from SDP was significantly higher (P<0.023).While post transfusion platelet increments at 1 hr and 24 hrs were significantly higher with SDP transfusion as compared to transfusions with RDP (P<0.01 for 1 hr and 24 hrs post transfusion period). However, the CCI and PR in both the groups were comparable and the difference was statistically not significant. The overall platelet counts and increments of the both groups are shown in detail in Table 2.

Discussion
Alloimmunized thrombocytopenic patients do not respond to platelet transfusions from random donors, but often respond to HLA-identical platelets from individual donors. HLA-matched platelets are expensive, take a long time to manufacture, and donors may not be available. The ability of transfused platelets to circulate and function depends on both the effects of extracorporeal storage injury that affects platelet function and the state of the transfused patient’s in vivo environment.[4] Platelet changes can be divided into three broad categories: platelet activation, metabolic changes, and platelet aging. Carefully prepared and immediately transfused without significant storage (within 24-48 hours of donation) consistently show high recovery rates, good survival, and maintenance of function.[5] A single donor platelet concentrate containing approximately 3×1011 platelets is expected to raise platelet count by 30,000- 60,000/µl, while random donor platelets containing approximately 7×1010 platelets increase the platelet count by 5,000- 10,000/µl in an average sized adult. Most institution adopted policies for “standard” platelet dose to give one platelet concentrate / 10 kg of body weight and this should increase the platelet count by approximately 40,000/µl. Post-transfusion platelet recovery is usually about 60% of the number of autologous platelets transfused, but may be as low as 20% to 40% after homologous transfusion in patients with factors affecting platelet recovery. The post-transfusion platelet count is affected by the viability of the platelets as well as the number of platelets in the platelet concentrates. It is also affected by the dilution of platelets in the patient’s blood volume. CCI and PR are measures that have been used to correct the post-transfusion platelet count for the patient’s blood volume and for the number of platelets in the platelet concentrates.[6] In this study patients who received SDP, the post- transfusion platelet counts increments achieved were significantly higher as compared to patients who received RDP (P< 0.01). However, when CCI and PR were calculated, the results with both preparations were comparable (p values are not statistically significant). Anderson et al demonstrated that the actual CCI at 1-6 and 18-24 hrs post-transfusion for all three types of PC (SDP, PRP-PC, BC-PC) did not differ significantly. They concluded that transfusion of PRP-PC is associated with a significant increase in non-hemolytic febrile transfusion reaction. The results of Anderson et al study was also comparable to present study and we found that those patients who received RDP had significantly low post- transfusion platelet count increments at 1 hr and 24 hrs as compared to patients who received SDP. The post transfusion therapeutic efficacy assessed by CCI and PR at 1 hour and 24 hours were comparable in both groups of patients.[7] Singh RP et al had concluded that patients transfused with apheresis PC had received higher platelet dosage than PRP-PC and Buffy Coat PC (BC-PC) and this difference was statistically significant (P<0.001). The post transfusion platelet counts and increments at 1 hour and 20 hours were significantly higher with apheresis-PC than PRP-PC and BC-PC (P<0.001). However, the CCI and PR in all three groups were comparable. This study was also comparable with present study.[8] Norol et al comparing the platelet doses, increments and PR in AML patients who had undergone allogenic BMT, it was observed that higher the dosage, higher was the platelet counts, increments but PR was similar. Three platelet doses [(medium dose (2-4 × 1011 platelets), high dose (4-6 × 1011 platelets) and very high dose (>6 × 1011 platelets)] were transfused. The author showed that increments in 12 hours post-transfusion platelet count and the time to next transfusion increased with higher platelet doses and this difference was statistically significant (P<0.01 to 0.05), but the percentage recovery was similar in all three groups and statistically not significant. The post transfusion therapeutic efficacy assessed by CCI and PR at 1 hour and 24 hours were comparable in both groups of patients and statistically not significant.[9] SDP provided better post-transfusion platelet counts and CCI (p values are 0.0004 and 0.0001) but this did not translate into clinically important parameters. The author concluded that in the context of allogeneic hematopoietic stem cell transplantation, PPC are as clinically effective as SDP. This study also comparable with present study in all aspects except one matter, CCI was comparable in both the groups (SDP and RDP transfusions) in present study.[10] Random-donor platelets that were strongly positive in the crossmatch with serum from a patient became negative after treatment with the acid solution. Furthermore, transfusion of these platelets gave a post-transfusion, platelet-count increment comparable with transfusion of HLA-compatible single-donor platelets.

Conclusion
From this study, it can be concluded that platelets generated by both methods were very satisfactory after generation. Post-transfusion gains were significantly higher in patients who received SDP compared to RDP, whereas CCI and PR were comparable in both patient groups. However, in developing countries, due to higher costs and the need for greater expertise, SDP may be recommended only for selected patients when RDP is not available in sufficient doses or when HLA-matched platelet transfusions are required.

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