How we approach a patient with symptoms of leukostasis requiring emergent leukocytapheresis

Abstract

Hyperleukocytosis can induce leukostasis, which can lead to vascular obstructions (usually in the lungs and central nervous system), tumor lysis syndrome, and disseminated intravascular coagulation. Although it has not been conclusively shown to improve long-term outcome, leukocytapheresis may be used as part of the management of hyperleukocytosis with or without leukostasis to rapidly reduce the white blood cell (WBC) burden. Since leukocytapheresis only temporarily decreases the WBC count, early initiation of more definite therapy, such as hydroxyurea and/or chemotherapy, is essential. In this article, clinical assessment of the patient's clinical status to determine the need for leukocytapheresis as well as a general guideline for management of the technical aspects and complications of the procedure are discussed.

The effect of therapeutic leukapheresis on early complications and outcomes in patients with acute leukemia and hyperleukocytosis: a propensity score‐matched study

“…Although it is hard to perform a well‐designed clinical trial because of the rarity of this situation, a randomized prospective study is needed to better understand the impact of leukapheresis on early mortality and early complications of hyperleukocytosis. Based on our findings and previous critical reviews, early initiation of induction chemotherapy with aggressive supportive care is most important for the treatment of patients who have acute leukemia with hyperleukocytosis. Routinely performed, prophylactic leukapheresis cannot be recommended, and leukapheresis can be considered in limited clinical settings of symptomatic leukostasis, such as serious respiratory failure, central nervous system involvement, and priapism.…”

“Black cloud” vs. “white cloud” physicians – Myth or reality in apheresis medicine?

“…As stated, the decision whether to perform an apheresis procedure emergently is up to each individual TM attending physician's clinical judgement in conjunction with the requested clinical service, the data was collected as part of an apheresis quality program without the awareness of any TM attending physicians except for the medical director of the Therapeutic Apheresis unit (HPP) to reduce Hawthorne's effect, which is a type of reactivity in which an individual modifies the behavior in response to the awareness of being observed. Moreover, retrospectively, all the procedures performed emergently during this study period were within the general consensus of both professional guidelines and/or institutional protocol . Another potential weakness of this pilot study is that the Pathology residents were not included.…”

“…Since the study was conducted over one year, the total number of on‐call nights add up to 365 (in a calendar year) for any particular category (TM attending physicians, nurses, days of the week, and season). Although there are both professional guidelines on the use of therapeutic apheresis from the American Society for Apheresis (ASFA), as well as institutional guidelines available, the final decision whether to perform an apheresis procedure emergently or not was based on each individual TM attending physician's clinical judgement in conjunction with the requesting physician or clinical service. Thus, in order to reduce any conscious or subconscious bias that may influence the decision of any physician on whether to perform an apheresis procedure emergent or not, the data was collected as part of an apheresis quality program without the awareness of any TM attending physicians except for the medical director of the Therapeutic Apheresis unit (HPP).…”

Reduced vision in a diabetic patient due to incidental leukaemic retinopathy

“…The pathophysiology and histopathological processes leading to leukostasis phenomena are complex and involve increased blood viscosity and small vessel occlusions leading to tissue hypoxia, most commonly manifesting with signs from the central nervous system or lungs . Due to the similar pathophysiological processes, the implication of leukostasis mechanisms in the development of proliferative retinopathy has been explored, with no evidence of definitive involvement to date …”