Leukapheresis versus no leukapheresis for hyperleukocytosis in acute myeloid leukemia: an updated systematic review and meta-analysis of early mortality.

INTRODUCTION

Leukapheresis is used for rapid cytoreduction in adults with acute myeloid leukemia (AML) and hyperleukocytosis, but its effect on early mortality remains uncertain. We performed an updated systematic review and meta-analysis of comparative studies.

METHODS

MEDLINE, CENTRAL, ClinicalTrials.gov, Google Scholar, and citation searching were searched from inception to March 2026. Comparative studies of leukapheresis versus no leukapheresis in adults with AML and hyperleukocytosis were included. Risk of bias was assessed using ROBINS-I, and certainty of evidence was assessed using GRADE. Random-effects meta-analysis of crude 2 × 2 data was performed using odds ratios (ORs).

RESULTS

Thirteen retrospective comparative studies were included; 10 studies comprising 1,406 patients contributed to the primary 30-day mortality analysis. Leukapheresis was not clearly associated with lower 30-day mortality compared with no leukapheresis (OR 0.94, 95% CI 0.65-1.34; I2 = 0.0%). Only one study reported an adjusted estimate. Most studies were at serious risk of bias, and certainty of evidence was very low.

CONCLUSIONS

Current non-randomized evidence does not establish a reliable early-mortality benefit of leukapheresis. Confounding 3by indication remains a major limitation.

REGISTRATION: This study was prospectively registered on PROSPERO (identifier: CRD420261351743).