Predicting response to splenectomy in children with immune thrombocytopenic purpura

Diagnosis and Management of Immune Thrombocytopenia in Paediatrics: A Comprehensive Review

Immune thrombocytopenia (ITP) in paediatric patients is a complex and heterogeneous disorder characterized by isolated thrombocytopenia and an increased risk of bleeding. The diagnosis of ITP involves a careful exclusion of other causes of thrombocytopenia, supported by clinical evaluation and laboratory findings. Management strategies have evolved significantly, emphasizing individualized treatment approaches based on disease severity, bleeding risk, and patient-specific factors. This comprehensive review provides an in-depth analysis of the current diagnostic criteria, including the role of novel biomarkers and genetic testing in distinguishing ITP from other haematological disorders. We also explore the latest therapeutic options, ranging from observation and first-line treatments such as corticosteroids and intravenous immunoglobulin (IVIG) to second-line therapies, including thrombopoietin receptor agonists and immunosuppressive agents. The review addresses the challenges of managing chronic ITP in pediatric patients, focusing on balancing treatment efficacy with the potential side effects and long-term outcomes. Additionally, we discuss the emerging role of personalized medicine in optimizing care for children with ITP, highlighting recent advances in targeted therapies and the potential for future research to refine diagnostic and treatment paradigms to refine diagnostic and treatment paradigms further.

Immune Thrombocytopenic Purpura Splenectomy in the Context of New Medical Therapies

BACKGROUND

As medical therapy improves, splenectomy has been relegated to third- or fourth-line therapy for immune thrombocytopenic purpura (ITP) in many hematologic practices. However, these medications have well-known associated morbidity and changes in treatment algorithms may affect the timing and degree of response to splenectomy as well as complications in heavily treated ITP patients.

MATERIALS AND METHODS

This is a retrospective study of consecutive patients who underwent ITP splenectomy from January 1994 to June 2017. Nonresponders after splenectomy and those with recurrent disease were compared to complete responders.

RESULTS

The cohort included 84 patients. Median number of medications received before splenectomy was 3 (1-6). 14.3% of patients had a medication-related complication, including heart failure, adrenal insufficiency, diabetes mellitus, infection, and osteoporosis. After splenectomy, 83.5% had a complete response, 7.5% partial response, and 9% no response. Complete response was associated with response to steroids before surgery (P < 0.01). Among responders, 19% had recurrent disease, which was associated with lower platelet count at diagnosis (P < 0.01). Forty-four patients (52.0%) had nonelective splenectomies for persistent bleeding or dangerously low platelets despite maximal medical therapy. Ten patients had Clavien-Dindo grade II or higher surgical complications (11.9%). Seven of these complications were related to recurrent or refractory ITP.

CONCLUSIONS

Many ITP patients have complications related to medication use, and 52.0% required nonelective splenectomy despite maximal medical therapy. Earlier splenectomy may avoid medication-related complications and may reduce the complications from splenectomy. Splenectomy remains an effective and safe treatment for ITP.

Management of thrombocytopenia

Thrombocytopenia is one of the most common hematologic disorders, characterized by an abnormally low number of platelets from multiple causes. The normal count of thrombocytes (platelets) is between 150,000 and 450,000 per microliter. The clinical expression of thrombocytopenia has broad variation from asymptomatic to life-threatening bleeding. Various syndromes and diseases are associated with thrombocytopenia. Thrombocytopenia is sometimes a first sign of hematologic malignancies, infectious diseases, thrombotic microangiopathies, and autoimmune disorders, and is also a common side effect of many medications. There are more than 200 diseases that include low number of platelets among their symptoms. A brief discussion of the most common etiologies and management of them is provided in this review.

Chronic immune thrombocytopenia in children: who needs splenectomy?

In the field of emerging innovative therapies, such as thrombopoietin mimetics, the question of who needs splenectomy remains highly relevant. Removal of the spleen is an accepted and potentially curative treatment of immune thrombocytopenia (ITP) after decades with a favorable economical-effect ratio but with relevant morbidity particularly in the young patients. ITP is rare and splenectomy is performed in a minority of children, which makes its research almost impossible, resulting in a poor standardization of the procedure. Hence, in children, recommendation and decision for splenectomy is individually based and rests on expert opinions. Furthermore, local practice and availability of health products affect the frequency of splenectomy. Current guidelines agree on one point: splenectomy should be postponed for at least 12 months after the initial diagnosis of ITP, due to the high probability of improvement or even spontaneous remission. However, evidence-based data are lacking and splenectomy remains controversial. This article reviews the current literature and delineates controversies and complexities of splenectomy in children with ITP. There is an urgent need for consensus of this procedure in pediatric patients.

Contemporary treatment of immune thrombocytopenia

Immune thrombocytopenia is an autoimmune-mediated disorder and the treatment strategies were directed mainly to suppression of the immune system or to removal of the spleen as a place of thrombocyte destruction. In last years, it was shown that other mechanisms are responsible for development of immune thrombocytopenia: reduced thrombocyte lifespan and ineffective marrow platelet production. New treatment strategies, such as thrombopoietin receptor agonists, were developed to overcome this mechanism. Still there are a difficult minority of patients unresponsive to multiple treatments, whose have severe bleeding and another group of patients with extensive morbidity from therapy, not restricted to steroids. In this review, focused on adult patients, we discuss newer results of therapies and consider newer treatment strategies.

Childhood immune thrombocytopenia: role of rituximab, recombinant thrombopoietin, and other new therapeutics

Childhood immune thrombocytopenia (ITP) is often considered a benign hematologic disorder. However, 30% of affected children will have a prolonged course and 5%-10% will develop chronic severe refractory disease. Until recently, the only proven therapeutic option for chronic severe ITP was splenectomy, but newer alternatives are now being studied. However, because immunosuppressive agents such as rituximab are not approved for use in ITP and the thrombopoietin receptor agonists are not yet approved in children, the decision to use alternatives to splenectomy needs to be considered carefully. This review describes the factors that should affect decisions to treat ITP at diagnosis and compares the options for the occasional child in whom ITP does not resolve within the first year.

Predictive value of response to steroid therapy on response to splenectomy in children with immune thrombocytopenic purpura

BACKGROUND

Many but not all studies suggest that a favorable response to preoperative steroid therapy predicts a successful outcome after splenectomy in children with immune thrombocytopenic purpura (ITP). The purpose of this study is to further examine the relationship between steroid response and outcome after splenectomy in children.

METHODS

After institutional review board approval, records of children undergoing splenectomy for ITP were reviewed. Patients' responses were determined by platelet counts and grouped by complete response (CR; ≥ 150,000/μL), partial response (PR; 149,999- ≥ 50,000/μL), or no response (NR; <50,000/μL).

RESULTS

Thirty-seven children were identified. After steroid therapy, 20 patients (54%) had CR, 9 (24%) had PR, and 8 (22%) had NR. After splenectomy, 31 patients (84%) had CR, 6 (16%) had PR, and 0 had NR. Of the 20 patients that had a CR to steroid therapy, 18 (80%) had CR and 2 (20%) had PR to splenectomy. Of the 9 patients that had PR to steroids, 7 (78%) had CR to splenectomy and 2 (22%) had PR. Of the 8 patients that had NR to steroids, 6 (75%) had CR and 2 (25%) had PR to splenectomy. Response to splenectomy was not associated with response to steroids (P = .59).

CONCLUSION

These data suggest that response to splenectomy in children with ITP is unrelated to previous response to steroids.

Contemporary pediatric splenectomy: continuing controversies

PURPOSE

We undertook the current study to update the literature on pediatric splenectomy in the age of minimally invasive proficiency among pediatric surgeons. The study is designed to address specific concerns among surgeons about the suitability of the laparoscopic approach in specific situations and among hematologists about the relative benefits and risks of splenectomy in children.

METHODS

Retrospective analysis of clinicopathologic data for 118 children who underwent open (OS) or laparoscopic (LS) splenectomy at an urban tertiary children's hospital from January 2000 to July 2008.

RESULTS

One hundred and three cases (87%) were started as LS. Operative times were equivalent for LS and OS (P = 0.8). In the LS group, there were four conversions (3.9%) from LS to OS and five early post-operative complications (4.9%). Median length of stay was 2 days for LS and 4 days for both OS and LS converted to OS (P < 0.0001). The ten largest spleens removed by LS had greater mass (P = 0.02) and tended to have greater volume (P = 0.1) than those removed by OS. Children with hereditary spherocytosis, ITP, and hemoglobinopathy had favorable clinical outcomes, regardless of operative approach. There were no cases of overwhelming post-splenectomy sepsis in this series.

CONCLUSIONS

Laparoscopic splenectomy is the preferred approach for splenectomy in children with hematological diseases, with or without splenomegaly. Compared to open splenectomy, laparoscopic splenectomy has equivalent operative time and improved length of stay. Both approaches have excellent therapeutic outcomes for appropriate indications.