Leukapheresis for acute leukemia with hyperleukocytosis: Line complications, resource utilization, and early mortality outcomes

Abstract

Abstract Background: Hyperleukocytosis (white blood cell [WBC] count >50–100 ×10³/µL) in acute leukemia can lead to leukostasis, tumor lysis syndrome (TLS), and disseminated intravascular coagulation (DIC). Leukapheresis is frequently employed for cytoreduction; however, its clinical benefit over pharmacologic approaches remains uncertain. Data on procedural risks, resource utilization, and timing of chemotherapy are sparse, with prior studies focusing primarily on mortality outcomes. Methods: We conducted a retrospective analysis of adults with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) and hyperleukocytosis (WBC >50 ×10³/µL) undergoing leukapheresis at Vanderbilt University Medical Center from June 2016 to August 2023. Outcomes included line-related complications, transfusion requirements, ICU utilization, time to chemotherapy, need for dialysis, and early mortality (10-day and 30-day). Demographic and clinical data were abstracted from electronic medical records. Results: Thirty-six patients (median age 64 years; range 30–80) underwent leukapheresis; 53% (n=19) were male. Racial distribution was 77% White (n=27), 11% Hispanic/Latino (n=4), 9% Black or African American (n=3), and 3% Asian (n=1). All but one patient had AML (n=35, 97%); one had ALL (n=1, 3%). Median baseline WBC was 199 ×10³/µL, hemoglobin 8.5 g/dL, and platelets 56 ×10³/µL. Median uric acid for the cohort was 7.9 mg/dL; 61% (n=22) required rasburicase for significant TLS, with a median uric acid of 10.3 mg/dL in this subgroup. Median fibrinogen was 361 mg/dL; 14% (n=5) received cryoprecipitate for severe DIC. Symptoms were present in 92% (n=33), including dyspnea (n=25, 69%), dyspnea with infiltrate on chest x-ray (n=8, 22%), neurological symptoms (e.g., headache, blurry vision, altered mental status) (n=23, 64%), and chest pain (n=8, 22%). Median leukapheresis sessions was 1 (range 1–3). Complications occurred in 14% (n=5): central line–associated bloodstream infection (n=2, 6%), hematoma (n=1, 3%), arterial puncture (n=1, 3%), and one fatal exsanguination after inadvertent line removal (n=1, 3%). No pneumothorax occurred. The patient with hematoma notably had severe DIC with fibrinogen < 60. Before induction chemotherapy, platelet transfusions were required in 39% (n=14), red blood cell transfusions in 58% (n=21), and FFP in 8% (n=3). Among transfused patients, median units administered were 2 for platelets, 2 for red blood cells, and 2 for FFP. No patients required dialysis for TLS. Median ICU stay was 3 days. Chemotherapy was administered in 81% (n=29), with a median time to induction of 2 days. Early mortality was 25% (n=9) at 10 days and 36% (n=13) at 30 days, comparable to prior studies. Of 22 total deaths, 21 (95%) were disease-related, primarily from respiratory failure, multiorgan failure, or intracranial hemorrhage; one death was due to a line complication. Conclusions: In this single-center cohort, leukapheresis was associated with low rates of line-related complications, limited ICU resource utilization, and rapid initiation of chemotherapy. Moreover, no patients required dialysis for TLS after induction chemotherapy. Early mortality rates aligned with prior studies, suggesting leukapheresis remains a reasonable management strategy for select patients with acute leukemia and hyperleukocytosis.