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DEPA classification: a proposal for standardising PRP use and a retrospective application of available devices

Authors:

Abstract

Background/aim Significant biological differences in platelet-rich plasma (PRP) preparations have been highlighted and could explain the large variability in the clinical benefit of PRP reported in the literature. The scientific community now recommends the use of classification for PRP injection; however, these classifications are focused on platelet and leucocyte concentrations. This presents the disadvantages of (1) not taking into account the final volume of the preparation; (2) omitting the presence of red blood cells in PRP and (3) not assessing the efficiency of production. Methods On the basis of standards classically used in the Cell Therapy field, we propose the DEPA (Dose of injected platelets, Efficiency of production, Purity of the PRP, Activation of the PRP) classification to extend the characterisation of the injected PRP preparation. We retrospectively applied this classification on 20 PRP preparations for which biological characteristics were available in the literature. Results Dose of injected platelets varies from 0.21 to 5.43 billion, corresponding to a 25-fold increase. Only a Magellan device was able to obtain an A score for this parameter. Assessments of the efficiency of production reveal that no device is able to recover more than 90% of platelets from the blood. Purity of the preparation reveals that a majority of the preparations are contaminated by red blood cells as only three devices reach an A score for this parameter, corresponding to a percentage of platelets compared with red blood cells and leucocytes over 90%. Conclusions These findings should provide significant help to clinicians in selecting a system that meets their specific needs for a given indication.
DEPA classication: a proposal for
standardising PRP use and a
retrospective application of available
devices
J Magalon,
1,2
A L Chateau,
1,2
B Bertrand,
3
M L Louis,
4
A Silvestre,
5
L Giraudo,
1
J Veran,
1
F Sabatier
1,2
To cite: Magalon J,
Chateau AL, Bertrand B, et al.
DEPA classification: a
proposal for standardising
PRP use and a retrospective
application of available
devices. BMJ Open Sport
Exerc Med 2016;2:e000060.
doi:10.1136/bmjsem-2015-
000060
Prepublication history for
this paper is available online.
To view these files please
visit the journal online
(http://dx.doi.org/10.1136/
bmjsem-2015-000060).
Accepted 1 January 2016
1
Cell Culture and Therapy
Laboratory, Hôpital de la
Conception, AP-HM, CIC BT
1409, Marseille, France
2
Vascular Research Center of
Marseille, Aix-Marseille
University, Marseille, France
3
Plastic Surgery Department,
Hôpital de la Conception, AP-
HM, Marseille, France
4
ICOS, Sport and
Orthopedics Surgery
Institute, Marseille, France
5
Radiology Department,
Bordeaux Merignac Sports
Clinic, Merignac, France
Correspondence to
Dr Jérémy Magalon;
jeremy.magalon@ap-hm.fr
ABSTRACT
Background/aim: Significant biological differences in
platelet-rich plasma (PRP) preparations have been
highlighted and could explain the large variability in the
clinical benefit of PRP reported in the literature. The
scientific community now recommends the use of
classification for PRP injection; however, these
classifications are focused on platelet and leucocyte
concentrations. This presents the disadvantages of (1)
not taking into account the final volume of the
preparation; (2) omitting the presence of red blood
cells in PRP and (3) not assessing the efficiency of
production.
Methods: On the basis of standards classically used
in the Cell Therapy field, we propose the DEPA (Dose
of injected platelets, Efficiency of production, Purity of
the PRP, Activation of the PRP) classification to extend
the characterisation of the injected PRP preparation.
We retrospectively applied this classification on 20 PRP
preparations for which biological characteristics were
available in the literature.
Results: Dose of injected platelets varies from 0.21 to
5.43 billion, corresponding to a 25-fold increase. Only
a Magellan device was able to obtain an A score for
this parameter. Assessments of the efficiency of
production reveal that no device is able to recover
more than 90% of platelets from the blood. Purity of
the preparation reveals that a majority of the
preparations are contaminated by red blood cells as
only three devices reach an A score for this parameter,
corresponding to a percentage of platelets compared
with red blood cells and leucocytes over 90%.
Conclusions: These findings should provide
significant help to clinicians in selecting a system that
meets their specific needs for a given indication.
INTRODUCTION
The potential role of platelet-rich plasma
(PRP) in enhancing the healing of bone,
muscle, ligaments and tendons, has resulted
in multiple applications within virtually all
the orthopaedic subspecialties. Several
uncontrolled studies have shown benet for
a variety of indications
12
and more recently
controlled studies have demonstrated less-
favourable results.
34
A common point
between these studies is the lack of biological
characterisation of the content of the PRP
used as therapy product.
Marx,
5
rst described PRP as a suspension
of platelets in plasma, with the platelet con-
centration being higher than the concentra-
tion in the original blood collected. Dohan
Ehrenfest et al
67
introduced the notion of
leucocyte-rich PRP (LR-PRP) characterised
by a leucocyte concentration higher than the
whole blood baseline leucocyte level,
whereas leucocyte-poor PRP (LP-PRP) or
Pure PRP includes a leucocyte concentration
lower than in whole blood. Accordingly, the
platelet increase factor, corresponding to
the platelet concentration increase in PRP
compared with whole blood, is the most
frequently described parameter in both sci-
entic publications and manufacturerspro-
motional literature, and is thought to
primarily inuence the PRP efcacy. A plate-
let concentration in PRP below whole blood
baseline level may not provide sufcient cel-
lular response
8
and platelet concentrations
higher than six-fold compared with platelet
whole blood baseline level may have an
inhibitory effect on healing.
9
Historical denitions from Marx and
Dohan associated with the described
What are the new findings?
Dose of injected platelets varies from 0.21 to
5.43 billion, depending on the device used.
Efficiency of the platelet-rich plasma (PRP) prep-
aration does not reach 90% of platelet recovery
no matter which device is used.
Some available devices furnish more red blood
cells than platelets in their PRP.
Magalon J, et al.BMJ Open Sport Exerc Med 2016;2:e000060. doi:10.1136/bmjsem-2015-000060 1
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inuence of platelet concentrations in PRP efcacy have
given rise to PRP classication
10 11
systems, but none of
these classications have been widely adopted.
In fact, the platelet increase factor in PRP compared
with whole blood is directly linked to the volume of PRP
obtained; these two factors should not be interpreted
alone. We previously introduced the notion of platelet
doses corresponding to the quantity of platelets and
growth factors (GFs) hypothetically delivered at the
injection site, as we previously described a positive cor-
relation between platelet dose and quantity of GF.
12
Based on the eld of haematology, which rst used cells
as a therapy, cell doses are the most relevant parameter
to assess clinical efcacy, and cell-dose effects are now
clearly established.
13
Otherwise, the current classica-
tions of PRP do not take into account the red blood cell
(RBC) content in PRP, which could represent a source
of released reactive oxygen species that could also be
clinically detrimental. That is why the global compos-
ition of PRP in platelets, leucocytes and RBCs, should be
documented to analyse the clinical impact. Finally, to
compare the efciency of the PRP preparation device,
the platelet recovery rate could be provided, allowing
assessment of the platelet loss due to the process,
although this parameter is not directly linked to clinical
efcacy.
The purpose of this article is to introduce a standar-
dised classication based on biological parameters clas-
sically used in the Cell Therapy eld. This classication
has been retrospectively applied to four publications
comparing and describing biological characteristics of
PRP devices available in Europe.
Definition of PRP characterisation criteria and analysis of
reported PRP preparations
With the previous information being taken into consid-
eration, the DEPA classication of PRP is based on four
different components: (1) the Dose of injected platelets,
(2) the Efciency of the production, (3) the Purity of
the PRP obtained, (4) the Activation process. The calcu-
lation of these parameters is only possible if complete
cell counts are performed for both whole blood and
PRP associated with the data of collected blood volume
and injected PRP. We previously described the associated
formulas.
12
Through a retrospective analysis of four publications
providing the mentioned data, we were able to classify 20
different PRP preparations using these variables.
12 1416
Table 1 reports the protocol of PRP preparation from
these publications.
Dose of injected platelets
The rst part of the classication identies the dose of
injected platelets, which is calculated by multiplying the
platelet concentration in PRP by the obtained volume of
PRP. The injected dose of platelets should be measured
in billions or millions of platelets and categorised as
follows: A, very high dose of injected platelets of >5
billion; B, high dose of injected platelets, from 3 to 5
billion; C, medium dose of injected platelets, from 1 to
3 billion and, D, low dose of injected platelets, <1
billion.
Given the information available in the four publica-
tions, we were able to calculate the injected dose of pla-
telets normalised with a baseline concentration of
platelets at 200×10
9
/L. The production of PRP using a
Selphyl device, described in the Kushida et al
16
study,
furnished 0.21 billion injected platelets, whereas the
Magellan device characterised in the same study furn-
ished 5.43 billion injected platelets, corresponding to a
25-fold increase. The complete data are provided in
table 2.
Efficiency of production
The second criterion of classication corresponds to the
efciency of the production used to obtain PRP. The
recovery rate in platelets (also called platelet capture ef-
ciency) corresponds to the percentage of platelets recov-
ered in the PRP from the blood. It is categorised as
follows: A, high device efciency if recovery rate in plate-
lets is >90%; B, medium device efciency if recovery rate
in platelets is from 70% to 90%; C, low device efciency if
the recovery rate is from 30% to 70% and, D, poor device
efciency for a recovery rate <30%. The retrospective
application of this parameter to published data revealed
that none of the processes described were of high ef-
ciency. The recovery rates in platelets varied from 13.1%
(the Selphyl device in the Kushida et al
16
study) to 79.3%
(RegenLab in the Kaux et al
15
study). The complete data
are provided in table 2.
Purity of the PRP
The third criterion of the classication corresponds to
the relative composition of platelets, leucocytes and
RBCs in the obtained PRP. It presents the advantage of
assessing the global purity of the PRP. It is categorised as
follows: A, very pure PRP if percentage of platelets in
the PRP compared with RBC and leucocytes is >90%; B,
pure PRP if percentage of platelets in the PRP com-
pared with RBC and leucocytes is from 70% to 90%; C,
heterogeneous PRP if percentage of platelets in the PRP
compared with RBC and leucocytes is from 30% to 70%;
D, whole blood PRP if percentage of platelets in the
PRP compared with RBC and leucocytes is <30%.
According to this criterion, the GPS II device furnishes
a product highly contaminated by RBC with only 6% of
platelets, which corresponds more or less to blood com-
position. Conversely, Curasan and Regen devices and
the homemade preparation described by Kaux et al
15
as
well as the Selphyl device described by Kushida et al,
give rise to very pure PRP.
It should be noted that leucocytes were at most only
1.64% (GPS II) in the nal composition of the obtained
PRP, but, the presence or absence of neutrophils is hotly
debated and could be precised.
The complete data are furnished in table 2.
2Magalon J, et al.BMJ Open Sport Exerc Med 2016;2:e000060. doi:10.1136/bmjsem-2015-000060
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Activation process
Finally, addition of exogenous clotting factor to activate
platelets is already described in available classica-
tions
10 11
and should be mentioned. Addition of
calcium chloride allows the release of GFs in a liquid
form and PRP gel can be obtained by mixing PRP with
autologous thrombin and calcium chloride. As this acti-
vation depends on the treatment indications and physi-
cians decision, we did not compare it in this analysis.
DISCUSSION
Several authors have demonstrated substantial differ-
ences in the content of platelet concentrates produced
by various automated and manual protocols described
in the literature.
12 1416
To face this issue, classications
recently appeared and are focused on two parameters:
the increased platelet and leucocyte factor compared
with whole blood. This presents some drawbacks: (1) the
volume is not taken into account, directly inuencing
the concentration. As an example, Plateltex, described
by Kaux et al, delivered an increased platelet factor of
only 3.43, because a very small nal volume of 0.34 mL
was obtained. The corresponded dose injected was only
0.23 billion. (2) They do not assess the efcacy of the
process allowing the comparison of one preparation
with another and (3) they do not take into account PRP
as a global product containing not only platelets and
leucocytes, but also RBCs. The major challenge of PRP
preparation is to remove RBCs and reverse the initial
composition of blood (95% of RBCs), and this is some-
times not achieved at allan example is the GPS II
device, globally composed of 93.9% RBCs.
Through the introduction of new parameters (dose of
injected platelets, recovery rate in platelets and the rela-
tive composition of PRP), the DEPA classication cir-
cumvents these issues. Thus, a PRP preparation reaching
an AAADEPA score will mean that a very high dose of
platelets was injected (>5 billion) with little contamin-
ation from RBCs, and that the preparation was optimal
with minor loss of platelets from blood. A limitation to
this ABCDscoring system is that an A score will often
be evaluated as better than a B, C or D score, whereas
the impact of platelet dose and purity remains
unknown.
It should be noted that devices corresponding to a
very high dose of injected platelets will necessarily cor-
respond to an important collected volume (minimum
30 mL). It will be also be difcult to reach a high dose
of platelets for indications necessitating very small
Table 1 Protocol, volume collected and volume obtained from each preparation system provided in publications
12 1416
Reference Device
Number of
centrifugation
steps Speed and time
Collected
volume
of blood (mL)
Volume of PRP
obtained (mL)
Kaux et al
15
Homemade 1 180 g 10 min 8 2.08
Curasan 2 1000 g 10 min,
2300 g 15 min
8.5 1
Plateltex 2 180 g 10 min, 1000 g
10 min
6 0.34
GPS II 1 180 g 15 min 50 6.01
RegenLab 1 300 g 5 min 6 3.068
Castillo et al
14
Cascade 1 1100 g 6 min 18 7.5
GPS III 1 1100 g 15 min 55 6
Magellan 1 1200 g 17 min 26 6
Magalon et al
12
Selphyl 1 1100 g 6 min 8 4.1
RegenPRP 1 1500 g 9 min 8 3.1
Mini GPS III 1 3200 rpm 15 min 27 3.21
Arthrex 1 1500 rpm 5 min 11 4.03
Homemade 2 130 g 15 min, 250 g
15 min
30 3.41
Kushida et al
16
JP200 2 1000 g 6 min, 800 g
8 min
20 1
GLO 2 1800 g 3 min, 1800 g
6 min
8.5 0.6
Magellan 2 610 g 4 min, 1240 g
6 min
60 3
Kyocera 2 600 g 7 min, 2000 g
5 min
20 2
Selphyl 1 525 g 15 min 8 2
MyCells 1 2054 g 7 min 10 1
Dr. Shin 1 1720 g 8 min 8.5 1
PRP, platelet-rich plasma.
Magalon J, et al.BMJ Open Sport Exerc Med 2016;2:e000060. doi:10.1136/bmjsem-2015-000060 3
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Table 2 Application of DEPA score to 20 PRP preparations in which biological characteristics are available on publications indexed in PubMed
DEPA classification
Dose of injected platelets
(billions)
Efficiency of the process
(platelet recovery rate %)
Purity of the PRP (relative
composition in platelets %)
A >5 Very high dose A >90 High A >90 Very pure PRP
B35 High dose B 7090 Medium B 7090 Pure PRP
C13 Medium dose C 3070 Low C 3070 Heterogeneous PRP Final DEPA
scoreD <1 Low dose D <30 Poor D <30 Whole blood PRP
Kaux et al
15
Homemade D 0.74 Low dose C 46.2 Low A 90.3 Very pure PRP DCA
Curasan D 0.55 Low dose C 32.4 Low A 97.7 Very pure PRP DCA
Plateltex D 0.23 Low dose D 19.4 Poor B 87.5 Pure PRP DDB
GPS II C 2.28 Medium dose D 22.8 Poor D 6.0 Whole blood PRP CDD
RegenLab D 0.95 Low dose B 79.3 Medium A 97.5 Very pure PRP DBA
Castillo et al
14
Cascade C 2.43 Medium dose C 67.5 Low B 81.5 Pure PRP CCB
GPS III C 2.48 Medium dose D 22.6 Poor D 27.0 Whole blood PRP CDD
Magellan B 3.41 High dose C 65.8 Low C 60.4 Heterogeneous PRP BCC
Magalon et al
12
Selphyl D 0.95 Low dose C 59.5 Low B 73.9 Pure PRP DCB
RegenPRP D 0.99 Low dose C 61.7 Low C 46.0 Heterogeneous PRP DCC
Mini GPS III C 2.56 Medium dose C 34.6 Low C 51.8 Heterogeneous PRP CCC
Arthrex C 1.06 Medium dose C 48.0 Low B 81.0 Pure PRP CCB
Homemade C 1.81 Medium dose C 30.2 Low B 80.7 Pure PRP CCB
Kushida et al
14
JP200 C 1.04 Medium dose D 26.0 Poor D 19.6 Whole blood PRP CDD
GLO D 0.64 Low dose C 37.4 Low C 38.2 Heterogeneous PRP DCC
Magellan A 5.43 Very high dose C 45.3 Low C 32.9 Heterogeneous PRP ACC
Kyocera B 3.12 High dose B 78.1 Medium D 29.4 Whole blood PRP BBD
Selphyl D 0.21 Low dose D 13.1 Poor A 99.7 Very pure PRP DDA
MyCells D 0.98 Low dose C 48.8 Low B 87.3 Pure PRP DCB
Dr. Shin D 0.78 Low dose C 45.9 Low D 18.8 Whole blood PRP DCD
DEPA, Dose of injected platelets, Efficiency of production, Purity of the PRP, Activation of the PRP; PRP, platelet-rich plasma.
4Magalon J, et al.BMJ Open Sport Exerc Med 2016;2:e000060. doi:10.1136/bmjsem-2015-000060
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volume (ie, intratendinous requirements) and could rep-
resent a challenge for future development to manufac-
turers of PRP production devices.
The clinical relevance of the DEPA classication
remains to be evaluated in clinical studies and review of
clinical trials. This point is still limited by the absence of
characterisation in the majority of clinical trials. A few
randomised clinical trials
17 18
performed a characterisa-
tion of the injected PRP, but these were restricted to the
publication of platelet concentration in PRP, and did not
broach the subject of the clinical impact of RBCs and leu-
cocytes in PRP. Future clinical studies should describe the
reported volumes, dose of platelets as well as the overall
composition of whole blood and PRP, and the number of
applications of PRP, in which the DEPA classication
could be considered as a tool (1) to determine the clin-
ical impact of the huge variability of PRP composition
and (2) to assess the quality of PRP production.
Contributors JM, AC and BB performed the review. ML, AS and LG assisted
with the review and edited the manuscript. JV and FS edited the final
manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with
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which permits others to distribute, remix, adapt, build upon this work non-
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Magalon J, et al.BMJ Open Sport Exerc Med 2016;2:e000060. doi:10.1136/bmjsem-2015-000060 5
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group.bmj.com on February 20, 2016 - Published by http://bmjopensem.bmj.com/Downloaded from
application of available devices
standardising PRP use and a retrospective
DEPA classification: a proposal for
Veran and F Sabatier
J Magalon, A L Chateau, B Bertrand, M L Louis, A Silvestre, L Giraudo, J
doi: 10.1136/bmjsem-2015-000060
2016 2: BMJ Open Sport Exerc Med
http://bmjopensem.bmj.com/content/2/1/e000060
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... The most important factors for this classification are the platelet concentration and the absence or presence of leucocytes [8]. The DEPA classification by Magalon et al. [67] which was introduced in 2016 is based on the dose of platelets injected, as well as the efficiency, purity, and activation of PRP [2]. Recently, Lana et al. [8] proposed a new classification system called "MARSPILL," which is based on eight parameters concerning the preparation and application of PRP: method (automated or handmade), activation, red blood cells (rich or poor), spin (one or two spins), platelet number, image guidance, leucocyte concentration, and light activation. ...
... Other authors support labeling different PRP products according to the DEPA classification by Magalon et al. [67] which is based on the dose of injected platelets, the efficiency of the production (percentage of platelets retrieves from blood), the purity of PRP (ratio of platelets compared to red and white blood cells), and the activation process [2]. ...
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Introduction: Platelet-rich plasma (PRP) is gaining popularity and is applied in a variety of clinical settings. This review aims to present and evaluate available evidence regarding the use of PRP in various applications in plastic surgery. Methods: PubMed, Web of Science, Medline, and Embase were searched using predefined MeSH terms to identify studies concerning the application of PRP alone or in combination with fat grafting for plastic surgery. The search was limited to articles in English or German. Animal studies, in vitro studies, case reports, and case series were excluded. Results: Of 50 studies included in this review, eleven studies used PRP for reconstruction or wound treatment, eleven for cosmetic procedures, four for hand surgery, two for burn injuries, five for craniofacial disorders, and 17 as an adjuvant to fat grafting. Individual study characteristics were summarized. Considerable variation in preparation protocols and treatment strategies were observed. Even though several beneficial effects of PRP therapy were described, significance was not always demonstrated, and some studies yielded conflicting results. Efficacy of PRP was not universally proven in every field of application. Conclusion: This study presents an overview of current PRP treatment options and outcomes in plastic surgery. PRP may be beneficial for some indications explored in this review; however, currently available data are insufficient and systematic evaluation is limited due to high heterogeneity in PRP preparation and treatment regimens. Further randomized controlled trials employing standardized protocols are warranted.
... Furthermore, although the literature on PRPs has developed intensively, there are still numerous contradictions in the classification terminology. The most complete classification was proposed in 2016 by Magalon et al. [137], based on dose, efficiency, purity and activation parameters. The so-called DEPA classification focuses on the platelet concentration obtained with PRP kits, the purity of the PRP obtained, the efficiency of the production and platelet activation prior to injection. ...
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... Transparency by using a classification system or algorithm that describes the PRP formulations has to be implemented. A similar need, but in the clinical field, has motivated the suggestion of several systems for the classification and standardization of reporting on PRP [95][96][97][98][99]. Based on the results of this review and the classification systems of PRP in the clinical field, several items were identified in order to have a transparent description of PRP from the perspective of cell therapy. ...
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There has been an explosion in scientific interest in using human-platelet-rich plasma (PRP) as a substitute of xenogeneic sera in cell-based therapies. However, there is a need to create standardization in this field. This systematic review is based on literature searches in PubMed and Web of Science databases until June 2021. Forty-one studies completed the selection criteria. The composition of PRP was completely reported in less than 30% of the studies. PRP has been used as PRP-derived supernatant or non-activated PRP. Two ranges could be identified for platelet concentration, the first between 0.14 × 106 and 0.80 × 106 platelets/µL and the second between 1.086 × 106 and 10 × 106 platelets/µL. Several studies have pooled PRP with a pool size varying from four to nine donors. The optimal dose for the PRP or PRP supernatant is 10%. PRP or PRP-derived supernatants a have positive effect on MSC colony number and size, cell proliferation, cell differentiation and genetic stability. The use of leukocyte-depleted PRP has been demonstrated to be a feasible alternative to xenogeneic sera. However, there is a need to improve the description of the PRP preparation methodology as well as its composition. Several items are identified and reported to create guidelines for future research.
... The platelet number was determined using a hematology analyzer (Abacus Junior 30, USA). At the same time, PRP samples were characterized according to the DEPA classification based on four different components, the Dose of injected platelets, the Efficiency of the production, the Purity of the PRP obtained, the Activation process [20]. Platelet-rich plasma was loaded into the scaffolds with a pipette at 50, 80, and 100 μL volumes to decide how much PRP will be absorbed by the scaffolds, and the samples were incubated at 37 • C for 1 h in a laminar flow cabinet according to previous studies [21,22]. ...
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... A very high dose can be achieved by obtaining a minimum of 30 cc of venous blood. This study used that very high dose to get optimal study results [10]. ...
Background Several studies showed that Adipose derived mesenchymal stem cells (AMSCs) can differentiate into mesenchymal lineages, including cardiac cell types, but complete differentiation into cardiomyocytes is challenging. . Unfortunately, the optimal method to maximize AMSCs differentiation has not yet established. Platelet rich plasma (PRP) which contains rich growth factors, is believed could stimulate stem cell proliferation and differentiation in the context of cardiac tissue regeneration. Objective To analyze the effect of PRP administration to enhance the differentiation of AMSCs into cardiomyocytes. Methods This study used arandomized post-test only controlled group design. AMSCs were isolated from adipose tissues and cultured until 4 passages. The samples were divided into 3 groups, negative control group (α-MEM), positive control group (differentiation medium), and treatment group (PRP). The assessment of GATA-4 expression was conducted using flowcytometry on day-5. The assessment oftroponin expression was conducted using immunocytochemistry on day-10. Data analysis was conducted using T-test and One-Way ANOVA. Results Flowcytometry of GATA-4 expression revealed a significant improvement in PRP group compared to negative and positive control group (67.04 ± 4.49 vs 58.15 ± 1.23 p < 0.05; 67.04 ± 4.49 vs 52.96  2.02 p < 0.05). This was supported by the results of immunocytochemistry on troponin expression, which revealed significant improvement in the PRP group compared to negative and positive controls (38.13 ± 5.2 vs 10.73 ± 2.39 p < 0.05; 38.13 ± 5.2 vs 26.00 ± 0.4 p < 0.05). Conclusion PRP administration in the AMSCs culture could significantly improve the differentiation of AMSCs into cardiomyocytes measured by GATA-4 and troponin expressions. This was concordant with our hypothesis, which stated that there was an effect of PRP administration on AMSCs differentiation into cardiomyocytes.
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The therapeutic potential of platelet-rich plasma (PRP) has been widely studied for accelerating the process of healing in different tissues. In addition to the major role of promoting coagulation, platelets are considered to play an important role in the wound healing process. Platelets release several growth factors such as platelet-derived growth factor, transforming growth factors, vascular endothelial growth factor, platelet-derived endothelial cell growth factor, and basic fibroblast growth factor that promote the healing process. The cellular composition of PRP varies substantially among the final products obtained from different production methods, and therefore the biological activity varies according to its composition. As a result, the individual cellular components (platelets, leukocytes, and erythrocytes) and growth factors present in the PRP have to be determined before in vitro, in vivo, or clinical evaluation. In addition to the composition of PRP, the protocols used for production has to be defined systematically to ensure repeatability. The heterogeneity existing in the PRP-based biological therapy can be eliminated in future studies by implementing a two-phase strategy that involves the establishment of a universal PRP classification/coding system and deciding “minimum reporting requirements” for all studies involving PRP. Although several classification systems have been proposed, none of them completely describes the important variables associated with PRP production and composition. Therefore, this chapter aims to provide a guideline/protocol for the preparation, characterization, classification, and coding of PRP for tissue engineering.
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Introduction Intracavernosal injections of platelet-rich plasma (PRP) or P-shot® are increasingly proposed as a curative treatment for organic sexual dysfunction despite the lack of evidence of effectiveness. Objectives We conducted a pilot study to evaluate the safety and efficacy of intracavernous PRP injections in patients with vascular erectile dysfunction (ED). Methods Three intracavernosal injections of PRP were performed 15 days apart in 15 patients with vascular ED unresponsive to medical treatment with 5-phosphodiesterase inhibitors and/or prostaglandin E instillations or injections. Questionnaires assessing erectile function (IIEF-EF, EHS, SEP, Sexual discomfort score) were completed prior to treatment and 1, 3 and 6 months after the last injection. Results No side effects were noted during the study period. The IIEF-EF score was significantly improved after treatment (P < 0.001) with a gain of 5 points at 1 month, 4 points at 3 months and 3 points at 6 months (respectively P = 0.001, P = 0.003 and P = 0.022). The other questionnaires did not change significantly. In total, 20% of patients considered that the erection lasted long enough to have a sexual intercourse (SEP score) before P-shot® versus 26.7% after the treatment (P = 1). Conclusion This study suggests that the effect of P-Shot® remains moderate in cases of ED with vascular origin. Larger clinical studies are needed to determine the real effectiveness of this therapeutic strategy. Level of proof 2.
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Platelet-rich plasma (PRP) has been the subject of hundreds of publications in recent years. Reports of its effects in tissue, both positive and negative, have generated great interest in the orthopaedic community. Protocols for PRP preparation vary widely between authors and are often not well documented in the literature, making results difficult to compare or replicate. A classification system is needed to more accurately compare protocols and results and effectively group studies together for meta-analysis. Although some classification systems have been proposed, no single system takes into account the multitude of variables that determine the efficacy of PRP. In this article we propose a simple method for organizing and comparing results in the literature. The PAW classification system is based on 3 components: (1) the absolute number of Platelets, (2) the manner in which platelet Activation occurs, and (3) the presence or absence of White cells. By analyzing these 3 variables, we are able to accurately compare publications.
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Platelet rich plasma (PRP) is a powerful new biologic tool in sports medicine. PRP is a fraction of autologous whole blood containing and increased number of platelets and a wide variety of cytokines such as platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and transforming growth factor beta-1 (TGF-B1), fibroblast growth factor (FGF), Insulin-like growth factor-1 (IGF-1) among many others. Worldwide interest in this biologic technology has recently risen sharply. Basic science and preclinical data support the use of PRP for a variety of sports related injuries and disorders. The published, peer reviewed, human data on PRP is limited. Although the scientific evaluation of clinical efficacy is in the early stages, elite and recreational athletes already use PRP in the treatment of sports related injuries. Many questions remain to be answered regarding the use of PRP including optimal formulation, including of leukocytes, dosage and rehabilitation protocols. In this review, a classification for platelet rich plasma is proposed and the in-vitro, preclinical and human investigations of PRP applications in sports medicine will be reviewed as well as a discussion of rehabilitation after a PRP procedure. The regulation of PRP by the World Anti-Doping Agency will also be discussed. PRP is a promising technology in sports medicine; however, it will require more vigorous study in order to better understand how to apply it most effectively.
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Clinical studies claim that platelet-rich plasma (PRP) shortens recovery times because of its high concentration of growth factors that may enhance the tissue repair process. Most of these studies obtained PRP using different separation systems, and few analyzed the content of the PRP used as treatment. This study characterized the composition of single-donor PRP produced by 3 commercially available PRP separation systems. Controlled laboratory study. Five healthy humans donated 100 mL of blood, which was processed to produce PRP using 3 PRP concentration systems (MTF Cascade, Arteriocyte Magellan, Biomet GPS III). Platelet, white blood cell (WBC), red blood cell, and fibrinogen concentrations were analyzed by automated systems in a clinical laboratory, whereas ELISA determined the concentrations of platelet-derived growth factor αβ and ββ (PDGF-αβ, PDGF-ββ), transforming growth factor β1 (TGF-β1), and vascular endothelial growth factor (VEGF). There was no significant difference in mean PRP platelet, red blood cell, active TGF-β1, or fibrinogen concentrations among PRP separation systems. There was a significant difference in platelet capture efficiency. The highest platelet capture efficiency was obtained with Cascade, which was comparable with Magellan but significantly higher than GPS III. There was a significant difference among all systems in the concentrations of WBC, PDGF-αβ, PDGF-ββ, and VEGF. The Cascade system concentrated leukocyte-poor PRP, compared with leukocyte-rich PRP from the GPS III and Magellan systems. The GPS III and Magellan concentrate leukocyte-rich PRP, which results in increased concentrations of WBCs, PDGF-αβ, PDGF-ββ, and VEGF as compared with the leukocyte-poor PRP from Cascade. Overall, there was no significant difference among systems in the platelet concentration, red blood cell, active TGF-β1, or fibrinogen levels. Products from commercially available PRP separation systems produce differing concentrations of growth factors and WBCs. Further research is necessary to determine the clinical relevance of these findings.
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To determine whether the use of platelet-rich plasma gel (PRPG) affects magnetic resonance imaging (MRI) findings in the anterior cruciate ligament (ACL) graft during the first year after reconstruction. A prospective single-blinded study of 50 ACL reconstructions in 50 patients was performed. In group A (study group) PRPG was added to the graft with a standardized technique, and in group B (control group) no PRPG was added. An MRI study was performed postoperatively between 3 and 9 months in group A and between 3 and 12 months in group B. The imaging analysis was performed in a blind protocol by the same radiologist. The mean heterogeneity score value at the time of MRI, assigned by the radiologist, was 1.14 in group A and 3.25 in group B. Both groups were comparable in terms of sex and age (P < .05). The mean time to obtain a completely homogeneous intra-articular segment in group A (PRPG added) was 177 days after surgery, and it was 369 days in group B. Using the quadratic predictive model, these findings show that group A (PRPG added) needed only 48% of the time group B required to achieve the same MRI image (P < .001). ACL reconstruction with the use of PRPG achieves complete homogeneous grafts assessed by MRI, in 179 days compared with 369 days for ACL reconstruction without PRPG. This represents a time shortening of 48% with respect to ACL reconstruction without PRPG.
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The purpose of this study was to compare the biological characteristics of platelet-rich plasma (PRP) obtained from 4 medical devices and a preparation developed in our laboratory using a single-donor model. Ten healthy persons donated blood that was processed to produce PRP by use of 4 commercial preparation systems and a protocol developed in our laboratory. Volumes and platelet, white blood cell (WBC), and red blood cell concentrations were recorded. The platelet activation status was assessed by flow cytometry. Enzyme-linked immunosorbent assay was used to determine the concentrations of vascular endothelial growth factor, platelet-derived growth factor AB, epidermal growth factor, and transforming growth factor β1. We calculated platelet capture efficiency, relative composition, and increase factors from whole blood in platelets and WBC, as well as platelet and growth factor (GF) doses, provided from each preparation. Leukocyte-rich PRP was obtained with RegenPRP (RegenLab, Le Mont-sur-Lausanne, Switzerland) and the Mini GPS III System (Biomet Biology, Warsaw, IN) and provides PRP with higher proportions of red blood cells, WBCs, and neutrophils than leukocyte-poor PRP obtained with the Selphyl System (Selphyl, Bethlehem, PA), Arthrex ACP (Arthrex, Naples, FL), and the preparation developed in our laboratory. The highest platelet and GF concentrations and doses were obtained with the Mini GPS III System and the preparation developed in our laboratory. Different centrifugation protocols did not show differences in the percentages of activated platelets. Finally, a positive correlation between platelet doses and all the GFs studied was found, whereas a positive correlation between WBC doses and GFs was found only for vascular endothelial growth factor and epidermal growth factor. In a single-donor model, significant biological variations in PRP obtained from different preparation systems were highlighted. The observed differences suggest different results for treated tissue and could explain the large variability in the clinical benefit of PRP reported in the literature. Our findings will help clinicians to choose a system that meets their specific needs for a given indication.