2. Conclusions
• LRA remains a useful tool in the acute setting of
hyperleukocytosis
• It will require more studies to establish definitive
LRA therapy guidelines
• The procedure is not without complications-
physicians should treat the patient not the
numbers
• New research on molecular interactions
between myeloblasts and endothelial cells might
lead to additional treatment options
3. Complications/Disadvantages
• Expense
• Technical skill required
• Personal time required
• Citrate toxicity-be wary in small children
• In infants, measure serum Ca every 30-45
minutes and possibly start a Ca Drip
4. Benefits of LRA in Leukemia
• Physical removal of blasts reduces burden
on patient as chemotherapy destroys the
blasts- LRA is an important pre-
chemotherapy treatment
• Removal of circulating blasts, draws extra-
vascular blasts into circulation
• Removal of blasts increases cells in S-
phase, this improves response to some
chemotherapy
5. Procedural Complications
• Vascular Access- always better to have a central
line, but large bore peripheral access can be
used in emergencies
• Large volume of blood needs to be processed
• Machine must be primed with 250-300 cc of
blood, important in small infants where is could
represent their entire blood volume
• 6% hydroxyethyl starch (HES) is used as a red
cell sedimentation agent, to facilitate blast and
mature leukocyte removal
6. Disseminated Intravascular
Coagulation
• This is related to the release of
intracellular contents
• There are many interfering substances
described in hyperleukocytosis that may
cause DIC, but few studies have been
done
• More common presentation in ALL in
combination with tumor lysis syndrome
7. Tumor Lysis Syndrome
• Tumor lysis syndrome is the release of
intracellular chemicals
• Potassium, phosphate are important
electrolytes that are released
• Potassium should be corrected quickly as
fatal arrhythmia
• Purine and pyrimidine nucleotides are
degraded to uric acid- this can damage the
kidney
8. Hyperviscosity Syndrome
• Viscosity is the internal sheer force of a
liquid, it can be thought of as thickness
• Leukocrit between 12-15 mL/dL will cause
significant increases in viscosity, this is
dependent on blast size and morphology
• Increased viscosity reduces the proper
flow of blood in circulation
9. Leukostasis
• Clinically significant when pulmonary or
nervous system vascular blockage occurs
causing hypoxemia, respiratory distress,
and stroke
• Found at lower blast counts in AML (300-
450K) than ALL (600-800K), this is related
to blast size and expression of adhesion
markers
10. Complications of
Hyperleukocytosis
• Leukostasis
• Hyperviscosity syndrome
• Tumor Lysis syndrome
• Disseminated intravascular coagulation
(DIC)
• The goal of LRA is to reduce the incidence of
these complications by physically removing
blasts from the circulation
11. Indications for LRA
• Hyperleukocytosis
• Patients with significant
hyperleukocytosis are reported in cases
of:
• acute myelogenous leukemia (AML) 5%-25%
• acute lymphoid leukemia (ALL) 10%-30%
• chronic myelogenous leukemia (CML) ?%
• chronic lymphoid leukemia (CLL) ?%
• chronic monomyelocytic leukemia (CMML)
one reported case
13. Leukoreduction Apheresis
(LRA)
• The process of removing unwanted WBC
or blasts from the circulation
• The procedure is indicated for the rapid
correction of hyperleukocytosis, generally
defined as a WBC count over 30-50K
• One procedure generally removes
between 20-80% of WBC by processing 7-
10 liters of blood
14. Time Frame of WBC Reduction
WBC Count
0
20
40
60
80
100
120
140
160
180
200
Date Day 1-
Apheresis
Day 2-
Apheresis
Day 3 Day 4-
Apheresis
Day 5-
Induction
Chemo
Day 6 Day 7 Day 8 Day 9
Hospital Day
WBC
WBC count
