Leukocytosis is NOT a Contraindication for Plasma Exchange
Leukocytosis is not a contraindication for therapeutic plasma exchange (TPE); in fact, plasma exchange and related apheresis procedures are specifically indicated for managing hyperleukocytosis in acute leukemias when leukostasis is present or imminent. 1
Key Clinical Context
The question appears to conflate two distinct apheresis procedures:
- Therapeutic plasma exchange (TPE): Removes plasma proteins and is used for hyperviscosity syndrome, autoimmune conditions (e.g., Guillain-Barré syndrome), and other disorders 2, 1
- Leukapheresis/cytoreduction: Removes excessive white blood cells in hyperleukocytosis 1
Neither procedure is contraindicated by the presence of leukocytosis itself.
When Apheresis is Indicated in Leukocytosis
Leukapheresis for Hyperleukocytosis
- Leukapheresis is specifically indicated for initial management of leukostasis in patients with hyperleukocytosis in acute leukemias, particularly myeloid leukemias 1
- Emergency exchange transfusion or red cell exchange can rapidly reduce excessive leukocyte burden when leukapheresis is unavailable, reducing white blood cell counts from dangerously high levels (e.g., 630,000/μL to 70,000/μL) within 2 hours 3, 4
- Red cell exchange provides similar leukoreduction to standard therapeutic approaches and may be superior in patients with severe anemia or monocytic leukemias when rapid treatment is required 5
Important Exception: Acute Promyelocytic Leukemia (APL)
- Leukapheresis is NOT recommended in APL due to increased risk of coagulopathy and bleeding 2, 1
- In life-threatening APL cases with leukostasis unresponsive to other modalities, leukapheresis can be considered with extreme caution 2
Plasma Exchange in Other Conditions with Leukocytosis
Guillain-Barré Syndrome
- Plasma exchange remains a first-line treatment for GBS regardless of white blood cell count 2
- Neither IVIg nor plasma exchange is contraindicated during pregnancy, though IVIg may be preferred due to simpler administration 2
Sepsis and Critical Illness
- Leukocytosis is a diagnostic criterion for sepsis (WBC >12 × 10³/μL), not a contraindication to any specific therapy 2
- Blood transfusion itself frequently causes acute leukocytosis in critically ill patients (45/50 patients in one study), which should not be mistaken for infection 6
Clinical Pitfalls to Avoid
- Do not withhold plasma exchange from patients with autoimmune neurologic conditions (e.g., GBS) simply because they have leukocytosis 2
- Do not confuse leukocytosis as a contraindication when it is actually the indication for cytoreductive apheresis in hyperleukocytosis with leukostasis 1
- Recognize that bacterial contamination of the wound is a relative contraindication to intraoperative blood salvage, but this is unrelated to the patient's white blood cell count 2