www.transfuslon.org
`
`Transfusion.
`v. 54, no. 6 (June 2014)
`General Collection
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`Page 1 of 14
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`CSL EXHIBIT 1048
`
`CSL V. Shire
`
`
`
`PROPERTY or m:
`NATIONA
`LIBRARY OLE
`
`~ MEDICINE
`
`
`
`
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`Page 1 of 14
`
`CSL EXHIBIT 1048
`CSL v. Shire
`
`

`

`Table of Contents
`
`EDITORIALS
`
`1447 Transfusion CME hits 50
`A. F. Eller and P.M. Ness
`
`1446
`
`"Do you catch my dr ift?"
`T. Hannon
`1450 Can a comparative database study help to develop :m effective risk index
`system?
`]. Detlton and E. Farag
`
`HOW DO 1 • • • ?
`1452 How do we use molecular red blood cell an tigen typing to supplem ent
`pretransfuslon testing?
`S. Sapatnekar and P.I. Figueroa
`
`Our cover was penned by Jessica Hagy,
`an artist and writer b est known for her
`award-winning blog, lmlexed (http://
`thisisindexed.com/).
`
`TRANSFUSION MEDICINE ILLUSTRATED
`
`1459 Schlstocytes
`]. -R Lesesve, 0 - Fermeteau, aml G. Zini
`
`r-~~~~~~rher. MUU and Cdimrs cannot be held responsible for errors or any consequences arising from the usc of lufnrmation coma!ncd in tltis jou,rnal; the
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`
`TRANSFUSION Volume 54, June 2014
`
`T'hi.! m.st.e_dsl wa.sco.pie<CI
`at the NLNI and mayb•
`
`Page 2 of 14
`
`

`

`TABLE OF CONTENTS (Continued)
`
`BLOOD MANAGEMENT
`1460 Clinical pr d'
`M C G
`e Ictors of postoperative hemoglobin drift
`· · rant, G.]. Whitman, W.]. Savage, P.M. Ness, and S.M. Frank
`~~~~~ting ~lood loss and transfusion requirement in patients undergoing surgery for musculoskeletal tumors
`ompson, D. May, P.H Clwong, M. Tacey, D. Liew, and M.H Cole-Sinclair
`·
`
`1469
`
`IMMUNOHEMATOLOGY
`1478
`~~i~es~io~ of a single-chain human leukocyte antigen-DRA/DRB3*01:01 molecule and differential binding of a monoclonal
`~ E B 0 Y m the presence of specifically bound human platelet antigen-1a peptide
`· · ouwmans, P.A. Smethurst, S.E Garner, W.H. Ouwehand, and S.L. Morley
`J\ttewl bead-based human platelet antigen antibodies detection assay versus the monoclonal antibody immobilization of
`P a e et antigens assay
`L. Porcelijn, B. Huiskes, I. Comijs-van Osselen, A. Chhatta, V. Rathore, M. Meyers, and M. de Haas
`
`1486
`
`1501
`
`TRANSPLANTATION AND CELLULAR ENGINEERING
`1493
`S~perior.ity of preemptive donor lymphocyte infusion based on minimal residual disease in acute leukemia patients after
`a ~gene1c hematopoietic stem cell transplantation
`Y. Ian, K Du, Y. Luo, ]. Shi, L. Cao, Y. Zheng, G. Zheng, Y. Zhao, X. Ye, Z. Cai, and H. Huang
`Ev:Uu~tion of peripheral blood stem cell quality in products transported by traditional courier or commercial overnight
`shippmg services
`A. aoward, P. c_;hitphakdithai, E.K Waller, W. Harris, H. Rosenthal, W. Nelson, N. Majhail, W. Navarro, S. Waldvogel,]. Lisy,
`ecker, ]. Mtller, and S.R. Spellman
`f.
`~ryopreserved stem cell products containing dimethyl sulfoxide lead to activation of the coagulation system without any
`1m pact on engraftment
`A. Holbro, L. Graf, M. Topalidou, C. Bucher, ].R. Passweg, and D.A. Tsakiris
`The natural killer-activating receptor, NKG2D, on CD3+CD8+ T cells plays a critical role in identifying and killing
`autologous myeloma cells
`L. Talebian, D.A. Fischer,]. Wu, ]. Y. Channon, C.L. Sentman, M.S. Ernstoff, and KR. Meehan
`
`1508
`
`1515
`
`TRANSFUSION PRACTICE
`1522
`
`Continuing Medical Education Program in Transfusion
`A.H Eder
`
`1523
`m
`1530
`
`1537
`
`1542
`
`1552
`
`The impact of platelet additive solution apheresis platelets on allergic transfusion reactions and corrected
`count increment
`A.A.R. Tobian, A.K Fuller, K Uglik, D.]. Tisch, P.D. Borge, R.]. Benjamin, P.M. Ness, and K.E. King
`Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation
`K.E Brookfield, L.1: Goodnough, D.]. Lyell, and A.]. Butwick
`The use of an objective structured clinical examination to assess internal medicine residents' transfusion knowledge
`E. Saidenberg and D. Pugh
`Deferasirox improves hematologic and hepatic function with effective reduction of serum ferritin and liver iron
`concentration in transfusional iron overload patients with myelodysplastic syndrome or aplastic anemia
`f.-W. Cheong, H.-]. Kim, K-H. Lee, S.-S. Yoon,].H. Lee, H.-S. Park, H.Y. Kim, H. Shim, C.-M. Seong, C.S. Kim,]. Chung, M.S. Hyun,
`D.-Y. ]o, C. W. lung, S.K Sohn, H.-]. Yoon, B.S. Kim, Y.-D.]oo, C.-Y. Park, and Y.H. Min for the Korean Society of Hematology Acute
`Myeloid Leukemia!Myelodysplastic Syndrome Working Party
`Pharmacokinetics of plasma-derived C1-esterase inhibitor after subcutaneous versus intravenous administration in
`subjects with mild or moderate hereditary angioedema: the PASSION study
`.
`I. Martinez-Saguer, M. Cicardi, C. Suffritti, E. Rusicke, E. Aygoren-Pilrsiln, H. Stoll, T. Rossmanith, A. Feussner, U. Kalma,
`andW. Kreuz
`
`1569
`
`1580
`
`BLOOD COMPONENTS
`In vitro properties of platelets stored in a small container for pediatric transfusion
`1562
`N. 1'ynngard, M. Trinks, and G. Berlin
`Isoprostane and isofuran lipid mediators accumulate in stored red blood cells and influence platelet functi~n in vit~o .
`S.L. Spinelli, KL. Lannan, A. E. Casey, A. Croasdell, T.M. Curran, KE Henrichs, S.]. Pollock, G.A. Milne, M.A. Refam, C. W. Fmncts,
`R.P. Phipps, and N. Blumberg
`Comparison of antibody titers in donor specimens and associated AS-1 leukoreduced donor units
`B.A. Hill and B.]. Bryant
`Quality of red blood cells washed using an automated cell processor with and without irradiation
`A.L. Hansen, T.R. Turner, Q.-L. Yi, and].P. Acker
`The effects of rejuvenation during hypothermic storage on red blood cell membrane remodeling
`].D.R. Kurac/z, R. Almizraq, B. Bicalho, ].P. Acker, and J.L. Holovati
`
`1585
`
`1595
`
`This mate ria I was H}pcied
`at the NLM and may be
`~u bject US Copcyright Laws
`
`Volume 54, June 2014 TRANSFUSION
`
`Page 3 of 14
`
`

`

`TABLE OF CONTENTS (Continued)
`
`1604
`
`1610
`
`Leukoreduced whole blood-derived platelets treated with antimicrobial peptides maintain in vitro properties during
`storage
`M. Bosch-Marce, S. Seetharaman,]. Kurtz, K. V.K. Mohan, S.]. Wagner, and C.D. Atreya
`Determination of thromboelastographic responsiveness in stored single-donor platelet concentrates
`I.]. Bontekoe, P.R van der Meer, and D. de Korte
`
`BLOOD GROUP GENOMICS
`1619 HNA-3 gene frequencies in Brazilians and a new polymerase chain reaction-restriction fragment length polymorphism
`method for HNA-3a/3b genotyping
`.
`.
`L.B. Lopes, W. Baleotti Jr. R.B. Suzuki, A. Fabron Jr. A.K. Chiba, J.P. B. Vieira-Filho, B. de Souza Castro, A.M. Kunwshz, and
`].0. Bordin
`
`HEMAPHERESIS
`1622 Unstimulated leukapheresis in patients and donors: comparison of two apheresis systems
`M. Schulz, H. Bialleck, K. Thorausch, G. Bug, U. Dilnzinger, E. Seifried, and H. Bonig
`1630 Severe pertussis and hyperleukocytosis: is it time to change for exchange?
`A. Kuperman, Y. Hoffmann, D. Glikman, H. Dabbah, and Z. Zonis
`
`DONOR INFECTIOUS DISEASE TESTING
`1634 Evaluation of a rapid colorimetric assay for detection of bacterial contamination in apheresis and pooled random-donor
`platelet units
`W.A. Heaton, C.E. Good, R. Galloway-Haskins, R.A. Yomtovian, and M.R. Jacobs
`1642 A novel approach for rapid detection of bacterially contaminated platelet concentrates via sensitive measurement of
`microbial DNA polymerase activity
`D.R. Zweitzig, N.M. Riccardello, ].M. Pester, R. ]eanmonod, M.]. Kopnitsky, and S.M. O'Hara
`1652 Estimating window period blood donations for human immunodeficiency virus Type 1, hepatitis C virus, and hepatitis B
`virus by nucleic acid amplification testing in Southern Pakistan
`B. Moiz, T. Moatter, U. Shaikh, S. Adil, N. Ali, E Mahar, N. Shamsuddin, and M. Khurshid
`
`BLOOD DONORS AND BLOOD COLLECTION
`1660 Acute hepatitis Bin blood donors over a 5-year period in England and North Wales: who is getting infected?
`G.K. Rosenberg, S. Lattimore, S.R. Brailsford, P.E. Hewitt, K.I. Tettmar, A.D. Kitchen, S. Ijaz, and R.S. Tedder
`
`TRANSFUSION COMPLICATIONS
`Incidence of acute transfusion reactions to platelets in hospitalized pediatric patients based on the US hemo~gilance
`1666
`reporting system
`N. Li, L. Williams, Z. Zhou, and Y.-Y. Wu
`
`REVIEW
`1673 Adoptable strategic approaches to improve outcomes of allogeneic peripheral blood stem cell transplantations from
`unrelated donors
`·
`S.K. Sohn and ].H. Moon
`
`LEITERS TO THE EDITOR
`
`1681
`
`1681
`
`Fresh-frozen plasma should not be given to non bleeding premature infants with "abnormal" coagulation tests
`A.K. Keir and S. Stan worth
`In reply:
`C. Dani
`1682 Parvovirus B19 Genotype 2 in blood donations
`A.M. Eis-Hiibinger, U. Reber, A. Edelmann, U. Kalus, and]. Hofmann
`1685 Does transfusion of salvaged blood products have a significant impact on coagulation?
`B. Ferro,]. Frugiuele, C. Faldini, and S. Bonarelli
`
`OBITUARY
`1686 George Garratty, PhD, FIBMS, FRCPath, 1935-2014
`L.D. Petz
`
`ERRATUM
`1688
`
`TRANSFUSION Volume 54. June 2014
`
`Page 4 of 14
`
`

`

`TRANSFUSION PRACTICE
`
`Pharmacokinetics of plasma-derived Cl-esterase inhibitor after
`subcutaneous versus intravenous administration in subjects with
`mild or moderate hereditary angioedema: the PASSION study
`
`Jnmaculada Martinez-Saguer, 1 Marco Cicardi,Z Chiara Suffritti, 2 Eva Rusicke, 3
`Emel Aygoren-Piirsiln,3 Hildegard Stoll/ Tanja Rossmanith,S Annette Feussner, 6 Uwe Kalina, 6 and
`Wolfhart Kreuz 1
`
`BACKGROUND: Hereditary angioedema (HAE) is a
`rare disease caused by C1-esterase inhibitor (CHNH)
`deficiency, characterized by periodic attacks of acute
`edema affecting subcutaneous (SC) tissues and
`mucous membranes. Human C1-INH concentrate given
`intravenously (IV) is effective and safe, but venous
`access may be difficult. We compared SC and IV
`administration of human pasteurized C1-INH concen(cid:173)
`trate with respect to pharmacokinetics, pharmacody(cid:173)
`namics, and safety.
`STUDY DESIGN AND METHODS: This was a prospec(cid:173)
`tive, randomized, open-label, crossover study. Twenty(cid:173)
`four subjects with mild or moderate HAE were randomly
`assigned during an attack-free interval to receive 1000
`units of human pasteurized C1-INH concentrate IV or
`SC. Plasma levels of C1-INH activity and antigen, C4
`antigen, cleaved high-molecular-weight kininogen
`(ciHK), and CHNH antibodies were measured.
`RESULTS: The mean relative bioavailability of func(cid:173)
`tional CHNH after SC administration was 39.7%.
`Maximum C1-INH activity after SC administration
`occurred within 48 hours and persisted longer than after
`IV administration. C4 antigen levels increased and ciHK
`levels decreased after IV and SC administration, indi(cid:173)
`cating the pharmacodynamic action of C1-INH. The
`mean half-life of functional C1-INH was 62 hours after
`IV administration and 120 hours after SC administration
`(p = 0.0595). C1-INH concentrate was safe and well
`tolerated when administered via both routes. As
`expected, SC administration resulted in a higher inci(cid:173)
`dence of injection site reactions, all of which were mild.
`CONCLUSION: With a relative bioavailability of 39.7%,
`SC administration of human pasteurized C1-INH yields
`potentially clinically relevant and sustained plasma
`levels of C1-INH and is safe and well tolerated.
`
`1552 TRANSFUSION VolumP. !'14 .ltmP. 2014
`
`ABBREVIATIONS: AE(s) =adverse event(s); AUC =area under
`the curve; Cl-INH = C1-esterase inhibitor; CL =total clearance;
`cli-IK =cleaved high-molecular-weight kininogen;
`Cmax = maximum concentration; HAE =hereditary angioedema;
`HK =high-molecular-weight kininogen; MHT = mean residence
`time; SC =subcutaneous; t 112 =terminal elimination half-life;
`T max = time of maximum concentration; Vz = volume of
`distribution at the terminal phase.
`
`From the 1Hemophilia Center Hhine Main GmbH,
`Miirfelden-Walldorf, Germany; the 2Department of Clinical
`Science "Luigi Sacco," University of Milan, Milan, Italy;
`the 3Department of Pediatric Hematology, Oncolob'Y·
`Hemostaseology and Cardiology, University Hospital Frankfurt,
`Frankfurt am Main, Germany; the '1Technical Solutions Center,
`Siemens Healthcare Diagnostics GmbH, Eschborn, Germany;
`the 5Clinical Trial Center Hhine-Main (KSHM), University
`Hospital Frankfurt, Frankfurt am Main, Germany; and GCSL
`Behring GmbH, Marburg, Germany.
`Address reprint requests to: lnmaculada Martinez-Saguer,
`Hemophilia Center Hhine Main GmbH, Hessenring 13a, 64546
`Miirfelden-Walldorf, Germany; e-mail:
`Inmaculada.Martinez@hzrm.de.
`This study was supported financially by CSL Behring
`GmbH, Marburg, Germany.
`ClinicalTrials.gov Identifier: NCT00748202.
`Heceived for publication June 7, 2013; revision received
`October 23, 2013, and accepted October 23, 2013.
`doi: 10.11111 trf.1250 1
`© 2013 The Authors. Transfusion published by Wiley
`Periodicals, Inc. on behalf of AABB.
`This is an open access article under the terms of the
`Creative Commons Attribution-NonCommercial-NoDerivs
`License, which permits use and distribution in any medium,
`provided the original work is properly cited, the use is
`non-commercial and no modifications or adaptations are
`made.
`THANSFUSION 2014;54:1552-1561.
`
`Page 5 of 14
`
`

`

`SUBCUTANEOUS PHARMACOKINETICS OF CHNH CONCENTRATE
`
`H ereditary angioedema (HAE), caused by func(cid:173)
`
`tional deficiency of C !-esterase in h. ibitot·1
`(Cl-INH), is a rare disease characterized by
`recurrent, spontaneous, nonallergic edema
`in subcutaneous (SC) tissues and mucous membranes. In
`case oflaryngeal edema, HAE is associated with high mor(cid:173)
`tality rates when there is a delay in treating the attacks. 2
`·'
`HAE is a debilitating disease that can have a severe effect
`on quality of life.
`Cl-INH is a serine protease inhibitor that controls
`vascular permeability by acting on the initial activation
`phase of the complement, coagulation, contact, and fibri(cid:173)
`nolytic sys tems. The functional deficiency of C1-INH
`leads to increased activation ·or plasma kallikrein and
`Factor (F)XIIa with a subsequent release of bradykinin,
`which is a key mediator of vascular permeability.• Addi(cid:173)
`tionally, C 1-INH is the main inhibitor ofFXIa, which plays
`an important role in the generation of thrombin, a positive
`modulator of vasopermeability.5 ·6
`HAE Type I results from a quantitative deficiency
`in functional Cl-INH, whereas the less common HAE
`Type II, atl'ecting 15% of patients, results from a dysfunc(cid:173)
`tional form of Cl-INH circulating at normal or elevated
`plasma concentrations.• Both defects are inherited as an
`autosomal dominant trait. HAE Type III is extremely rare,
`with mainly women being clinically affected; it is not asso(cid:173)
`ciated with Cl-INH deficiency and its pathophysiology
`is uncertain.9 Common anti-inflammatory treatments,
`such as corticosteroids, antihistamines, or epinephrine,
`are usually inappropriate for treating acute attacks caused
`by HAE.wClinical studies, 11
`. 13 as well as more than 30years
`of clinical use, 11
`15 have shown that intravenous (IV)
`•
`Cl-INH replacement therapy with human Cl-INH con(cid:173)
`centrate is an effective and safe treatment for acute
`edema attacks in patients with HAE. Therefore, Cl-INH
`concentrate is recommended as first-line therapy in this
`indication.16
`In patients with HAE requiring frequent IV treatment
`with Cl-INH concentrate, either for acute edema attacks or
`for prophylaxis, venous access may become d ifficult over
`time. The SC administration of Cl-INH concentrate
`is therefore being investigated as a potential alternative
`therapeutic approach, specifically for the prophylactic
`treatment ofHAE.ln support of this approach, a preclinical
`study with CSL Behring's human pasteurized Cl-INH
`concentrate (Berinert, CSL Behring, Marburg, Germany)
`revealed a relative bioavailability of approximately 70%
`after SC administration in rabbits, compared with IV
`administration (lngo Pragst, CSL Behring, May 2013).
`Building on this preclinical experience, the primary objec(cid:173)
`tive of our study was to compare the pharmacokinetics of
`the same preparation of C 1-INH concentrate after IV and
`SC administration in subjects with mild or moderate HAE
`during an attack-free interval, evaluating the relative
`bioavailability ofSC administration based on plasma levels
`
`of C1-INH acnvny. In addition to assessing the safety
`and tolerability ofC 1-INH concentrate when administered
`via both these routes, we also assessed plasm a levels
`of Cl-INH antigen and cleaved high-molecular-weight
`kininogen (clHKJ. serum levels of C4 antigen, and the
`presence of Cl-INH antibodies after treatment. These
`additional endpoints were assessed to provide insight into
`the pharmacokinetic and pharmacodynamic effects of
`the Cl-INH concentrate administered.
`
`MATERIALS AND METHODS
`
`Study design and treatment
`TWs was a single-center, prospective, randomized, open(cid:173)
`label, crossover study in adults with mild or moderate
`HAE Type I or 1ype II. The study was conducted between
`September 22, 2008 (first subject first visit), and November
`l , 2010 (last subject last visit). Subjects enrolled into the
`study had to present during an attack-free interval. In
`total, 24 subjects were each randomly assigned to one of
`two treatment sequences, AB or BA (A= IV; B = SC), at a
`ratio of 1:1. Blinded randomization envelopes were used.
`Blinding procedures were otherwise not needed because
`the study involved treatment with only one study drug.
`The sample size was calculated in accordance with the
`guideline on clinical investigation of recombinant or
`human plasma-derived F IX products (EMA/CHMP/
`BPWP /144552/2009).
`According to the randomization sequence, human
`pasteurized C1-INH concentrate (Berinert, CSL Behring)
`was administered during an attack-free interval as either
`an IV infusion or an SC infusion, in each case as a single
`doseofiOOO U in20 mLofsolution, with a washout period
`of at least 7 days before study enrollment and between the
`two treatments. The IV infusion was administered over a
`time period of 3 minutes. The SC infusion was adminis(cid:173)
`tered over a 15-minute period using two medical infusion
`pumps for continuous, simultaneous administration
`(MEDIS Infusa Tl portable syringe driver, OMT, Minden,
`Germany) of two doses of 500 U each at two different loca(cid:173)
`tions in the abdomen. A follow-up visit was performed
`3 months after the second administration of C1-INH
`concentrate.
`Plasma samples for pharmacokinetic and pharmaco(cid:173)
`dynamic analyses were collected at 0, 0.25, 0.5, 0.75, l , 2, 4,
`6, 0, 12, 16, 20, 24, 36, 48, 60, 72, 120, and 168 hours after
`each treatment. In addition, after amending the protocol
`during the study, additional sampling times (at 336 ±
`48 and 504 ± 48 hr after treatment) were introduced for
`the analysis of C1-INH activity and antigen levels, and C4
`antigen levels, to investigate pharmacokinetic and phar(cid:173)
`macodynamic trends over a longer period in six subjects.
`The analysis of c!HK levels was also added, for which
`blood samples were collected at 0, 12, 36, 60, 168, and 504
`hours after treatment in these six subjects.
`
`fh is material wa:Hopie-d
`~+ .-h;ec tJI ~A ~..,...4 ,..,.,~u h:e.
`
`Volume 54, June 2014 TRANSFUSION 1553
`
`Page 6 of 14
`
`

`

`MARTINEZ-SAGUER ET AL.
`
`Study population
`The study was conducted at the University Hospital
`Frankfurt (Frankfurt am Main, Germany), after receiving
`approval from the applicable ethics committee. All poten(cid:173)
`tial study participants provided written informed consent
`before being screened for eligibility. Men and women
`could only be enrolled if they were at least 18 years of age
`and presented with mild or moderate HAE Type I (C1-INH
`activity< 50% and C1-INH antigen< 15.4 mg/dL) or Type
`II (Cl-INH activity< 50% and C1-INH antigen in normal
`or elevated concentrations) during an attack-free interval.
`All but two of the enrolled subjects had mild HAE. Subjects
`were excluded from the study ifHAE was not diagnosed or
`if their last treatment with C1-INH concentrate (i.e., their
`last attack) had occurred within 7 days before enrollment.
`Subjects with acquired angioedema and all other types of
`angioedema not associated with C1-INH deficiency were
`also excluded. Additionally, subjects who had received any
`investigational drug (excluding drugs appropriate for
`treating acute angioedema) during the 30 days before
`treatment in the current study, subjects who had received
`any other drug appropriate for the treatment of acute
`angioedema within 7 days before each administra(cid:173)
`tion of study drug in the current study, and subjects
`undergoing prophylaxis with danazol, antifibrinolytics,
`e-aminocaproic acid, or tranexamic acid were also
`excluded. Further exclusion criteria included known
`hypersensitivity to the study drug, pregnancy (a rapid
`pregnancy test was required for women of childbearing
`potential), breast-feeding, malignant disease, immunode(cid:173)
`ficiency, and concurrent serious or acute illness or
`infection.
`
`Pharmacokinetic and pharmacodynamic
`assessments
`The primary endpoint was the bioavailability of functional
`C1-INH after SC administration relative to IV administra(cid:173)
`tion of human pasteurized Cl-INI-1 concentrate, calcu(cid:173)
`lated on the basis of plasma C1-INH activity. Secondary
`endpoints were analyses of plasma C1-INH activity and
`antigen levels, serum C4 antigen levels, and plasma clHK
`levels.
`Cl-INI-1 activity was determined using the functional
`chromogenic assay (Berichrom Cl-INH, commercially
`available from Siemens Healthcare Diagnostics, Eschborn,
`Germany). Standard human plasma served as the calibra(cid:173)
`tor; the results are expressed as percentage of normal
`values. The assay was performed according to the manu(cid:173)
`facturer's instructions. The citrated plasma samples were
`analyzed undiluted.
`Both Cl-INH and C4 antigen levels were analyzed
`using nephelometric technology from Beckman Coulter
`(Brea, CA). The reagents for C1-INH antigen were
`obtained from Siemens Healthcare Diagnostics. The
`
`reagents for C4 antigen analysis were obtained from
`Beckman Coulter. The analysis of serum for C4 levels was
`conducted according to the manufacturer's instructions.
`Citrated plasma samples were analyzed undiluted.
`CIHK was assessed according to the method of
`Berrettini and colleagues. 17 Plasma samples underwent
`nonreducing sodium dodecyl sulfate-polyacrylamide gel
`electrophoresis (8% wt/vol). Mter electrophoretic transfer
`of the separated proteins from the gel onto a polyviny(cid:173)
`lidene difluoride membrane
`(Immobilon, Millipore,
`Bedford, MA), high-molecular-weight kininogen (HK)
`forms were identified with goat polyclonal anti-light
`chain-HK antibody that does not recognize the heavy
`chain (Nordic, Tiburg, the Netherlands) and visualized
`with a biotinylated rabbit anti-goat antibody (Sigma
`Chemical Company, StLouis, MO). The apparent molecu(cid:173)
`lar masses of proteins were derived by comparison with
`high-molecular-weight protein markers from Bio-Rad
`Laboratories (Hichmond, CA). With this method, native
`HK appears as a band in the molecular range of 130 kDa
`and clHK is seen as two bands in the molecular ranges of
`107 and 98 kDa.
`
`Safety assessments
`Safety endpoints included the incidence of treatment(cid:173)
`emergent adverse events (AEs), analyses of standard labo(cid:173)
`ratory safety variables, assessments of vital signs, and
`assessments of virus serology and the presence ofC1-INH
`antibodies at 1 and 3 months after the last administration
`of C1-INH concentrate relative to baseline (before the first
`administration of C1-INH concentrate).
`All AEs reported in this study occurred after adminis(cid:173)
`tration ofCl-INI-1 concentrate and were considered treat(cid:173)
`ment emergent. Standardized assessments were used for
`categorizing AEs according to intensity (mild, moderate,
`or severe) and causal relationship to administration of
`Cl-INH concentrate (none, unlikely, possible, and prob(cid:173)
`able). Missing values were not imputed.
`Standard laboratory safety variables included hema(cid:173)
`tology (hemoglobin [Hb], hematocrit, red blood cell
`count, total and differential white blood cell count,
`platelet count, mean corpuscular Hb, mean corpuscular
`volume), clinical chemistry (creatinine, uric acid, urea,
`total bilirubin, aspartate aminotransferase, alanine ami(cid:173)
`notransferase, gamma-glutamyl
`transferase, amylase,
`lipase), and coagulation (prothrombin time, activated
`partial thromboplastin time, fibrinogen).
`Viral serology included analysis of hepatitis A virus
`antibodies, hepatitis B virus surface antigen, antibodies
`to hepatitis surface B antigen, antibodies to hepatitis B
`core antigen, hepatitis C virus (I--ICV) antibodies, human
`immunodeficiency virus Type l (HIV-1) and HIV-2 anti(cid:173)
`bodies, and polymerase chain reaction (PCH) assays for
`HCVand HIV.
`
`1554 TRANSFUSION Volume 54, June 2014
`
`This materia I was <o-pi.ed
`at the N LM and may b-e
`
`Page 7 of 14
`
`

`

`SUBCUTANEOUS PHARMACOKINETICS OF C1-INH CONCENTRATE
`
`mean residence time (MHT), total clearance (CL)
`, and
`'b
`.
`f d.
`I
`1
`vo ume o _rstn utwn at t 1e terminal phase (Vz).
`All vanables were analyzed descriptivelv · 1 d'
`J• me u mg
`95% Cis based on log-transformed data and
`h
`grap s
`.
`.
`(boxplo~s). No rmputatwn of missing data was applied for
`any vanable. An exploratory analysis of variance and
`graphs were used to check for the influence of the factor
`s
`d "
`. . d"
`l
`"
`t
`t"
`trea men
`an
`periO
`on t 1e pharmacokinetic and
`pharmacodynamic variables as well as for carryover
`effects ("treatment x period" interaction).
`The percentage of c!HK compared to total HK and the
`safety assessments were analyzed using summary statis(cid:173)
`tics. The differences over time for laboratory safety vari(cid:173)
`ables (comparing values between baseline, i.e., before first
`treatment and 3 months after baseline) were analyzed
`using an analysis of covariance model with "sequence"
`and "treatment" as fixed effects, the baseline value as a
`covariate, and "subject" as a random effect. The treatment
`difference for vital signs was compared using a two-sided,
`two-sample t test. All statistical analyses were performed
`using computer software (SAS, Version 9.1, SAS Institute,
`Cary, NC).
`
`RESULTS
`
`Demographics and baseline characteristics
`A total of 24 subjects with mild or moderate HAE Type I or
`Type II were enrolled, comprising the safety set (Table 1).
`One subject, in Sequence BA, was excluded from the phar(cid:173)
`macokinetic per-protocol set because of unscheduled IV
`treatment with C1-INH concentrate less than 12 hours
`before the scheduled SC administration of C1-INH
`concentrate.
`
`TABLE 1. Demographic data (safet~ set)*
`Sequence AB
`Sequence BA
`(n = 12)
`(n = 12)
`
`C1-INH antibodies were screened by a highly sensi(cid:173)
`tive direct binding enzyme-linked immunosorbent assay
`(ELISA) in samples taken at the baseline, 1-month, and
`3-month follow-up time points. C1-INH was coated to
`micr