What Is Leukapheresis?

What to expect when undergoing this procedure

Leukapheresis is a medical procedure in which white blood cells (leukocytes) involved in the body's immune response are separated from a sample of blood. It is a specific form of apheresis in which a component of blood, such as red blood cells or platelets, are extracted while the remaining blood is returned to circulation.

Leukapheresis is often used to decrease very high white blood cell (WBC) counts such as can occur with chronic blood cancers like chronic lymphocytic leukemia (CLL). It can also be performed to obtain white blood cells for later transplant, such as to treat steep declines in WBC counts during cancer chemotherapy. Another use is as part of a novel form of immunotherapy, called chimeric antigen receptor (CAR) T-cell therapy, to help fight leukemia, prostate cancer, and other forms of cancers.

Leukapheresis can be performed on the person requiring treatment (called autologous apheresis) or on a donor for later transplant (called allogeneic apheresis).

Purpose of the Procedure

Leukapheresis can be used to extract white blood cells in their entirety or just certain types (such as T-cells lymphocytes which the body uses to activate the immune response).

Broadly speaking, leukapheresis is used for the following purposes: Chronic lymphocytic leukemia (CLL), chemotherapy-induced leukopenia, CAR T-cell therapy, and systemic infections associated with granulocytopenia.

Chronic Lymphocytic Leukemia

Leukapheresis may be indicated for people with CLL and other types of blood cancer, such as acute myeloid leukemia and chronic myeloid leukemia, to reduce abnormally high WBC counts (referred to as leukocytosis).

On rare occasions, CLL leukocytosis can lead to a medical emergency called leukostasis in which the white blood cells begin to clump together and block circulation. Symptoms of leukostasis include dyspnea (shortness of breath), hypoxia (low blood oxygen), tachycardia (rapid heartbeats), and, in extreme cases, coma.

Leukapheresis is often performed before chemotherapy to quickly reduce white blood cell counts and alleviate adverse respiratory and cardiovascular symptoms.

Chemotherapy-Induced Leukopenia

High-dose chemotherapy used to treat advanced breast cancer and other forms of cancer can lead to a sharp decline in the WBC count. Declines like this, referred to as leukopenia, can increase the risk of infection.

By extracting white blood cells from the patient beforehand (or from a matched donor with a compatible blood type), the WBC count can be restored with a transfusion.

CAR T-Cell Therapy

CAR T-cell therapy is an evolving form of immunotherapy in which extracted white blood cells are altered in the lab to stimulate a specific immune response. The procedure adds a receptor to the white blood cells that the body recognizes as harmful, causing it to produce defensive antibodies to attack the perceived threat.

CAR T-cell therapy is intended to amplify the body's immune response against certain cancer. The drugs currently prepared through leukapheresis include:

  • Yescarta (axicabtagene ciloleucel), used to treat certain types of lymphoma
  • Kymriah (tisagenlecleucel), used to treat acute lymphoblastic leukemia (ALL)
  • Provenge (sipuleucel-T), used to treat metastatic prostate cancer

Systemic Infection

Leukapheresis may be used, albeit rarely, to treat people with severe granulocytopenia in people with systemic (whole-body) infections. Granulocytopenia is a condition characterized by low levels of white blood cells called granulocytes, including neutrophils, eosinophils, and basophils.

For this procedure, granulocytes isolated from a donor are irradiated to reduce the risk of graft-versus-host-disease (in which the donated cells inadvertently attack the host's tissues). So-called granulocyte transfusions are considered controversial and are only used as a last resort.

Risks and Contraindications

As with any other medical procedure, leukapheresis is associated with a number of risks, most of which are relatively mild. It is important to discuss these risks prior to the procedure to fully weigh the benefits and consequences of treatment. Leukapheresis is generally considered safe and would not be recommended unless there is a serious risk to your health.

Leukapheresis is relatively painless, although it may cause discomfort, redness, and bruising at the venipuncture (vein puncture) site. Fainting may also occur.

Among the possible risks associated with leukapheresis:

  • Hypocalcemia is an abnormal drop in blood calcium that may occur when white blood cells are extracted. The loss of calcium can cause muscle spasms or numbness and tingling in the hands and feet. Calcium supplements and eating calcium-rich food can often counteract this effect.
  • Anemia or thrombocytopenia can sometimes occur during which red blood cells or platelets, respectively, drop suddenly following the procedure. Most cases are mild.
  • Local or systemic infections can sometimes occur following leukapheresis, especially if the individual is immunocompromised or a venous catheter or cannula needs to be placed. Antibiotics or antifungal drugs may be used to treat an infection or to prevent infection in those with a weakened immune system.

Before the Procedure

Leukapheresis is a scheduled procedure that uses a specialized apheresis machine to remove blood under gentle pressure, spin it to remove the desired cells, and return the blood to the body at a stable temperature.

Leukapheresis is performed in one of two ways:

  • Continuous apheresis involves the removal of blood through one venipuncture site and the return of blood through a separate venipuncture site. This is the most common form of apheresis.
  • Intermittent apheresis involves the removal of blood through a venipuncture site which, after spinning, is returned to the body all at once through the same venipuncture site.

Speak with your doctor to better understand what is involved in your specific procedure and how long it might take.

Timing

Leukapheresis generally takes between one to three hours depending on the indications for the procedure and the system used. A continuous autologous procedure may take less time, while one that requires a specific type of white blood cell may take the full three hours. (Apheresis used in Provenge therapy has been known to take up to five hours.)

If a vein cannot be accessed with a regular intravenous (IV) needle or multiple procedures are needed, a temporary central venous catheter (CVC) may be inserted into the neck or chest in a separate surgical procedure. This generally takes between 45 minutes to one hour.

Location

Leukopheris is typically performed in a hospital or specialized facility equipped with an apheresis machine. Some comprehensive cancer centers include them in their services to patients.

Most apheresis machines are mobile and roughly the size of a garbage can. A video screen on the unit will monitor your progress, The room will also be equipped with a reclining chair with armrest and an IV pole.

If you are hospitalized, the apheresis machine can be rolled next to your bed.

What to Wear

It is best to wear loose-fitting clothes with short sleeves or sleeves you can easily roll up. If a central catheter was placed, wear a loose button-down shirt to provide easy access to the shoulder area.

Since you will be sitting for a while, you can also bring slippers to make you more comfortable. Sweat pants with stretchy waistbands are also suitable.

If you are incontinent or have an overactive bladder, you may want to consider wearing adult diapers since you won't be able to move once the procedure begins.

Food and Drink

Most doctors will recommend that you drink plenty of fluids several days in advance of a leukapheresis procedure. Caffeine should be avoided as it promotes urination and can reduce the relative pressure in the veins.

On the day before the procedure, avoid any caffeinated beverages, foods (including dark chocolate), or medications (including pain relievers like Anacin, Aspirin-Free Excedrin, or No-Doze). Eat a hearty meal prior to the procedure but not one that is large enough to cause you discomfort.

Cost and Health Insurance

Apheresis is a common procedure with costs generally hovering between $1,500 and $3,000 or more, depending on where you live and the aims of the procedure.

If indicated for the treatment of CLL or other cancers, leukapheresis will generally be covered, at least in part, by your health insurance. Check copay/coinsurance costs in advance to understand what your out-of-pocket expenses will be.

Prior authorization is typically needed in advance of leukapheresis. If a CAR T-cell therapy is approved, it almost always includes authorization of apheresis. Even so, apheresis may be billed separately from the approved drug, so check with your insurer in advance so that you are not hit with surprise billing.

If you don't have insurance, ask the facility if they offer discounts for upfront cash payments or a no-interest payment plan.

Never hesitate to shop around for the best prices. In-network insurance providers are generally less costly than out-of-pocket providers, but not always.

What to Bring

Be sure to bring your insurance card, your driver's license (or some other form of official ID), and a method of payment to cover copay costs. You might want to bring something to read or watch while you are sitting. Many apheresis rooms offer TV and reading materials to help pass the time.

You can also bring food and drinks to snack on; they will not affect the procedure in any way. Some people like to bring their own pillows or blankets as well.

Other Considerations

Plan on having someone drive you home after the procedure as you may feel dizzy or faint. Though the staff will not stop you from driving yourself home, they may insist that you rest until you seem reasonably recovered.

During the Procedure

Leukapheresis can be performed by a blood specialist known as a hematologist or a qualified medical technologist, nurse, or doctor certified in apheresis. Certification is offered by the American Society for Apheresis (AFSA) in conjunction with the American Society for Clinical Pathology (ASCP).

State laws vary as to who can oversee specific apheresis procedures. Therapeutic procedures, including those used in cancer patients, typically require a physician, such as an oncologist, to be on-site.

Pre-Evaluation

For an autologous procedure in which the blood is removed and returned to the same individual, a complete blood count (CBC) will be performed to check for anemia or any other blood abnormalities. Blood calcium levels are also assessed as well as your blood pressure and heart rate. Other tests may be ordered based on the indications for apheresis. These tests are typically done on the day of the procedure.

For an allogeneic procedure, pre-evaluation testing is used to ensure you are an eligible donor. This includes a physical exam and a review of your medical history, allergies, and medications. ABO blood typing will be used to ensure you are a match to the recipient. A screening panel of infectious diseases, including HIV, will also be needed. These tests are typically done several days in advance of the procedure.

An informed consent form will need to be signed to confirm that you understand the nature and potential risks of the procedure.

Throughout the Procedure

Once you've been cleared for the procedure—and your blood pressure, temperature, pulse, and respiration rate have all checked OK—you will be taken to the apheresis room.

The nurse or technologist will recommend that you go to the bathroom beforehand. Once the procedure starts, you will not be able to go to the bathroom since you will be connected to the machine.

If you are undergoing a continuous procedure, an IV line will be placed in each arm (usually the antecubital vein near the crook of the arm). Intermittent procedures require only one arm.

Once an IV line is placed in the antecubital vein, you will not be able to bend the arm until the needle is removed. If that's a problem, let the staff member know. A larger vein in the forearm may be used.

If you were provided a central catheter, the line will be attached to the machine via two exterior tubes, which alternately deliver and return blood to the body.

The procedure itself is relatively straightforward and is similar to what you would have experienced if you ever donated blood,

  1. You will be seated in a reclining chair with a blanket and pillows.
  2. The venipuncture site(s) will be cleaned with a sterile swab. If a catheter is used, the line will be flushed with normal saline.
  3. To reduce discomfort, a local anesthetic may be offered prior to the insertion of the needle, which can numb the area in around one minute.
  4. An IV line is inserted into the vein(s) with a needle. People with catheters are connected to the machine via attachment to the lumens.
  5. To ensure that blood doesn't clot and clog the lines during the procedure, an anticoagulant (blood thinner) like heparin or sodium citrate is injected into IV or catheter line.
  6. The machine is then turned on. As the blood is extracted and delivered to a collection chamber, it is spun high speeds (900 to 1,300 rotations per minute) to separate the white blood cells from the rest of the blood.
  7. Once separated, the white blood cells are passed to a sterilized chamber for collection while the remaining plasma, red blood cells, and platelets are pumped back to the body.
  8. After enough white blood cells are collected, the machine will be turned off and the IV/catheter lines disconnected.
  9. The IV needle will then removed and covered with gauze and an adhesive bandage. The catheter would be cleaned and secured to the chest with an adhesive dressing.

You should not feel anything during the procedure. If you experience numbness or a tingling sensation, let the nurse know. This is likely due to the anticoagulant and can often be remedied with a calcium supplement.

Post-Procedure

Following the completion of leukapheresis, you will be asked to relax awhile to ensure that you are neither dizzy, faint, or nauseous. Once you are cleared by the nurse, you can leave. For safety sake, have someone drive you home.

After the Procedure

It is not uncommon to feel tired after leukapheresis. To get back on your feet faster, limit your activities for the 12 to 24 hours. If you have an IV drip placed in your arm, keep the bandages dry and in place for at least five to six hours.

Your arm may also feel sore after being kept in place for the duration of the procedure. If so, you can take an over-the-counter pain reliever like Tylenol (acetaminophen) which is less likely to promote bruising than nonsteroidal anti-inflammatory drugs like aspirin or Advil (ibuprofen).

Be sure to keep well hydrated by drinking at least eight 8-ounce glasses of water or non-caffeinated beverages. If you feel dizzy or lightheaded, lie down and elevate your feet until the feeling passes.

Injection site infections are rare following leukapheresis but can occur.

Call your doctor immediately if you experience persistent or worsening pain at the injection site as well as increased swelling, redness, fever, chills, or discharge. Antibiotics may be needed to bring the infection under control.

Follow-Up

Depending on the aim of leukapheresis, the white blood cells may be banked until needed (such as to treat chemotherapy-induced leukopenia). A preservative solution is typically added to the blood to extend its shelf life.

People with CLL may undergo leukapheresis prior to the start of chemotherapy. Since chemotherapy can take a few days before high WBC counts are reduced, leukapheresis can bridge treatment by quickly reducing those numbers.

If the white blood cells are harvested for CAR T-cell therapy, they may undergo procedures to alter their immune function before being returned to the body. Provenge therapy, for example, typically takes three days before the altered cells can be transfused.

Granulocyte transfusions need to be performed within 24 hours of their collection as the cells tend to clump together and become too viscous to use after this time.

A Word From Verywell

Leukapheresis is an important procedure that can help alleviate symptoms and improve the quality of life in people with CLL and other types of cancer. What's more, its use in immunotherapy may one day open the door to creating even more effective targeted cancer therapies.

If leukapheresis is recommended, ask the doctor to walk you through the procedure so that you have a better understanding of what to expect. By asking all of your questions ahead of time, you'll likely feel less stressed and be more comfortable on the day of the procedure.

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