Autologous Blood Plasma Therapy (Chapter 3)

In 2017, Lana et al. published the MARSPILL classification system. The authors note that in the previous classifications, the cellular and molecular components present in PRP have not been stated and fully analyzed. In this system, special focus is placed on the peripheral blood mononuclear cells and their role in ensuring the effectiveness of PRP. The classification also considers the following parameters: 1) the preparation method (manual or automated); 2) spin number (1 or 2); 3) the content of red blood cells (rich in red blood cells or poor in red blood cells); 4) platelet concentration (2–3, 4–6, 6–8 and 8–10 times higher than at baseline); 5) imaging guidance (use or non-use); 6) white blood cells concentration (rich in white blood cells or poor in white blood cells); 7) activation and light activation (activated or not, light-activated or not).

Disconcertingly, however, no one has managed to create a universally recognized classification system for PRP preparations. Their characteristics depend on the type of devices used and the corresponding instructions of its manufacturers (spin number, centrifugation speed and time), as well as on the platelet activation status.

The table below provides an overview of different types and techniques of platelet concentrates that exist today (adapted from Amit Agrawal) [1].

Type of platelet concentrate	Method of preparation	Description
P-PRP	Cell separator PRP	PRP is collected by discontinuous method, while the patient is connected to the device continuously. About 300 ml of PRP can be collected. When blood bags of 450 ml are used, 40 mL of PRP can be obtained per bag.
	Vivostat PRF	Advanced cell separator designed to produce fibrin sealant. The device is bulky, expensive, and has low and damaged platelet yielding capacity.
	Anitua's PRGF	Citrated blood is collected in 5 ml tubes and gently centrifuged for 8 minutes at 460 g. The platelet-poor layer (1 ml) is eliminated, and the PRGF layer, located above the buffy coat, is pipetted into a separate tube. Calcium chloride is added for clotting. Ergonomic and reproducibility problems.
	Nahita PRP	Protocol similar to Anitua's PRGF.
L-PRP	PCCS PRP	Consists of two compartments. Citrated blood enters the first compartment, where it is centrifuged for a short time. Under air pressure, the upper layer PPP and the buffy coat are transferred into the second compartment, where they are centrifuged for a longer time. PPP is transferred back to the first compartment, and the final product is left behind.
	SmartPReP PRP	This system also consists of two compartments, but less manipulation is required to use it. The system is multifunctional and can be used to concentrate stem cells obtained from bone marrow transplants.
	Megalian APS PRP	An advanced cell separator with an optical reader. Compact, designed for small blood samples (up to 50 ml). Efficient platelet collection but cell preservation is yet to be known.
	GPS PRP	Another system of 2 compartments, a double spin protocol is used. PPP is discarded, and the second spin is carried out with the layer of red blood cells. The final product (PRP) is aspirated from the surface of the RBC layer.
	Friadent PRP	Both techniques are based on the classic two-stage centrifugation method. After the first spin, PPP and buffy coat are transferred to another tube; after the second spin PPP is eliminated, the PRP remains. Depending on the technique of collecting buffy coat, one can randomly get either P-PRP or L-PRP.
	Curasan PRP
	AutoloGel	The final product is called "autologous platelet-rich plasma gel."
	Regen PRP	Both techniques use specific jellifying agents, such as calcium gluconate and lyophilized purified batroxobin, an enzyme that promotes fibrin polymerization without bovine thrombin. The Regen method also involves the use of a separator gel within the centrifugation tubes to improve platelet and leukocyte collection.
	Plateltex PRP
	Ace PRP	A similar protocol, differing only in centrifugation force and types of anticoagulant.
P-PRF	Fibrinet PRFM	The kit consists of two tubes, one for blood collection, another for PRFM clotting. About 9 ml of blood is collected in a tube containing sodium citrate and a separator gel, and centrifuged for 6 minutes at high speed. The buffy coat and PPP are transferred to the second tube containing calcium chloride and centrifuged for 15 minutes. It is possible to obtain only a tiny number of white blood cells, but the resulting fibrin matrix is denser and more stable than that of PRP.
L-PRF	Choukroun’s PRF	Considered a second-generation platelet concentrate obtained naturally without the addition of anticoagulants or jellifying agents. Venous blood is centrifuged at low speed until the red blood cell layer, PRF clot in the middle, and acellular plasma top layer are obtained.
	Intra-spin	The only FDA approved PRP kit. The kit includes a 9 ml tube, centrifuged at room temperature at 2700 rpm for 12 minutes. Contains an Xpression Membrane Kit.
	Titanium-prepared PRF	Platelet activation by using titanium tubes (instead of glass tubes) improves the characteristics of the resulting preparation: the PRF obtained has a better structure and continuous integrity. The fibrin meshwork is thicker and covers a larger area.
Cgf	Medifuge , Silfradent	Allows one to isolate a larger and denser fibrin matrix containing more growth factors. The presence of TGF-b, VEGF, and CD34 + is demonstrated.
Sticky bone	Sticky bone	Autologous fibrin glue mixed with bone graft.
T-PRF	T-PRF	Instead of glass tubes for blood collection and centrifugation blood, titanium tubes are used.
A-PRF	Advanced PRF Process	Earlier vascularization, faster soft tissue growth, more cytokines, and release of BMPs.
i-PRF	i-PRF	Blood collected in a 9 ml tube, without additives, centrifugation for 2 minutes at 3300 rpm. The resultant orange liquid is the i-PRF.

Even though every system for PRP preparation is claimed the most appropriate by its developer, the ability of all these systems to concentrate platelets varies significantly. The result is that the platelet and leukocyte concentrations differ dramatically among the PRP preparations. There is no consensus on almost every aspect related to the preparation and use of PRP, be it the optimal volume of its administration, frequency and method of application, or technique/system of preparation. Therefore, it is challenging to determine which technique of PRP preparation or the corresponding device is better.

To finish this chapter, I would like to cite the words of Dr. Arun Garg, an internationally-recognized dental educator and surgeon, previously a full-time professor of surgery at Miami University, who, alongside Robert Marx, pioneered the use of platelet-rich plasma. Speaking of the many nomenclatures that have appeared since the first time a tube with autologous blood was placed in a centrifuge to obtain plasma at the top, fibrin in the middle and red blood cells at the bottom, he remarked: "I could play the same game and introduce 5th generation PRP, but that would be disingenuous. The truth is, PRP is PRP whatever way you look at it, and PRF, i-PRF and so on are all PRP too! The only difference between the 1990s when Robert and I created this by-product of patients' own blood and now is that we have kept up with changing technology. All autologous blood concentrates are the same, irrespective of what another user may call it.".

Autologous Blood Plasma Therapy (Chapter 3)

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