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Zhang D, Lin H, Huang L. Repeated small-volume exchange transfusion for hyperleukocytosis in pediatric acute leukemia: A retrospective analysis. Front Pediatr 2023; 11:1155481. [PMID: 37033185 PMCID: PMC10073680 DOI: 10.3389/fped.2023.1155481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Leukapheresis reduces hyperleukocytosis in children with acute leukemia. Although the usefulness of this procedure is under debate, a repeated small-volume exchange transfusion along with leukapheresis yielded satisfactory results. Methods Forty-seven patients with acute leukemia [32 acute lymphocytic leukemia (ALL) and 15 acute myeloblastic leukemia (AML)] were enrolled between January 2017 and June 2022 and underwent repeated small-volume exchange transfusion. The following were measured: demographic and clinical characteristics, time of the procedure, PWBC (peripheral white blood cell) count, hemoglobin, platelet count, blood biochemistry, electrolytes, coagulation, leukostasis, TLS (tumor lysis syndrome), DIC (disseminated intravascular coagulopathy), adverse events (AEs), and serious AEs (SAEs). Results The demographic and clinical characteristics were not significantly different between ALL and AML patients, but differences were observed in PWBC counts (424.2 ± 135.6 vs. 223.8 ± 58.0 × 109/L). The procedures needed 3-8 processes, and the average procedure time was not significantly different between ALL and AML. The PWBC count gradually reduced to <100 × 109/L; hemoglobin, platelet count, K+, Na+, and Ca2+ were unchanged. Alanine aminotransferase, aspartate aminotransferase, total bilirubin, blood urea nitrogen, creatinine, troponin-I, creatine kinase-MB, prothrombin time, and activated partial thromboplastin time maintained normal or recovered from abnormal ranges. The manifestations of leukostasis, TLS, and DIC improved or disappeared. No AEs and SAEs occurred. The required total blood volume was based on initial PWBC count, manifestations of leukostasis, and age. Conclusions Our finding suggests that repeated small-volume exchange transfusion is effective and safe for treating hyperleukocytosis in children with acute leukemia.
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Affiliation(s)
- Dongxiu Zhang
- Department of Pediatrics, the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hailong Lin
- Department of Pediatrics, the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Leting Huang
- Department of Hematology and Oncology, the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
- Correspondence: Leting Huang
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2
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Jones SR, Rahrig A, Saraf AJ. Leukapheresis in Pediatric Acute Leukemia with Hyperleukocytosis: A Single-Center Experience. CHILDREN 2022; 9:children9040503. [PMID: 35455547 PMCID: PMC9024808 DOI: 10.3390/children9040503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022]
Abstract
Hyperleukocytosis in pediatric acute leukemia is associated with increased morbidity and mortality and at present there is no consensus on the use of leukapheresis (LPH) for its management. Our aim was to review characteristics and outcomes of newly diagnosed leukemia patients with hyperleukocytosis (HL) comparing those who received LPH and those who did not. An IRB approved retrospective case control study reviewed data from a single institution over a 10 year period. At our institution, LPH was used in 8 of 62 (13%) patients with hyperleukocytosis with minimal complications. Mean leukocyte count in patients who received LPH versus those who did not was 498 k cells/mm3 and 237 k cells/mm3, respectively. Patients who had symptoms of neurologic (63 vs. 17%) or pulmonary leukostasis (75 vs. 17%) were more likely to have undergone leukapheresis. The time from presentation to the initiation of chemotherapy was not different between those who received LPH and those who did not (mean of 35 h vs. 34 h). There was one death in the LPH group, that was the result of neurologic sequelae of hyperleukocytosis and not LPH itself. The use of LPH in patients with hyperleukocytosis is safe, well tolerated and does not alter time to chemotherapy at our institution.
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Affiliation(s)
- Sandra Renee Jones
- Department of Internal Medicine, University of Miami and Jackson Memorial Hospital Internal Medicine Residency Program, Miami, FL 33136, USA;
| | - April Rahrig
- Division of Pediatric Hematology & Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Amanda J. Saraf
- Division of Pediatric Hematology & Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
- Correspondence:
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Suwita BM, Sekarsari D. Pediatric acute lymphoblastic leukemia and leukapheresis: CT evidence of hemorrhagic complication. Eur J Radiol Open 2020; 7:100269. [PMID: 32984452 PMCID: PMC7494483 DOI: 10.1016/j.ejro.2020.100269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Leukapheresis has been used widely to quickly reduce white blood cell count (WBC) in patients with hyperleukocytosis. Despite its wide utilization, leukapheresis has risks of complication, which have not been thoroughly reported in pediatric patients. No report was found in English literatures about leukapheresis complications in children with acute lymphoblastic leukemia (ALL). We reported a 4-year-old girl with ALL and hyperleukocytosis, with no sign of bleeding. After leukapheresis, WBC and platelet count decreased, and patient complained of headache. Neurological deficit developed quickly afterwards. Intracranial infection was suspected clinically. Contrast-enhanced head CT revealed multiple hyperdense lesions and diffuse cerebral oedema. The patient was subsequently diagnosed with multiple intraparenchymal hemorrhage, and leukapheresis was stopped. Intracranial hyperdense lesion in leukemic patients has many differential diagnosis, such as infection, granulocytic sarcoma (chloroma), and hemorrhage. Lesion characteristics in CT could help point the diagnosis. History of leukapheresis should also raise suspicion of hemorrhage. This article discussed CT characteristics of multiple brain hemorrhage in pediatric ALL after leukapheresis and how to differentiate it with other common intracranial complications of leukemia.
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Affiliation(s)
- Benedicta Mutiara Suwita
- Radiology Department, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Indonesia
| | - Damayanti Sekarsari
- Radiology Department, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Indonesia
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Merlin E, Hequet O, Kanold J. Red blood cell exchange in children and adolescents with sickle cell disease. Transfus Apher Sci 2019; 58:136-141. [DOI: 10.1016/j.transci.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Runco DV, Josephson CD, Raikar SS, Goldsmith KC, Lew G, Pauly M, Fasano RM. Hyperleukocytosis in infant acute leukemia: a role for manual exchange transfusion for leukoreduction. Transfusion 2018; 58:1149-1156. [PMID: 29399859 DOI: 10.1111/trf.14512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/22/2017] [Accepted: 12/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hyperleukocytosis is a serious, life-threatening complication of pediatric acute leukemia that can cause neurologic injury, pulmonary leukostasis, metabolic derangements, and coagulopathy. Acute leukemia has the highest risk of mortality and morbidity at presentation when associated with hyperleukocytosis. Infant leukemia presents unique challenges and treatment considerations due to the disease itself and size and overall health of the patient. While medical management of hyperleukocytosis in older patients with acute leukemia has been described, including cytoreductive procedures with automated leukapheresis (AL) or manual whole blood (WB) exchange transfusion, very little data exist for standardized management of hyperleukocytosis in infant leukemia patients. CASE REPORTS We describe four cases of infant acute leukemia presenting with hyperleukocytosis and leukostasis who each received manual WB exchange transfusions in conjunction with induction chemotherapy and review the existing literature on the use of procedural leukoreduction in infants with hyperleukocytosis. Special attention is given to challenges and technical aspects of leukapheresis in infants: when to perform manual WB exchange versus AL, optimal vascular access, blood product selection, exchange rates, and the monitoring for complications. Using published cases, we outline benefits versus risks of manual WB exchange and AL in infants less than 10 kg. CONCLUSION If providers perform procedural leukoreduction, the literature and our experience demonstrate manual WB exchange transfusion is favored over AL in infants less than 10 kg because of technical and complication risks associated with AL. Additional studies are needed to understand the impact of cytoreduction on long-term outcomes.
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Affiliation(s)
- Daniel V Runco
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia
| | - Cassandra D Josephson
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia.,Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil S Raikar
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia
| | - Kelly C Goldsmith
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia
| | - Glen Lew
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia
| | - Melinda Pauly
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology/BMT, Atlanta, Georgia
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Zeng F, Huang H, Fu D, Huang Q, Fan L, Wei S. Leukapheresis in 15 patients weighing 20kg or less: A single centre experience. Transfus Apher Sci 2017; 56:889-893. [PMID: 29169683 DOI: 10.1016/j.transci.2017.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 08/14/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
Abstract
The application of apheresis equipment to perform leukapheresis (LK) in low weight paediatric patients is logistically complex and lacking of largest clinical performing experiences, meanwhile, the benefit from LK is controversial. In this study, 15 children with acute lymphoblastic leukemia(ALL)and acute myeloid leukemia (AML) and hyperleukocytosis were treated with the COBE Spectra apheresis system in the general paediatric ward by the staff from the department of Blood Transfusion. 26 LK procedures were performed. 12 patients (80%) were performed with peripheral veins, others (20%) with femoral veins. Median age, body weight of the patients was 4 years (range from1year 10 month to 7 years) and 15kg (range from10 to 20kg). The median white blood cell (WBC) count of pre-first-LK was 289×109/L (range from 108×109/L to 579×109/L). The median decrease in WBC count after each LK was 34% (range from 14% to 54%), and overall decrease in WBC after completion of LK procedures was 45% (range from 15% to 70%). All of the patients had no further signs of leukostasis and achieved marked reductions in WBC counts. Only minor clinical adverse events were attributable to LK. With adequate monitoring and experienced team, LK is a safe and may be a beneficial leukoreduction method in small patients weighing 20kg or less with ALL and AML.
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Affiliation(s)
- Feng Zeng
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
| | - HaoBo Huang
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China.
| | - DanHui Fu
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China; Department of Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China.
| | - QingHua Huang
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
| | - LiPing Fan
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
| | - ShiJing Wei
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
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Zeller B, Glosli H, Forestier E, Ha SY, Jahnukainen K, Jónsson ÓG, Lausen B, Palle J, Hasle H, Abrahamsson J. Hyperleucocytosis in paediatric acute myeloid leukaemia - the challenge of white blood cell counts above 200 × 109
/l. The NOPHO experience 1984-2014. Br J Haematol 2017; 178:448-456. [DOI: 10.1111/bjh.14692] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/02/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Bernward Zeller
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Heidi Glosli
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Erik Forestier
- Department of Medical Biosciences, Genetics; Umeå University Hospital; Umeå Sweden
| | - Shau-Yin Ha
- Department of Paediatrics and Adolescent Medicine; Queen Mary Hospital and Hong Kong Paediatric Haematology & Oncology Study Group (HKPHOSG); Hong Kong China
| | - Kirsi Jahnukainen
- Children's Hospital; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Ólafur G. Jónsson
- Department of Paediatrics; Landspitali University Hospital; Reykjavík Iceland
| | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Josefine Palle
- Department of Woman′s and Children′s Health; Uppsala University; Uppsala Sweden
| | - Henrik Hasle
- Department of Paediatrics; Aarhus University Hospital Skejby; Aarhus Denmark
| | - Jonas Abrahamsson
- Department of Paediatrics; Institution for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Abstract
Hyperleukocytosis in children with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) is associated with early morbidity and mortality. The benefit from leukapheresis is controversial, and its complications are not well defined. We analyzed the frequency of early complications in children with ALL and AML presenting with white blood cell (WBC) count >100 × 10(9)/L, and the type and frequency of complications related to leukapheresis. During a 12-year period, 84 of 634 (13%) ALL and 18 of 143 (12.5%) AML patients presented with hyperleukocytosis. Leukapheresis was performed in 18 ALL and 12 AML patients. The median initial WBC was 474 × 10(9)/L in the leukapheresis group compared with 175 × 10(9)/L in the nonleukapheresis group. Neurological leukostasis occurred in 6 ALL (7.1%) and 4 AML (22.2%) patients. Pulmonary leukostasis occurred in 16 ALL (19%) and 4 AML patients (22.2%). Neurological symptoms improved in few patients after leukapheresis, except in patients with very high WBC (>650 × 10(9)/L in ALL and >400 × 10(9)/L in AML). Leukapheresis improved respiratory symptoms in some patients but caused worsening symptoms in others. Early death was associated with neurological complications, AML diagnosis, and coagulopathy. Leukapheresis did not delay initiation of chemotherapy, nor did it impact early response to chemotherapy or long-term survival. Complications included femoral vein thrombosis, electrolyte imbalances, and hemodynamic instability, which were all reversible. The role of leukapheresis as a cytoreductive procedure in childhood hyperleukocytic leukemia remains to be well defined.
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Henry M, Sung L. Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia. Pediatr Clin North Am 2015; 62:27-46. [PMID: 25435110 DOI: 10.1016/j.pcl.2014.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.
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Affiliation(s)
- Meret Henry
- Division of Hematology/Oncology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien, Detroit, MI 48201, USA.
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
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