Abstract
There are a large number of publications describing the use of platelet-rich plasma (PRP) in multiple fields of application. These illustrate a large number of therapeutic elements with different and specific actions within ‘platelet gel’ (this term is used in the current regulations to define this product). This term, however, lacks specificity and, depending on the method used in its production is variable both in its blood composition and in platelet concentration, and several publications consider better and easier methods of platelet gel production, which may or may not lead to greater standardization in the product. The authors illustrate the general aspects of PRP and other blood components for non-transfusion use, briefly touching on the history and different fields of application and the rational of for its use. Given the increased use of such preparations, the authors describe critically the regulations in force in Europe and propose a new regulatory framework aimed to simplify and facilitate the use of such material as a therapeutic agent within medicine.
Introduction
The promising results of early trials on the use of platelet concentrate as an inductor of bone growth in spongious bone transplant 1 have initiated scientific progress and clinical experience in the use of platelet-enriched plasma as a source of growth factors with the aim of increasing tissue regeneration and repair. This procedure was initially introduced in the field of odontostomatology, but it was rapidly introduced immediately as a clinical tool to enhance tissue healing, in the treatment of many pathologies. The clinical use of this technique includes soft tissue repair including the regeneration of skin ulcers, tendons, corneal epithelium 2–5 and it is now widely used in the regenerative medicine area. Growing clinical application and promising results have led to increased scientific interest and specific research to better understand the mechanisms of action and potential use of various platelet formulations. The large literature describing the wide variety of applications in which platelet-rich plasma (PRP) has been used also reveals that ‘platelet gel’ (this term is used in the current regulations to define this product) is a non-specific term that, in its production, leads to many heterogeneous product types and different potential uses. Some applications are in liquid form, others so thick that the material can be sutured. Different extraction processes can produce material intended to educe growth factors, or encourage the extraction of stem cells and the efficiency of the production itself has come under some scrutiny.
Briefly, the process of preparing PRP consists of four phases: blood collection, centrifugation for platelet concentration, induction of gelation (if the PRP is to be used in gel form) and activation. In general, most systems, whether large or small volume, do not concentrate the plasma proteins of the coagulation cascade.
The classical platelet gel consists of concentrate plasma that contains more than 300,000 platelets. In a single injection, the PRP acts to stimulate the production of skin fibroblasts and favours tissue growth by promoting collagen synthesis. 6
The wide use to which this material has been put is illustrated in a number of publications. Platelet gel is used in oral and maxillofacial surgery. 7,8
The release of platelet growth factors is said to enhance bone grafts maturation, help tissue repair and reduces the risk of graft dehiscence and infection. 9 In orthopaedic surgery the application of platelet gel has been reported as being extremely helpful both in osteosynthesis procedures, and in the treatment of soft tissues lesions where it was also used in addition to bone matrix leading to shorter and better healing. 10
The efficacy of the regenerative stimuli evidenced after the application of activated platelets on bone led to the idea that the same stimulus could also be used to restore coetaneous lesions (ulcers, necrosis and fistulas). 11,12
Several publications show beneficial effects of the use of platelet gel in the adjuvant treatment of tissue regeneration. In particular, in patients with inveterate chronic ulcers of the lower limbs, it allowed a faster induction of granulation, leading to lesion healing and reversal of the clinical deterioration. 2,3,13–15
Wound healing occurs in four phases: haemostasis, inflammation, proliferation and remodelling, during which, platelet growth factors serve as messengers to regulate a complex series of events involving cell–cell and cell–matrix interactions that promote the proliferation of mesenchymal and other stem cells at the wound site. 16 The treatment of wounds with PRP gel induced accelerated epithelial differentiation and produced tissue with organized, interlocking collagen bundles.
In a study in 2003, sequential wound biopsies collected at days 7, 36 and 79 postwounding, demonstrated that wounds treated with PRP gel exhibited more rapid epithelial differentiation and enhanced organization of dermal collagen compared with controls. 17
The addition of platelet gel in the treatment of chronic ulcers demonstrated that the successful tissue regeneration due to the platelet growth factors was not dependent on the type of lesion; 18–20 the approach has been used to treat a variety of ulceration types: traumatic, vascular (arterial and venous), neuropathic, diabetic and pressure. 14,21
Recently, the use of topical blood components has spread to the treatment of various degenerative and traumatic pathologies of mesenchymal tissues and, in particular, in the treatment of tendon lesions arising from traumatic events. 4 In these conditions the gel is used as a regenerative and anti-inflammatory stimulus for tendon lesions with delayed regeneration epicondylitis or fasciitis. The patients are mostly young, with sports or work-related injuries that result in major activity limitation. Clinical observation reveals that significant benefits can be achieved from this kind of treatment. Pain relief was observed after a week with substantial reduction in pain after 15 days and a reduced swelling. A second injection generally leads to resolution of the problem; inflammatory processes are turned off and there is an almost complete restitution of normal activity. 4
One of the more recent applications is its use in the treatment of degenerative pathologies of intervertebral discs. The goal is the same; enhance tissue regeneration with platelet growth factors and stimulate the transport of mononuclear cells, important for the regeneration process, to the site of lesion. 22,23
Platelet gel is injected into the degenerating intervertebral disc under radiological control in a process that is minimally invasive and avoids hospitalization. Patients often experience rapid improvement of their symptoms leading to early total recovery.
Given the increasing potential for the use of this biological material we have looked critically at the regulations in force in Europe and, propose a new regulatory organization, aimed at the simplification of its used in medicine.
The aims of this paper are: (a) a description of the uses of ‘platelet gel’; (b) an overview of current legislation; (c) critical reading of the regulation; (d) identification of the limitations and (e) proposed new regulatory organization.
Current regulations
Platelet gel is of human origin, and is considered to be a blood component, and thus subject to regulations that define transfusion activities.
In order to understand the sense of the current European regulations it is necessary to differentiate between blood components for topical use and those used in cell therapy, which involves complex techniques of bioprocessing of therapeutic cells. Therefore, the set of rules must be shaped on products that maintain the quality standards of biopharmaceutical drugs. Accordingly, the regulations are linked to the related laws, which describe a complex pathway for authorization. Reference is made to the Regulation n. 1394/2007 of the European Parliament (EC) and of the Council 13 November 2007 on medicines for advanced therapies, where the definition of ‘bioprocess engineering products’ is given. Here it is specifically said that this definition excludes those products that contain, or are made exclusively of, cells and non-vital human or animal tissues and that do not have pharmacological, immunological or metabolic action. Included among the advanced therapy pharmaceutical products are those used for gene and somatic cell therapy (Directive 2001/83/(EC) –European Community-, Annex I). Cells and tissues are to be considered products of bioprocess engineering if they undergo ‘considerable manipulation’. The same regulation defines the difference between extensive and minimum manipulation, and lists, which are considered relevant, or not. Manipulations that are not considered ‘bioprocess engineering’ are: cutting, grinding, shaping, sterilization, centrifugation, soaking in antibiotic or antimicrobial solutions, sterilization, irradiation, separation, concentration or purification, filtration, lyophilisation, freezing, cryopreservation and nitrification.
The extensive manipulation of cells and tissues is a process that may lead to cell activation and/or a stimulation of cell proliferation and these are also considered ‘extensively manipulated’ cells that, although not specifically activated or stimulated to proliferate, are associated with biomaterials. All cells that have undergone a manipulation of their genes are considered to be ‘extensively manipulated’.
As mentioned, blood components for topical use are differently considered even when used with a regenerative purpose. These are included among those cited from the Law n. 219 21 October 2005 concerning new transfusion activities and the national production of blood components. The M D 3 March 2005, Annex n. 2 gives a precise description of the modalities of donation, preparation and storage of ‘blood components for non-transfusion use’. These regulations rule any linked activity.
The definition of medicines for advanced therapy excludes non-repetitive preparations carried out under supervision of a physician, running a personal prescription for a product specifically designed for that particular patient, without, of course, violating the relevant rules relating to quality and safety.
It is important to underline the foregoing, to frame properly the legal considerations related to blood components for non-transfusion use and explain the rationale behind the reserve given by the standard in force. It is considered equally appropriate to highlight the differences between the production of blood components suitable for cell therapy compared with those directed to topical use. While the first, require special handling procedures and details of product derivation, the second, where the effect is extrinsic and an amplification of physiological function at the site of insertion, is much simpler with the product being – easily derived by simple physical means, but nonetheless important to include within the legislation while not limiting its use.
All the rules have a common purpose: ensure voluntary donation of blood components; self-sufficiency of blood, blood components and plasma-derived products; guarantee the donors and recipients health; quality and safety of the procedures and the products of transfusion medicine. In addition, the rule clarifies that the therapeutic use of blood products cannot be a source of profit, as pronounced in Article 1, Law 1 October 2005, n. 219, ‘New discipline of the transfusion activities and national production of blood components’. The Law also provides a number of other specific technical standards, such as the MD 3 March , 2005, ‘Characteristics and methods for the donation of blood and blood components’, and subsequent additions and modifications’. Likewise, the Legislative Decree of 20 December 2007, n. 261: ‘Review of Law 19 August 2005, n. 191, implementing Directive 2002/98/EC setting standards of the quality and safety for the collection, processing, storage and distribution of human blood and its components’.
Later, rules are designed to encode all actions related – always considering transfusion medicine as an activity reserved to approved facilities – such as the Decree of 9 November 2007, n. 207, ‘Implementation of Decree 2005/61/EC implementing Directive 2002/98/EC for what concerns the prescription in means of traceability of blood and blood components intended for transfusion and the notification of adverse and severe reactions’ and the Legislative Decree of 9 November 2007, n. 208, ‘Implementation of Directive 2005/62/EC implementing Directive 2002/98/EC with regard to standards and specifications relating to a quality system of blood’.
The main articles that encode the management of human blood and its products are summarized below.
The requirements for storage of blood components are already part of the law for the transfusion medicine activity, Law 219/05, where the area that is intended to be protected is already expressed. The Law states, ‘Discipline for activities related to human blood transfusion and its components and for the production of plasma derivatives’. This concept is confirmed by the MD 3 March 2005 – also required by the same law and therefore has the same importance – which further specifies that the article content is about ‘… All the activities related to the allocation, conservation and distribution of human blood and its components…’
The following Legislative Decree 261/07, Art. 1, n. 1 further specifies, ‘This decree applies to the collection and testing of human blood and blood components, to any intended purpose…’
To assert the concept expressed, the severity of the penalties provided by the law 219/05, which in the Art.22, first paragraph reads that ‘Unless the act is not a more serious crime, anyone who collects, affords, stores and distributes blood, or produces with the intent to market products or offers for sale blood outside of accredited facilities or without the authorizations required by law or for profit, shall be punished with imprisonment from one to three years and a fine of 206 euro to 10,329 euro…’
And again, the second paragraph provides that ‘If the offender is a person who practices in the health care system, at the condemnation follows the disqualification from the profession for the same amount of time’. To make the punishment more severe, it is extended to the facility in which the rule is substantially violated, the third paragraph of the same article provides that ‘In the cases referred to paragraph 1, the health facility unit responsible for the area is in charge of the closure of the non-authorized facility…’
With the Note to prot. N.DPGV. XIII/CNST. 3Q/2181 09.05.2002 the Italian Ministry of Health expressed the opinion that blood products for topical use should be subject to the same reserve, production, conservation and allocation reserved for the other blood components.
Moreover, also the Italian Board of Health has also expressed its opinion on the topic, reiterating the concepts previously mentioned.
Since this activity, usually, involves many, it is considered appropriate to mention the Article 110 c.p. which reads: ‘When more people compete in the same offence each of them will be condemned as decided…’
In addition to this, in our opinion, the reserve so strongly represented by the EU and national legislation, and in the light of our experience with blood transfusion, is grounded in a series of brief considerations that will be reported: the need to protect the good health, in any case constitutionally protected; the fact that public facilities are indifferent to possible commercial pressure; the potential hazard of the product; the need to guarantee quality and effectiveness of the product and its complete traceability.
In conclusion the topical use of these components may be a benefit to the patients and provide a significant cost saving; their safe administration is paramount.
Organization
As has been indicated, these products have a homeostatic, sealant, adhesive and stimulating actions and there are many fields of application which will also determine the method of blood sampling, its preparation method (manual or automated), storage (including freezing) and dispensing, sometimes all at once, sometimes in repeated session at appropriate intervals of time.
The management of such an organization concerned with production and provision of these topical preparations must be administrated by the staff within the same facility.
However it is also important to allow, the ready and easy use of such products.
With this assumption, considering the operational realities of the transfusion facilities and the foreseeable needs of the users, it is important to draw up protocols that facilitate the safe and easy use of these products.
The protocols must consider:
Where the product is produced; The features of the product− that is being produced and its therapeutic action; Operators qualifications; Quality, sterility and efficacy controls; Inspections and frequent audits.
It is important to define better rules and quality standards for the management of these blood components for topical use, both at national and regional levels, with reference to the community legislation on blood transfusion.
Transfusion medicine already considers haemovigilance, looking at the safety and the final clinical efficacy (benefit/risk ratio) in relation to collection, handling and storage of the blood components. Nevertheless, additional manipulation stages (that anticipate the application of the product) will require a management system within transfusion medicine to register these products.
Therefore, the Italian Health Care Range of Fees that concern the outpatient services, should be modified, including in it all those activities that make use of blood components for topical use that should be considered at the same level of other outpatient services.
As already happens for disposable blood components, the management and the activities connected to allogenic and autologous donation, the collection of the product, the preparation and its distribution must be referred back to the Transfusion Medicine Service and supervised by appropriately trained staff involved in the therapeutic treatment.
Since the number of potential applications for these topical blood component products is high, the following must be taken into consideration:
The need of a multidisciplinary collaboration between experts in Transfusion Medicine and other specialities involved (surgeon, dermatologist, angiologist, diabetologist and anaesthesist specialized in pain therapy); The diagnostic and therapeutic path should be decided with the cooperation of all the specialized figures involved.
In conclusion, in order to define a correct operational organization for the diffusion and the utilization of blood components for topical use, we suggest the following organization framework.
Organization framework
Present organization and critical aspects
The request for use of these products is increasing especially in some specialties such as orthopaedic surgery, plastic surgery, dentistry, ophthalmology, traumatology, etc. However, since the manufacturing of this product is restricted to transfusion facilities, even if produced using a small amount of blood, production cannot currently meet demand blood components are, thus, either not used or, worse, used without an adequate restrain because they are produced independently from a transfusion facility.
The small number of transfusion facilities that are able to deal with such a field of transfusion medicine, and the general lack of suitably trained staff, limits use of these therapeutic techniques, particularly in care facilities that are not connected to the public health system.
Organization proposal
The new proposal (well defined in other regions) assigns the management of production of blood components for topical use to Transfusion Medicine facilities with supervision of the activities at Blood Regional Centres (or similar). They would be responsible for defining and implementing the relevant rules and regulations.
We believe that this model is more appropriate in respect of the standards defined by law allowing for the preparation and utilization of these topical blood component preparations independently of the transfusion services: the material envisaged being prepared for use is the manufacture of platelet gel – which includes platelet growth factors – or similar products obtained from peripheral blood, including fibrin glue.
Although there is currently a very poor evidence base for the use of these therapeutic materials the introduction of a proposal that allows the manufacturing of blood components in different facilities, while maintaining the correct standards of preparation and application in private and public facilities, will lead to a material that can be safely used and properly evaluated for its potential efficacy.
According to the actual laws, the preparation of blood components is under the Transfusion Medicine responsibility. Those hospitals (without transfusion services) that wish, which to use these bioactive products, must be provided a medical expert, a Referee Coordinator, responsible to the transfusion services. The person in charge must be qualified as stated in the bill n. 261 20 December 2007, and receive a special training that will be certified by the company that produced the disposal. The name of the coordinator will be formally announced by the company to the health-care facility place of the transfusion services, which will also benefit of special agreements. Additional, not-qualified-for transfusion services, personnel may take part to the same activities if what is said in the bill n. 261 20 December 2007 is satisfied. In the same way any public or private hospital, or professional that does not have a transfusion service, may cooperate with experts qualified for such services. In any case, agreements with specialized facilities are needed.
The convention, signed in accordance with DM 1 September 1995 ‘the conduct of relations between the public facilities provided with blood transfusion services, and between public and private, non-accredited, equipped with a mini blood bank’, represents an act to grant authorization for the activity. The operational procedures must be described in the Annex to the Convention and will concern the scope of the product, the model of informed consent, the procedure of preparation of the blood components, the name of the Referee Coordinator.
For each service this must be performed:
Evaluation of the indication for use and of the clinical validity; Evaluation of the eligibility of the patient for the blood draft; Blood draft in asepsis: regardless of the method of production of blood components asepsis must be respected in all stages of production and application of the platelet gel, as well as the platelet mean concentration that is considered effective from the literature (1.5×109 per μL); in the case of an open system, the asepsis must be controlled for each sample (1/20 patient); Records of law for traceability.
Whenever there is more than one procedure, ABO and Rh group should be determined and a Hepatitis B surface antigen (HbsAg), Hepatitis C virus (HCV), anti-hepatitis C antibody (HCVab) and anti-HIV 1–2 screening is undertaken.
In addition, periodically and at least once a year, the transfusion facility reference must be informed of the preparation processes used and their application along with evidence of a correct conservation of the products through delivery of appropriate documentation.
Summary of the regulations
Law 21 October 2005 n. 219
(‘Discipline for transfusion activities related to human blood and its components and for the production of plasma’)
This is the principal law for this topic, it defines which facilities are adequate for the transfusion medicine activities and indicates the fees.
Bill 6 November 2007, n. 191
(‘Implementation of Directive 2004/23/EC on setting standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells’)
Bill 9 November 2007, n. 207
(‘Implementation of Directive 2002/98/EC implementing Directive 2005/98/CE concerning the requirement for traceability of blood and blood components intended for transfusion and notification of adverse reactions’)
The transfusion services and the collection units must, for 30 years, guarantee the traceability of blood and blood components regardless the use (see Art. 2, nn. 1, 2, 3 and 5) taking care of what follows:
Accurate identification procedures; Keeping registers; Adequate labelling system; Traceability of the location and the stage of production; Single identifier; Appropriate procedures that can verify that the unit was transfused to the right person or (if not transfused) the destination. All the severe adverse reactions; The transmission of infections with a transfusion; Describe the measures adopted for the other blood components; Evaluate the possible adverse reactions; Complete the notification when the research is finished with the appropriate modules; Turn in within 02/28 of the following year an accurate report on severe adverse reactions by using the appropriate modules. Prepare (and keep for 30 years) a system to record each unit and the final destination, whatever is transfused, discarded or returned (see Art. 5, n. 1); Notify the SIMT any severe side-effects attributable to the quality and safety of blood and blood components (see Art. 5, n. 1).
The following must be notified with the appropriate modules to the authorities:
The facilities that receive blood or blood components must:
Bill 9 November 2007, n. 208
(‘Implementation of Directive 2005/62/EC implementing Directive 2002/98/EC with regard to standards and specifications relating to a quality system of blood’). Published in the ordinary supplement of the Official Gazette, general series, on 9 November 2007, n. 261.
The responsibility for monitoring binds, each for their part of responsibility, all those who exercise their activities in blood transfusion services and collection units. The whole process from the selection of the donor to the production of the material – blood component or blood product – ready for transfusion, is equivalent to the production of drugs and require the same compliance with a good manufacturing practice. It follows that all aspects related to this process, however – the staff, personnel, equipment, the different stages of the process, the traceability of documents, measures of self-control, the management of non-compliance – must be considered in a quality system as to ensure a good management and a continuous improvement. This system of total quality management must refer to a precise figure able to monitor all processes and intervene promptly.
The quality system must include (see Art. 2, c. 1: Annex. 1):
The total management of the system must aim at a continuous quality improvement; Detailed presentation with appropriate instructions of all the critical processes; All processes should be carried out according to the standards and the specifications; The staff; The premises; The equipment; The documentation; The collection, the process control and blood processing; Quality controls of blood components; The withdrawal of the blood components; External and internal audits; The management of contracts for outsourced activities; The management of non-compliance and self-control. Collaboration in solving problems related to quality; Examine and approve all related documents; Validate procedures, premises and equipment affect the quality and them safety of the blood; (‘Review of the legislative Decree 19 August 2005, n. 191, implementing Directive 2002/98/EC setting standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and its components’). The activities relating to the collection and testing of human blood and blood components, including the execution of the biological validation tests provided by law, whatever is their purpose, and to their preparation, storage, distribution and assignment, when intended for transfusion, are performed by blood transfusion services. Limited to the activities of collection of blood and blood components, from the collection units. The entities upon which the blood transfusion services and the voluntary donor associations that manage the collection units adapt their structures to the requirements.
The SIMT and the RU are supported by a function of quality assurance, internal or associated with the task of:
Any substantial change in the activities of a blood transfusion service and a collection unit is subject to prior authorization by the region.
Regions organize inspections and appropriate control measures.
The person in charge of the services has a medical degree and the requirements needed to access the direction of SC in the discipline of Transfusion Medicine. If the person is temporarily or permanently replaced the managing body communicates to the region the name of the new manager.
The staff performs adequate training, regularly updated.
The identification system of the single unit is also adopted for the collection units.
Any serious accident and any adverse reactions must be reported to the Region.
The collection units observe the procedures established by the SIMT technical reference.
The SIMT provides storage and transportation of blood and blood components.
Anyone who prevents, or is otherwise impeded in any way, the performance of duties or the performance of the staff for the planned activities shall be punished with administrative sanctions from €5000 to 30,000.
The report on the activities of SIMT should be sent to the Region in the previous year.
DECLARATION