Response to chronic leukapheresis procedures and survival of chronic myelogenous leukemia patients

Therapeutic Leukapheresis in a Patient with Prolymphocytic Transformation of B-cell Chronic Lymphocytic Leukemia

A 64-year old woman with chronic lymphocytic leukemia (CLL) developed a prolymphocytic transformation with severe anemia, thrombocytopenia and deterioration of the general clinical condition.

Neither treatment with chlorambucil and prednisolone, nor a combination chemotherapy (cyclophosphamide, vincristine, prednisolone) were successful. Splenectomy was not considered as the bone marrow presented signs of dyserythropoiesis.

Encouraged by the results of therapeutic leukapheresis in different forms of leukemia, it was decided to start such therapy in our patient.

During a seven-month period, thirty weekly aphereses were performed. The white blood cell count did not decrease, but the clinical condition of the patient improved dramatically.

Alternatives to albumin: starch replacement for plasma exchange

Today, albumin, or a combination of saline and albumin, is used and widely accepted as a replacement for routine plasma exchange. However, decreased availability (due to market recalls secondary to Creutzfeld-Jacob or bacterial contamination risk) rising costs, recognition of drug interactions with albumin (i.e., ACE inhibitors) and a fear of disease transmission have led several groups to reconsider the use of colloid starches as partial or full replacement for plasma during plasma exchange. There are two hydroxyethyl starches: hetastarch (Hespan and Pentaspan) currently licensed for human use in the United States. While both are approved for granulocyte collection only Hespan is approved as a plasma volume expander. Anecdotal experience and limited reports in the literature with the use of starches as a replacement for plasma exchange suggest that such starch products are a reasonable replacement for albumin as an initial wash-out fluid or in combination with either albumin or saline. Kinetic modeling of the wash-out of starch used as a replacement fluid demonstrate that relatively little residual starch remains compared to the total amount infused. Hydroxyethyl starches are biochemically similar to glycogen, which likely explains the lack of immunogenicity and lack of adverse reactions. Substantial cost savings are associated with the substitution of starch for albumin. It is concluded that HES is well-tolerated and cost-effective as full or partial volume replacement with plasma exchange. It is anticipated that the use of HES will emerge as a standard of care in apheresis.

The use of hetastarch as adjunct therapy in 26 dogs with hypoalbuminemia: a phase two clinical trial

The purpose of this study was to evaluate the safety and efficacy of the synthetic colloid hetastarch in dogs with hypoalbuminemia. Individual doses of hetastarch ranged from 9 to 27 mL/kg, and multiple doses were used frequently. Total doses ranged from 9 to 59 mL/kg. Colloid oncotic pressure was measured in 13 dogs before and after treatment. Mean colloid oncotic pressure +/- SD was 9.32 +/- 2.35 mm Hg before treatment and 16.41 +/- 1.61 mm Hg in 8 healthy pet dogs used as controls. The difference in these values was significant (P < .001). There was a significant increase in mean colloid oncotic pressure after the first dose of hetastarch, but there was no relationship between the dose of hetastarch and the magnitude of increase in colloid oncotic pressure. Peripheral edema or body cavity transudates resolved or decreased in 83% of the dogs despite concurrent use of crystalloid fluid therapy. There was also no relationship between the dose of hetastarch and resolution of edema. Worsening of the results from coagulograms occurred in 5 of 18 dogs, and included increased prothrombin time (n = 1), increased partial thromboplastin time (n = 5), and decreased platelet count (n = 3). Bleeding that occurred in 3 dogs could not be directly attributed to the hetastarch. There was no relationship between the dose of hetastarch and worsening of the values in the coagulograms.

Therapeutic cytapheresis: continuous flow versus intermittent flow apheresis systems

In this retrospective study, we compared two systems, continuous flow (CF) (COBE Spectra) versus intermittent flow (IF) (Haemonetics V-50, M-30), in performance of therapeutic plateletapheresis (TP: N = 49 each) and therapeutic leukapheresis (TL: N = 29 each). Pre- and post-procedure cell reductions, specificity of removal, volumes removed, and incidence of adverse reactions were compared. Standard procedures with minor modifications, starch with IF only, and 180 minutes blood processing time were used. The CF system had a significantly lower percent reduction of platelets during TP at 43 +/- 17% than IF at 53 +/- 19%. However, no significant difference was found between CF and IF in percent reduction of white blood cells during TL with 49 +/- 16% and 42 +/- 14%, respectively. The CF system had significantly less hemoglobin reduction (5 +/- 4% vs. 19 +/- 9%, respectively) and white blood cell reduction (13 +/- 15% vs. 27 +/- 17%, respectively) for TP than IF and lower (not significant) hemoglobin reduction (9 +/- 8% vs. 12.4 +/- 8.2%, respectively) as well as platelet reduction (27 +/- 18% vs. 35 +/- 19%, respectively) for TL. CF also had significantly less volume removed than IF during TP (559 +/- 97 vs. 883 +/- 304, respectively) and TL (710 +/- 134 vs. 1405 +/- 421 ml, respectively). Incidence of reactions was lower for CF than IF during TP (8% vs. 10%, respectively) and during TL (14% vs. 21%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Relief of respiratory distress with leukapheresis in a child with chronic myelocytic leukemia

Therapeutic leukapheresis of a 10-year-old girl with adult-type chronic myelocytic leukemia is described. The efficiency of WBC removal was noted to improve significantly after addition of hydroxyethyl starch to the anticoagulant infusion. In fact, the percentage of white cells removed more than doubled (39% vs. 16%) when comparing procedures of similar duration, with and without the sedimenting agent. Of particular interest was the relief of the patient's respiratory distress concomitant with the decline in her leukocyte count, a finding that has not previously been documented in pediatric patients. The arterial oxygen pressure remained greater than 95 mmHg after the procedure with hydroxyethyl starch compared with 70 mmHg after the procedures without it. In addition, her respiratory rate decreased from 70 on admission to the low 20s after the final procedure. Leukapheresis with hydroxyethyl starch was shown to be a safe procedure, and the use of hydroxyethyl starch was shown to be of particular benefit for prevention of prolonged apheresis procedures.

Effects of cytapheresis on cell cycle distribution of peripheral blood and bone marrow cells in some hematological malignancies

Feulgen-DNA cytophotometry and 3H-thymidine autoradiography were used to evaluate therapeutic cytapheresis effects on cell cycle distributions of peripheral blood leukemic cells in 15 acute leukemia, 5 CML and 8 CLL patients and of bone marrow erythroblasts in 18 PV patients. Both individual cytapheresis procedures and a long-term program of cytapheresis altered cell cycle distributions and biochemistry which may be summarized as follows: An increase in percentage of cells in S-phase (acute leukemia, CML); a decrease in the differences between values of S-cell number obtained by cytophotometry and autoradiography (acute leukemia, CML, PV); a decrease in some cases in enlarged fraction of cells in G2 (blast crisis of CML, PV); an activation of G0----G1 transition and an increase in the PAS-positive lymphocyte fraction in CLL patients. An apparent increase of blasts in S-phase was found after a pheresis in acute leukemia patients who responded to subsequent chemotherapy. In "nonresponders", a pheresis had no effect on cell cycle distributions. The results of the study demonstrate that despite the wide variability of individual responses, cytapheresis activates cell proliferation and metabolic processes in patients with hematological malignancies.

Response of chronic myelogenous leukemia patients to COAP-splenectomy. A Southwest Oncology Group study

Eighty-seven patients from 18 institutions with a confirmed diagnosis of chronic myelogenous leukemia were registered on a Southwest Oncology Group protocol for multiagent induction and single-agent maintenance chemotherapy, with randomization to an immunotherapy arm. Elective surgical splenectomy was performed for 42 patients at the completion of 3 months of induction therapy. Final analysis of the study revealed statistically significant survival advantages were correlated with age, splenectomy, the absence of hepatic leukemic infiltrate at the time of splenectomy, and race.