Thrombocytopenia in liver disease:

Recurrent TIPS dysfunction and variceal bleeding: A combined, staged, use of large-bore aspiration thrombectomy and partial splenic artery embolization-A case report

A 51-year-old man, with a history of cirrhotic portal hypertension and recurrent transjugular intrahepatic portosystemic shunt (TIPS) stenoses, presented with an acute gastro-esophageal variceal hemorrhage in the setting of an acute and massive thrombotic TIPS shunt occlusion. The clinical presentation was complicated by patient's severe, chronic thrombocytopenia which had precluded empiric anticoagulation previously for recurrent TIPS dysfunction. Following endoscopic treatment of the variceal bleeding, the CAT 12 Indigo aspiration system (Penumbra) was used to remove a large burden of thrombus from the TIPS, allowing successful re-stenting and restoration of blood flow through the TIPS. A staged partial splenic artery embolization was performed a few days later to reduce hypersplenism and treat the thrombocytopenia. The patient was then therapeutically anticoagulated to prevent future TIPS occlusion.

S, Bhola H. Spontaneous rectus sheath hematoma as a differential diagnosis for localized abdominal swelling in chronic liver disease: A rare case report

Key Clinical Message

Spontaneous rectus sheath hematoma is a rare complication in chronic liver disease patients. Early clinical suspicion with prompt radiological evaluation is crucial for accurate diagnosis and timely management.

Abstract

Spontaneous rectus sheath hematoma can present as an acute abdomen in the emergency department. The rupture of the upper and lower epigastric arteries and their branches is the main cause of hematoma formation. Hepatic dysfunction can affect the clotting process, increasing the risk of hematoma development. Computed tomography is the preferred diagnostic tool. Most hematomas can be managed conservatively, with only a few requiring minimal intervention or surgical management. We report an uncommon instance of spontaneous rectus sheath hematoma in a patient with chronic liver disease presenting with painful abdominal distention, mimicking a hernia and initially posing a diagnostic challenge. The rectus sheath hematoma was definitively diagnosed through clinical and radiological evaluation and subsequently evacuated with successful outcomes.

Relationship between Circadian System Status, Child-Pugh Score, and Clinical Outcome in Cirrhotic Patients on Waiting Lists for Liver Transplantation

Background/Objectives: Many patients suffering from liver cirrhosis are eventually added to waiting lists for liver transplantation whose priority is established based on scales such as the Child-Pugh score. However, two marker rhythms of the circadian system, motor activity and distal temperature, are not evaluated. Methods: To determine the relationship between the functional status of the circadian system and the Child-Pugh scale in patients awaiting liver transplantation, distal temperature, motor activity, and light exposure rhythms were monitored for a full week using a wrist device (Kronowise 6.0) in 63 patients (17 women, 46 men) aged between 20 and 76 years. Results: Circadian parameters (amplitude, regularity, and fragmentation) of motor activity rhythms, distal temperature, and light exposure worsen in close association with liver disease severity as assessed by using the Child-Pugh score. Likewise, the worsening of rhythmic parameters and liver disease is associated with a deterioration in the markers of the red series: count, hemoglobin, and hematocrit. Conclusions: These results indicate the utility of ambulatory monitoring of marker rhythms to complement the clinical information provided by the Child-Pugh scale and to help establish nutrition, physical exercise, and sleep guidelines that promote better survival and quality of life in these patients.

Comparative proteomics reveals different protein expression in platelets in patients with alcoholic liver cirrhosis

BACKGROUND

The role of platelets in disease progression as well as the function of platelets as part of the haemostatic and immunological system in patients with liver cirrhosis is only incompletely understood. This is partly due to difficulties in assessing platelet function. Proteome analyses of platelets have been used to further investigate the role of platelets in other diseases.

AIM

To assess possible changes in the platelet proteome during different stages of alcohol induced liver cirrhosis compared to healthy donors.

PATIENTS AND METHODS

A 45 ml blood sample was drawn from 18 participants aged 18-80 years evenly divided into three groups of healthy donors, patients with less advanced alcohol induced liver cirrhosis (Child-Pugh < 7) and patients with advanced liver cirrhosis (Child-Pugh > 10). The blood was processed to isolate platelets and perform subsequent two-dimensional gel-electrophoresis using a SYPRO™ Ruby dye. After computational analysation significantly in- or decreased protein spots (defined as a two-fold abundance change between different study cohorts and ANOVA < 0.05) were identified via liquid chromatography-mass spectrometry (LCMS) and searching against human protein databases.

RESULTS

The comparative analysis identified four platelet proteins with progressively decreased protein expression in patients with liver cirrhosis. More specifically Ras-related protein Rab-7a (Rab-7a), Ran-specific binding protein 1 (RANBP1), Rho GDP-dissociation inhibitor 1 (RhoGDI1), and 14-3-3 gamma.

CONCLUSION

There is significant change in protein expression in the platelet proteome throughout the disease progression of alcohol induced liver cirrhosis. The identified proteins are possibly involved in haemostatic and immunoregulatory function of platelets.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

DIC Score Combined With CLIF-C OF Score Is More Effective in Predicting Prognosis in Patients With Hepatitis B Virus Acute-on-Chronic Liver Failure

Coagulation and fibrinolysis disorders are major prognostic factors in hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients. Here, we aimed to clarify the role of disseminated intravascular coagulation (DIC) scores in predicting HBV-ACLF patient prognosis. We assessed the DIC score from HBV-ACLF patients at Huashan Hospital in Shanghai, China from June 2013 to May 2021 and evaluated it in relation to short-term mortality, clinical course, and infection. A novel prognostic scoring model was proposed based on DIC scores. A total of 163 transplant-free HBV-ACLF patients were enrolled. DIC scores were higher in non-survivors than survivors (6 vs. 4, P = 0.000) and were independently associated with short-term mortality [hazard ratio (HR): 1.397, 95% confidence interval (95% CI): 1.040–1.875, P = 0.026]. DIC scores were associated with ACLF grade, clinical course, and infection. Moreover, they were correlated with model for end-stage liver disease (MELD) scores (r = 0.521, P < 0.001). The area under the receiver operating curve (auROC) of CLIF-C OF-DICs [a novel prognostic score based on age, DIC score, and Chronic liver failure-consortium organ function score (CLIF-C OFs)] for 90-day mortality was 0.936, which was higher than six other generic prognostic scoring models. These results were confirmed in a validation cohort (n = 82). In conclusion, elevated DIC score is associated with poor prognosis in HBV-ACLF patients, and can be used jointly with CLIF-C OFs to improve the accuracy of prognosis prediction.

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

BACKGROUND

Second-generation thrombopoietin receptor agonists (TPO-RAs) are emerging as the new standard for managing thrombocytopenia (TCP) in patients with chronic liver diseases (CLDs) undergoing scheduled procedures. However, practical guidance for their routine use in CLD patients undergoing specific invasive procedures is lacking.

METHODS

These practice guidelines were developed by the Initiative Group for Central European Hepatologic Collaboration (CEHC), composed of nine hepatologist/gastroenterologist experts from Central Europe. Using an adapted Delphi process, the CEHC group selected ten invasive procedures most relevant to the hepatology/gastroenterology setting in the region. Consensus recommendations for each invasive procedure are reported as a final percentage of expert panel responses.

RESULTS

A consensus was agreed that TPO-RAs should be considered for raising platelet count in CLD patients undergoing scheduled abdominal surgery, high-bleeding risk dentistry, endoscopic polypectomy, endoscopic variceal ligation, liver biopsy, liver surgery, liver transplantation and percutaneous ablation, but it was also agreed that they are less beneficial or not necessary for endoscopy without intervention and paracentesis.

CONCLUSIONS

Using a modified Delphi method, experts reached an agreement for TCP management in CLD patients undergoing ten invasive procedures. These practice guidelines may help with decision making and patient management in areas where clinical evidence is absent or limited.

Multimodal Ultrasound Model Based on the Left Gastric Vein in B-Viral Cirrhosis: Noninvasive Prediction of Esophageal Varices

OBJECTIVES:

To establish and verify a simple noninvasive model based on the left gastric vein (LGV) to predict the grade of esophageal varices (EV) and high-risk EV (HEV), to facilitate clinical follow-up and timely treatment.

METHODS:

We enrolled 320 patients with B-viral cirrhosis. All patients underwent endoscopy, laboratory tests, liver and spleen stiffness (SS), and ultrasonography. HEV were analyzed using the χ² test/t test and logistic regression in the univariate and multivariate analyses, respectively. EV grades were analyzed using the variance/rank-sum test and logistic regression. A prediction model was derived from the multivariate predictors.

RESULTS:

In the training set, multivariate analysis showed that the independent factors of different EV grades were SS, LGV diameter, and platelet count (PLT). We developed the LGV diameter-SS to PLT ratio index (LSPI) and LGV diameter/PLT models without SS. The area under the receiver operating characteristic curve of the LSPI for diagnosis of small EV, medium EV, large EV, and HEV was 0.897, 0.899, 0.853, and 0.954, respectively, and that of the LGV/PLT was 0.882, 0.890, 0.837, and 0.942, respectively. For the diagnosis of HEV, the negative predictive value was 94.07% when LSPI < 19.8 and the positive predictive value was 91.49% when LSPI > 23.0. The negative predictive value was 95.92% when LGV/PLT < 5.15, and the positive predictive value was 86.27% when LGV/PLT > 7.40. The predicted values showed similar accuracy in the validation set.

DISCUSSION:

Under appropriate conditions, the LSPI was an accurate method to detect the grade of EV and HEV. Alternatively, the LGV/PLT may also be useful in diagnosing the varices when condition limited.

Platelet function in dogs with chronic liver disease

OBJECTIVES

To assess platelet function, buccal mucosal bleeding time and plasma von Willebrand factor concentration in dogs with chronic inflammatory and/or fibrotic liver disease and to compare results with those obtained in healthy dogs.

MATERIALS AND METHODS

Preliminary study including 18 dogs with chronic inflammatory and/or fibrotic liver disease undergoing liver biopsy and 18 healthy age-matched control dogs. Platelet function was assessed by measuring closure time with the PFA-100® analyser using adenosine diphosphate (ADP) as an agonist. Buccal mucosal bleeding time, closure time and plasma von Willebrand factor antigen were measured in dogs in both groups. After undergoing ultrasound-guided needle biopsy, dogs were monitored for haemorrhage to determine if there was an association of any measurement with post-biopsy bleeding.

RESULTS

The closure time was not different between the liver disease group (median 76.3; range 53 to 118.5 seconds) and control group (72.8; 57 to 89.5 seconds). The buccal mucosal bleeding time was longer in the liver disease group (median 138; range 95 to 229 seconds) than the control group (103; 63 to 200 seconds). The plasma von Willebrand factor antigen concentration was not different between the liver disease group (median 203; range 109 to 351%) and control group (165.5; 63 to 246%).

CLINICAL SIGNIFICANCE

In this study, dogs with chronic necroinflammatory and/or fibrotic liver disease did not have overt, clinically relevant derangements in platelet function as assessed by buccal mucosal bleeding time, closure time and von Willebrand factor analysis. In addition, none of the dogs undergoing percutaneous ultrasound-guided biopsy in the study exhibited bleeding complications post-biopsy procedure.

Thrombocytopenia and Hemostatic Changes in Acute and Chronic Liver Disease: Pathophysiology, Clinical and Laboratory Features, and Management

Thrombocytopenia, defined as a platelet count <150,000/μL, is the most common complication of advanced liver disease or cirrhosis with an incidence of up to 75%. A decrease in platelet count can be the first presenting sign and tends to be proportionally related to the severity of hepatic failure. The pathophysiology of thrombocytopenia in liver disease is multifactorial, including (i) splenomegaly and subsequently increased splenic sequestration of circulating platelets, (ii) reduced hepatic synthesis of thrombopoietin with missing stimulation both of megakaryocytopoiesis and thrombocytopoiesis, resulting in diminished platelet production and release from the bone marrow, and (iii) increased platelet destruction or consumption. Among these pathologies, the decrease in thrombopoietin synthesis has been identified as a central mechanism. Two newly licensed oral thrombopoietin mimetics/receptor agonists, avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease, who are undergoing invasive procedures. This review summarizes recent advances in the understanding of defective but at low level rebalanced hemostasis in stable cirrhosis, discusses clinical consequences and persistent controversial issues related to the inherent bleeding risk, and is focused on a risk-adapted management of thrombocytopenia in patients with chronic liver disease, including a restrictive transfusion regimen.

Added Value of Blood Cells in Thrombin Generation Testing

The capacity of blood to form thrombin is a critical determinant of coagulability. Plasma thrombin generation (TG), a test that probes the capacity of plasma to form thrombin, has improved our knowledge of the coagulation system and shows promising utility in coagulation management. Although plasma TG gives comprehensive insights into the function of pro- and anticoagulation drivers, it does not measure the role of blood cells in TG. In this literature review, we discuss currently available continuous TG tests that can reflect the involvement of blood cells in coagulation, in particular the fluorogenic assays that allow continuous measurement in platelet-rich plasma and whole blood. We also provide an overview about the influence of blood cells on blood coagulation, with emphasis on the direct influence of blood cells on TG. Platelets accelerate the initiation and velocity of TG by phosphatidylserine exposure, granule content release and surface receptor interaction with coagulation proteins. Erythrocytes are also major providers of phosphatidylserine, and erythrocyte membranes trigger contact activation. Furthermore, leukocytes and cancer cells may be important players in cell-mediated coagulation because, under certain conditions, they express tissue factor, release procoagulant components and can induce platelet activation. We argue that testing TG in the presence of blood cells may be useful to distinguish blood cell-related coagulation disorders. However, it should also be noted that these blood cell-dependent TG assays are not clinically validated. Further standardization and validation studies are needed to explore their clinical usefulness.

Relationship between splenomegaly and transfusion requirements in patients with cirrhosis

Patients with cirrhosis and splenomegaly commonly develop cytopenias and require the transfusion of blood products. In this study, we evaluated spleen size as a clinical indicator for red blood cell transfusion effectiveness and hypothesized that transfusion would be less effective in patients with splenomegaly. Our retrospective cohort study compared 215 cirrhotic patients with splenomegaly and 114 cirrhotic patients without splenomegaly and measured their respective change in hemoglobin concentration after a unit of transfused red blood cells. The primary endpoint was the percent difference between the measured rise in hemoglobin after transfusion in these cohorts. Patient sex (P < 0.0035), body mass index (P < 0.0001), and the change in hemoglobin concentration after a leukocyte-reduced red blood transfusion (P < 0.0001) were found to be significantly related to spleen size. When compared to the nonsplenomegaly cohort, it was found that the splenomegaly cohort experienced 79.70% (95% CI 71.26%-89.14%) of the change in hemoglobin concentration after red blood cell transfusion when adjusted for patient sex and body mass index. In conclusion, in patients with cirrhosis, increased spleen size was correlated with a decreased responsiveness to red blood cell transfusion when adjusted for patient sex and body mass index.

Assessment and management of coagulopathy in critically-ill patients with liver failure

PURPOSE OF REVIEW

This review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment.

RECENT FINDINGS

Patients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at risk for both excessive clotting and bleeding. Hypercoagulability is associated with profound endothelial dysfunction and an increased concentration of liver-independent coagulation factors. Because of this rebalanced coagulation profile, standard laboratory tests have been demonstrated to be ineffective in either predicting and/or guiding the management of coagulopathy. Viscoelastic testing, however, is able to provide a dynamic assessment of clot formation in whole blood and has been demonstrated to be invaluable in both monitoring and management of coagulation problems associated with liver failure. More recently, there is increasing interest in thrombin generation tests to monitor coagulation in patients with ESLD.Multiple institutional protocols for prophylaxis and treatment of ESLD-related thromboses have been developed. High-quality studies evaluating these approaches are lacking.

SUMMARY

Patients with ESLD are at risk for excessive bleeding and clotting. Treatment of any significant coagulopathy should not be based solely on standard laboratory tests. Thrombosis prophylaxis has to be considered in susceptible populations.

Platelets and Hepatocellular Cancer: Bridging the Bench to the Clinics

Growing interest is recently being focused on the role played by the platelets in favoring hepatocellular cancer (HCC) growth and dissemination. The present review reports in detail both the experimental and clinical evidence published on this topic. Several growth factors and angiogenic molecules specifically secreted by platelets are directly connected with tumor progression and neo-angiogenesis. Among them, we can list the platelet-derived growth factor, the vascular endothelial growth factor, the endothelial growth factor, and serotonin. Platelets are also involved in tumor spread, favoring endothelium permeabilization and tumor cells' extravasation and survival in the bloodstream. From the bench to the clinics, all of these aspects were also investigated in clinical series, showing an evident correlation between platelet count and size of HCC, tumor biological behavior, metastatic spread, and overall survival rates. Moreover, a better understanding of the mechanisms involved in the platelet-tumor axis represents a paramount aspect for optimizing both current tumor treatment and development of new therapeutic strategies against HCC.

Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE)

Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.

Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients

INTRODUCTION AND AIM

EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia.

METHODS

We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL.

RESULTS

The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR&gt;1.5, platelet count &lt;50x109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) versus 230 mg/dL (104 - 638), P=0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding.

CONCLUSION

low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients' risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.

Evaluation of coagulation during treatment with directly acting antivirals in patients with hepatitis C virus related cirrhosis

BACKGROUND & AIMS

The effect of direct-acting-antivirals (DAA) on coagulation of hepatitis-C-virus (HCV)-related cirrhosis is unknown.

METHODS

We investigated 28 patients on DAA treatment and performed prothrombin-time, thrombin generation with and without thrombomodulin, whole-blood thromboelastometry, as well as the individual procoagulants (II, VIII, XIII, von Willebrand) and anticoagulants, antithrombin and protein-C.

RESULTS

Patients had undetectable HCV-RNA at the end-of- treatment and at 12-weeks after end-of-treatment (sustained virological response). Transaminases were significantly decreased at both end-of-treatment and at 12-weeks. Prothrombin-time declined at 12-weeks, but did not reach statistical significance. Factor-II, protein-C and antithrombin increased significantly at end-of-treatment (P<.001) and persisted at 12-weeks. Factor-VIII decreased at end-of-treatment and to a greater extent at 12-weeks when reached statistical significance (P<.05). Factor-VIII/protein-C ratio decreased sharply, reached statistical significance at end-of-treatment (P<.01) and persisted at 12-weeks. Von-Willebrand decreased at end-of-treatment and reached statistical significance at 12-weeks (P<.001). Endogenous-thrombin-potential without thrombomodulin increased significantly at end-of-treatment (P<.01) and persisted at 12-weeks. No changes were observed after addition of thrombomodulin. Endogenous-thrombin-potential ratio (with/without thrombomodulin) decreased and reached statistical significance at 12-weeks (P<.05). Thromboelastometry clotting time decreased sharply, reached statistical significance at end-of treatment (P<.001) and persisted at 12-weeks.

CONCLUSIONS

Treatment with DAAs in HCV-related cirrhosis results in improvement of the individual pro- and anticoagulants. It can be hypothesised that the net effect does not substantially modify their balance (as shown by the unchanged thrombin generation in the presence of thrombomodulin) but makes it more stable and less amenable to be perturbed as presumably occurs before treatment when there is a partial deficiency for both.

Reducing the incidence of hepatic artery thrombosis in pediatric liver transplantation: Effect of microvascular techniques and a customized anticoagulation protocol

We aimed to assess the incidence of HAT over three eras following implementation of microvascular techniques and a customized anticoagulation protocol in a predominantly cadaveric split liver transplant program. We retrospectively reviewed pediatric liver transplants performed between April 1986 and 2016 and analyzed the incidence HAT over three eras. In E1, 1986-2008, each patient received a standard dose of 5 U/kg/h of heparin and coagulation profiles normalized passively. In E2, 2008-2012, microvascular techniques were introduced. In E3, 2012-2016, in addition, a customized anticoagulation protocol was introduced which included replacement of antithrombin 3, protein C and S, and early heparinization. A total of 317 liver transplants were completed during the study period, with a median age of 31.7 months. In E1, 22% of grafts were cadaveric in situ split grafts, while the second and third eras used split grafts in 59.0% and 64.9% of cases, respectively. HAT occurred in 9.5% in the first era, 11.5% (P=.661) in the second, and dropped to 1.8% in the third era (P=.043). A routine anticoagulation protocol has significantly reduced the incidence of HAT post-liver transplantation in children in a predominantly cadaveric in situ split liver transplant program.

Hemostasis, bleeding and thrombosis in liver disease

The presence of cirrhosis poses an increased risk of both thrombosis and bleeding in individuals with chronic liver disease. This duality is a result of a dynamic disequilibrium between procoagulant and anticoagulant states in individuals with cirrhosis. The mechanism of this imbalance in cirrhosis remains unclear. It is known that the progression of cirrhosis leads to decreased synthetic function and a concurrent lack of natural anticoagulants. Other proposed mechanisms contributing to this hemostatic imbalance include decreased platelet production, increased platelet destruction from hypersplenism, decreased synthesis of Vitamin K-dependent and independent clotting factors and anticoagulant factors, and alterations in purinergic signaling pathways.

Given the current state of flux in our understanding of bleeding and thrombophilia in cirrhosis, the recommendations for treatment of these conditions are still evolving.

We provide a current update on the proposed pathophysiology of altered hemostasis and thrombophilia in cirrhosis. We discuss recent studies in portal vein thrombosis (PVT) and venous thromboembolism (VTE), which are the common thrombotic consequences of cirrhosis, resulting in substantive morbidity and mortality. To address these, we discuss new prophylactic interventions and current treatment options to manage the heightened risk of thrombosis in cirrhosis, while limiting hemorrhagic complications.

Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.

Hemostasis abnormalities in cirrhosis

PURPOSE OF REVIEW

The long-lasting paradigm of cirrhosis as the epitome of the acquired hemorrhagic coagulopathies has been challenged by evidence from the literature. This article reviews the mechanisms responsible for regulation of hemostasis in the light of the evidence provided within the last few years.

RECENT FINDINGS

Numerous studies have evaluated the mechanisms responsible for regulation of primary hemostasis, coagulation and fibrinolysis which were thought to be severely impaired in cirrhosis and were considered responsible for the abnormalities of the prothrombin time and the bleeding events observed in these patients. These evaluations have been performed by newer laboratory tests under experimental conditions that mimic closely the condition operating in vivo.

SUMMARY

Cirrhosis presents with thrombocytopenia and decreased levels of both pro- and anticoagulants. Notable exceptions are factor VIII and von Willebrand factor (VWF) which are increased. Thrombocytopenia (unless very severe) is no longer considered a bleeding risk as platelets from cirrhosis display normal adhesiveness in a flowing system that is mainly supported by the increased levels of VWF. Patients with cirrhosis generate normal amounts of thrombin that is mainly supported by the concomitant deficiency of pro- and anticoagulants that restores the balance between these two opposing drivers.

Patterns of blood component use in cirrhosis: a nationwide study

BACKGROUND & AIMS

Cirrhosis is a complex acquired disorder of coagulation and frequent indication for transfusion of blood components. We characterised blood component use in patients with cirrhosis and compared this to transfusion guidelines.

METHODS

All National Health Service trusts with representation on the British Society of Gastroenterology membership list were invited to take part. Data were collected prospectively on consecutive, unselected, hospitalised admissions with cirrhosis over 28 days. Detailed information was recorded for patients receiving blood components including indication (for bleeding or prophylaxis), type of component, laboratory indices triggering transfusion, complications, thromboembolic events and clinical outcome to day 28.

RESULTS

Data on 1313 consecutive patients with cirrhosis were collected from 85 hospitals. A total of 391/1313 (30%) were transfused a blood component; in 238/391 (61%), this was for treatment of bleeding and in 153/391 (39%) for prophylaxis of bleeding. In 48/185 (26%) cases with bleeding, the haemoglobin threshold was >80 g/L prior to red blood cell transfusion. In the prophylaxis group, 238/391 (61%) received transfusion in response to an abnormal haematological value in the absence of any planned procedure. In patients transfused for procedural prophylaxis, 10/34 (29%) received fresh frozen plasma at an International Normalised Ratio lower than the threshold where a benefit would be anticipated. An in-patient thromboembolic event was recorded in 3% (35/1313) and 10% (138/1313) died by day 28.

CONCLUSIONS

One-third of hospitalised patients with cirrhosis were transfused. Strategies for Patient Blood Management should include ensuring transfusion practice is consistent with guidelines and greater emphasis on alternatives to transfusion.

Prognostic role of mean platelet volume in patients with cirrhosis

BACKGROUND

Studies carried out in patients with chronic hepatitis have shown that mean platelet volume (MPV) is associated with worse disease stage, although the role of MPV in patients with cirrhosis is less clear.

AIM

To evaluate the association between MPV values and clinical characteristics and stage of cirrhosis, and to assess its prognostic role.

METHODS

We studied 75 patients with cirrhosis and assessed the association between MPV values and cirrhosis characteristics, prognostic scores, and survival. The prognostic role of longitudinal variations of MPV was also assessed in 50 patients who had at least 12 months follow-up and who had MPV determination at 3-monhtly intervals.

RESULTS

Median MPV values were not statistically different according to aetiology of liver disease (P=0.485) and disease severity both taking into consideration the Child-Pugh classification (P=0.438) and the Model for End-stage Liver Disease score (P=0.978). Median MPV values were not significantly different in 23 Child-Pugh class C patients who died or survived (9.15fL versus 9.10fL, P=0.794) during a 12-month follow-up. Lastly, there was no significant modification of MPV over time at the various study time-points (3-month, 6-month, 9-month, 12-month) between patients who died and those who survived.

CONCLUSIONS

In patients with cirrhosis, MPV has no association with severity of disease and prognosis.

Unconjugated Bilirubin exerts Pro-Apoptotic Effect on Platelets via p38-MAPK activation

Thrombocytopenia is one of the most frequently observed secondary complications in many pathological conditions including liver diseases, where hyperbilirubinemia is very common. The present study sought to find the cause of thrombocytopenia in unconjugated hyperbilirubinemic conditions. Unconjugated bilirubin (UCB), an end-product of heme catabolism, is known to have pro-oxidative and cytotoxic effects at high serum concentration. We investigated the molecular mechanism underlying the pro-apoptotic effect of UCB on human platelets in vitro, and followed it up with studies in phenylhydrazine-induced hyperbilirubinemic rat model and hyperbilirubinemic human subjects. UCB is indeed found to significantly induce platelet apoptotic events including elevated endogenous reactive oxygen species generation, mitochondrial membrane depolarization, increased intracellular calcium levels, cardiolipin peroxidation and phosphatidylserine externalization (p < 0.001) as evident by FACS analysis. The immunoblots show the elevated levels of cytosolic cytochrome c and caspase activation in UCB-treated platelets. Further, UCB is found to induce mitochondrial ROS generation leading to p38 activation, followed by downstream activation of p53, ultimately resulting in altered expression of Bcl-2 and Bax proteins as evident from immunoblotting. All these parameters conclude that elevated unconjugated bilirubin causes thrombocytopenia by stimulating platelet apoptosis via mitochondrial ROS-induced p38 and p53 activation.

Non-cirrhotic thrombocytopenic patients with hepatitis C virus: Characteristics and outcome of antiviral therapy

BACKGROUND AND AIM

Thrombocytopenia is frequently observed in patients with chronic hepatitis C virus (HCV) infection and cirrhosis, although it can also be observed in patients without cirrhosis by a virus-mediated phenomenon. This study assessed the prevalence, characteristics, and outcomes of antiviral therapy in patients with chronic HCV infection and thrombocytopenia not associated with cirrhosis.

METHODS

The study included 1268 patients with HCV infection and thrombocytopenia enrolled in the phase 3 ENABLE studies that assessed the impact of eltrombopag on achieving a sustained virologic response to pegylated interferon and ribavirin. The study population was subdivided according to baseline FibroSURE test results into patients with non-cirrhosis (FibroSURE < 0.4) and cirrhosis-related (FibroSURE ≥ 0.75) thrombocytopenia.

RESULTS

Compared with patients with cirrhosis-related thrombocytopenia (n = 995; 78.5%), non-cirrhotic patients with thrombocytopenia (n = 59; 4.6%) were younger (mean age [95% confidence interval (CI)]: 43.9 [40.7-47.2] vs 52.7 [52.2-53.3] years; P < 0.0001), predominantly female (64% [51-76] vs 30% [27-33]; P < 0.0001), and less frequently had a Model for End-Stage Liver Disease score ≥ 10 (24% [14-37] vs 45% [42-49]; P = 0.0012), low albumin levels (≤ 35 g/L; 2% [0-9] vs 32% [29-35]; P < 0.0001), and prevalence of diabetes mellitus (3% [0-12] vs 21% [19-24]; P = 0.0005). The sustained virologic response rate was higher in non-cirrhotic patients with thrombocytopenia (46% [95% CI, 33-59] vs 16% [14-18]; P < 0.0001).

CONCLUSIONS

Patients with thrombocytopenia associated with HCV who have lower FibroSURE test results may have better preserved liver function and higher sustained virologic response rates than patients with cirrhosis.

Portal vein thrombosis

Portal vein thrombosis (PVT) is a rare event in the general medical setting that commonly complicates cirrhosis with portal hypertension, and can also occur with liver tumors. The diagnosis is often incidental when a thrombus is found in the portal vein on imaging tests. However, PVT may also present with clinical symptoms and can progress to life-threatening complications of ischemic hepatitis, liver failure, and/or small intestinal infarction. This article reviews the pathophysiology of this disorder, with a major focus on PVT in patients with cirrhosis, and presents detailed guidelines on optimal diagnostic and therapeutic strategies.

Management of coagulation abnormalities in liver disease

Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.

Effects of increased von Willebrand factor levels on primary hemostasis in thrombocytopenic patients with liver cirrhosis

In patients with liver cirrhosis procoagulant and anticoagulant changes occur simultaneously. During primary hemostasis, platelets adhere to subendothelial structures, via von Willebrand factor (vWF). We aimed to investigate the influence of vWF on primary hemostasis in patients with liver cirrhosis. Therefore we assessed in-vitro bleeding time as marker of primary hemostasis in cirrhotic patients, measuring the Platelet Function Analyzer (PFA-100) closure times with collagen and epinephrine (Col-Epi, upper limit of normal ≤ 165 s) or collagen and ADP (Col-ADP, upper limit of normal ≤ 118 s). If Col-Epi and Col-ADP were prolonged, the PFA-100 was considered to be pathological. Effects of vWF on primary hemostasis in thrombocytopenic patients were analyzed and plasma vWF levels were modified by adding recombinant vWF or anti-vWF antibody. Of the 72 included cirrhotic patients, 32 (44.4%) showed a pathological result for the PFA-100. They had mean closure times (± SD) of 180 ± 62 s with Col-Epi and 160 ± 70 s with Col-ADP. Multivariate analysis revealed that hematocrit (P = 0.027) and vWF-antigen levels (P = 0.010) are the predictors of a pathological PFA-100 test in cirrhotic patients. In 21.4% of cirrhotic patients with platelet count ≥ 150/nL and hematocrit ≥ 27.0%, pathological PFA-100 results were found. In thrombocytopenic (< 150/nL) patients with cirrhosis, normal PFA-100 results were associated with higher vWF-antigen levels (462.3 ± 235.9% vs. 338.7 ± 151.6%, P = 0.021). These results were confirmed by multivariate analysis in these patients as well as by adding recombinant vWF or polyclonal anti-vWF antibody that significantly shortened or prolonged closure times, respectively. In conclusion, primary hemostasis is impaired in cirrhotic patients. The effect of reduced platelet count in cirrhotic patients can at least be partly compensated by increased vWF levels. Recombinant vWF could be an alternative to platelet transfusions in the future.

Procoagulant therapeutics in liver disease: a critique and clinical rationale

The complex nature of haemostasis in patients with liver disease can result in bleeding and/or thrombosis. These opposing outcomes, which have multiple contributing factors, can pose diagnostic and therapeutic dilemmas for physicians. With the high rate of haemorrhagic complications in patients with cirrhosis, we examine the various procoagulants available for use in this population. In this Review, we describe the clinical and current rationale for using each of the currently available procoagulants-vitamin K, fresh frozen plasma (FFP), cryoprecipitate, platelets, recombinant factor VIIa (rFVIIa), antifibrinolytics, prothrombin concentrate complexes (PCC), desmopressin and red blood cells. By examining the evidence and use of these agents in liver disease, we provide a framework for targeted, goal-directed therapy with procoagulants.

Transfusion and coagulation management in liver transplantation

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

Thrombocytopenia in Patients with Gastric Varices and the Effect of Balloon-occluded Retrograde Transvenous Obliteration on the Platelet Count

OBJECTIVES

Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration (BRTO) have aggravated splenomegaly, which potentially may cause worsening thrombocytopenia. The aim of the study is to determine the prevalence and degree of thrombocytopenia in patients with gastric varices associated with gastrorenal shunts undergoing BRTO, to determine the prognostic factors of survival after BRTO (platelet count included), and to assess the effect of BRTO on platelet count over a 1-year period.

MATERIALS AND METHODS

This is a retrospective review of 35 patients who underwent BRTO (March 2008-August 2011). Pre- and post-BRTO platelet counts were noted. Potential predictors of bleeding and survival (age, gender, liver disease etiology, platelet count, model for end stage liver disease [MELD]-score, presence of ascites or hepatocellular carcinoma) were analyzed (multivariate analysis). A total of 91% (n = 32/35) of patients had thrombocytopenia (<150,000 platelet/cm(3)) pre-BRTO. Platelet counts at within 48-h, within 2 weeks and at 30-60 days intervals (up to 6 months) after BRTO were compared with the baseline pre-BRTO values.

RESULTS

35 Patients with adequate platelet follow-up were found. A total of 92% and 17% of patients had a platelet count of <150,000/cm(3) and <50,000/cm(3), respectively. There was a trend for transient worsening of thrombocytopenia immediately (<48 h) after BRTO, however, this was not statistically significant. Platelet count was not a predictor of post-BRTO rebleeding or patient survival. However, MELD-score, albumin, international normalized ratio (INR), and etiology were predictors of rebleeding.

CONCLUSION

Thrombocytopenia is very common (>90% of patients) in patients undergoing BRTO. However, BRTO (with occlusion of the gastrorenal shunt) has little effect on the platelet count. Long-term outcomes of BRTO for bleeding gastric varices using sodium tetradecyl sulfate in the USA are impressive with a 4-year variceal rebleed rate and transplant-free survival rate of 9% and 76%, respectively. Platelet count is not a predictor of higher rebleeding or patient survival after BRTO.

Portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is considered to be a frequent complication of liver cirrhosis. However, unlike PVT in patients without cirrhosis, very few data are available on the natural history and management of PVT in cirrhosis, despite its association with potentially life-threatening conditions, such as gastroesophageal bleeding and acute intestinal ischemia. Moreover, no consensus regarding PVT in cirrhosis exists. Suggested causes of PVT in cirrhosis include reduced portal blood flow velocity, multiple congenital or acquired thrombophilic factors, inherited or acquired conditions, and derangement of liver architecture. However, the understanding of PVT in cirrhosis is incomplete. In addition, information on the management of PVT in cirrhosis is inadequate. The aims of this review are to: (1) assemble data on the physiopathological mechanism, clinical findings, diagnosis and management of PVT in cirrhosis; (2) describe the principal factors most frequently involved in PVT development; and (3) summarize the recent knowledge concerning diagnostic and therapeutic procedures.

Eltrombopag in patients with chronic hepatitis C and thrombocytopenia

ABSTRACT: 

Eltrombopag is a thrombopoietic drug that acts by interacting with the TPO receptor and stimulates megakaryocytopoiesis and platelet production. Thrombocytopenia is a fairly frequent hematological abnormality in patients with chronic liver disease, and may represent an obstacle to interferon-based antiviral therapy in patients with chronic HCV infection who are otherwise good candidates for treatment. In large, multicenter, randomized, placebo-controlled studies, eltrombopag consistently enabled thrombocytopenic chronic hepatitis C patients to be treated with interferon-based therapy and, as an adjunct to antiviral therapy, has shown to be able to increase the sustained virologic response rate to treatment. The safety profile of the drug, with particular attention to the risk of thromboembolic events and the potential for hepatic decompensation, should be taken into account when planning treatment. The aim of this article is to review the information currently available regarding the pharmacokinetics, clinical efficacy and side-effect profile of eltrombopag, and to assess the role of this drug into the current and future hepatitis C treatment paradigm.

Influence of clinically significant portal hypertension on survival after hepatic resection for hepatocellular carcinoma in cirrhotic patients

BACKGROUND

The role of clinically significant portal hypertension on the prognosis of cirrhotic patients undergoing hepatic resection for hepatocellular carcinoma (HCC) is debated.

AIMS

In this study, our aim was to assess the role of clinically significant portal hypertension after hepatic resection for HCC in patients with cirrhosis.

METHODS

We assessed the prognostic role of the presence of clinically significant portal hypertension (oesophageal/gastric varices/portal hypertensive gastropathy or a platelet count <100 × 10(9) /L associated with splenomegaly) in 152 patients with compensated cirrhosis who underwent hepatic resection for HCC at the Italian Liver Cancer centres. Survival rates were assessed in the whole series, in the subgroup of Child-Pugh score 5 patients with uninodular HCC ≤ 5 cm, and in Child-Pugh score 5 patients with uninodular HCC ≤ 2 cm and normal bilirubin.

RESULTS

Median survival was similar in patients with and without clinically significant portal hypertension (79 vs 77 months, P = 0.686). Child-Pugh score 5 was the only variable significantly associated with survival by Cox multiple regression (P = 0.007). In Child-Pugh score 5 patients with single HCC ≤ 5 cm or in those with single HCC ≤ 2 cm and normal bilirubin, there was no survival difference between patients with and without clinically significant portal hypertension (median survival: 94 vs 78 months, P = 0.121 and >100 vs 86 months, P = 0.742).

CONCLUSIONS

Presence of clinically significant portal hypertension has no influence on survival of patients with well-compensated cirrhosis undergoing hepatic resection for HCC.

Hepatic vein waveform and splenomegaly predict improvement of prothrombin time after splenectomy in hepatitis C virus-related cirrhotic patients

AIM

Whether hepatic function can recover in cirrhotic patients after splenectomy remains controversial.

METHODS

All consecutive Japanese patients with hepatic cirrhosis due to hepatitis C who had undergone elective splenectomy in Kyushu University Hospital between January 2008 and December 2009 were included in this retrospective study. Prothrombin time, serum albumin and total bilirubin concentrations were reviewed before and after splenectomy and analyzed to clarify whether splenectomy improves hepatic function in patients with cirrhosis and to determine the factors predictive of improvement in hepatic function.

RESULTS

Prothrombin time and total serum bilirubin concentration improved after splenectomy; however, serum albumin concentrations did not increase significantly. Twelve months after splenectomy, total serum bilirubin had decreased by over 0.3 mg/dL in 52.3% of patients and prothrombin time had improved by over 10% in 52.3% of patients. Multiple linear regression analysis identified hepatic vein waveform (HVWF) type I (P = 0.0174) and spleen weight (P = 0.0394) as independent predictors of improvement in prothrombin time and preoperative total serum bilirubin (P = 0.0002) as the only independent predictor of decrease in total bilirubin. Total bilirubin and prothrombin time were significantly improved after splenectomy in patients with HVWF type I, however, they were not improved in patients with HVWF type II.

CONCLUSION

Prothrombin time and total bilirubin improve in approximately half of cirrhotic patients within a year after splenectomy. HVWF type I and splenomegaly may be predictive factors for improvement in prothrombin time after splenectomy in patients with cirrhosis due to hepatitis C.

Severe thrombocytopenia due to hypersplenism treated with partial splenic embolisation

A 35-year-old woman with background of liver cirrhosis and portal hypertension secondary to chronic hepatitis C presented with complication of hypersplenism and thrombocytopenia. She developed severe menorrhagia requiring multiple blood transfusions. In addition, her interferon therapy was withheld owing to the underlying thrombocytopenia. Partial splenic embolisation was performed, which improved her platelet counts. Subsequently, the menorrhagia was resolved and her interferon therapy was restarted.

The role of eltrombopag in the management of hepatitis C virus-related thrombocytopenia

Eltrombopag is a 2nd generation thrombopoietin-receptor agonist. It binds with the thrombopoietin-receptors found on the surfaces of the megakaryocytes & increases platelet production. Many recent studies have suggested a potential role for this novel agent in the treatment of thrombocytopenia associated with hepatitis-C infection. Studies have shown that adjunct treatment with Eltrombopag can help avoid dose reductions/withdrawals of pegylated interferon secondary to thrombocytopenia. It may also have a role in priming up platelet levels to help initiate antiviral therapy. Similarly, chronic liver disease patients with thrombocytopenia who need to undergo an invasive procedure may be potential candidates for short two-week courses of eltrombopag in the periprocedural period to help reduce the risk of bleeding. Besides the price (deemed very expensive and probably not cost-effective), there are some legitimate concerns about the safety profile of this novel agent (most importantly, portal vein thrombosis, bone marrow fibrosis and hepatotoxicity). In this article, the potential role of eltrombopag in the context of hepatitis C virus (HCV)-related thrombocytopenia is reviewed. To write this article, a MEDLINE search was conducted (1990 to November 2012) using the search terms “eltrombopag,” “HCV,” and “thrombocytopenia.”

Eltrombopag in patients with chronic liver disease

INTRODUCTION

Thrombocytopenia may represent a barrier to optimal management of chronic liver disease patients undergoing invasive procedures, or who need to be treated with interferon-based antiviral therapy. Eltrombopag is a thrombopoietic drug that acts upon binding thrombopoietin receptor and stimulates megakaryocytopoiesis and platelet production.

AREAS COVERED

A summary of the preclinical studies and of studies carried out in patients with chronic liver disease with eltrombopag are presented in this paper. Data are based on abstracts from journal articles and international conferences found in a PubMed search of literature published up to November 2012.

EXPERT OPINION

Eltrombopag has shown to be capable of reducing the need for platelet transfusion in thrombocytopenic patients with advanced liver disease undergoing invasive procedures and help increase the sustained virological response rate to interferon-based antiviral therapy in patients with chronic hepatitis C who were poor candidates to treatment because of thrombocytopenia. In chronic liver disease patients, the possible benefits of eltrombopag administration should be accurately weighed against the adverse events profile of the drug due to possible concerns regarding the occurrence of thromboembolic events and the potential for decompensation of chronic liver disease.

Global hemostasis tests in patients with cirrhosis before and after prophylactic platelet transfusion

BACKGROUND/AIMS

Cirrhosis presents with variable degrees of thrombocytopenia that might cause bleeding during invasive procedures. Transfusion of one standard adult platelet dose is often employed to prevent bleeding in thrombocytopenia, but the threshold platelet count that is clinically effective is not well established because clinical studies and laboratory tools to judge on efficacy are insufficient. However, in vitro studies showed that patients with cirrhosis generate as much thrombin as healthy individuals provided that their platelet count is at least 100 × 10(9) /L.

METHODS

To assess the in vivo relevance of these in vitro studies, we investigated 26 thrombocytopenic patients with cirrhosis, undergoing 36 variceal ligations, to see whether transfusion of one standard adult platelet dose was able to attain the above platelet count. We also evaluated the effect of platelet transfusion on such global hemostasis tests as thrombin generation and thromboelastometry.

RESULTS

Transfusion did slightly increase platelet count [pre- vs. post-infusion: 39 × 10(9) /L(16-64) vs. 52 × 10(9) /L(19-91), P < 0.001], without significant effect on thrombin generation, probably because post-transfusion platelet count was less than the target of 100 × 10(9) /L in all patients. In addition, the percentage of patients with abnormal thrombin generation (i.e. below the lower limit of normal range) was scarcely affected by transfusion (pre- vs. post-infusion: 36% vs. 42%). The small post-transfusion increase in platelet count was paralleled by some degree of improvement of thromboelastometry, but none of the patients reached normal values after transfusion.

CONCLUSIONS

Infusing one standard adult platelet dose secures only a small increase in platelet count without normalizing thrombin generation and thromboelastometry tests. To obtain greater increases in platelet count and normalization of laboratory tests more intensive platelet transfusions or treatment with non-transfusional drugs are probably needed.