Platelet dynamics in chronic liver disease with special reference to the role of the spleen

Spontaneous muscle haematoma in a patient with cirrhosis

Decompensated liver disease is associated with alterated haemostasis that can either lead to spontaneous bleeding or development of thrombosis. Alcohol consumption coupled with advanced liver disease favours spontaneous bleeding. There have been only few documented cases of spontaneous muscle haematoma (SMH) in patients with cirrhosis. The pathogenesis of SMH is hypothesised to be multifactorial and it has been seen in patients on anticoagulation or with haemostatic disorders. We report a case of alcohol-related cirrhosis presenting with an expanding, voluminous haematoma in the intermuscular plane between the trapezius and the teres major muscles. This patient also had a retroperitoneal haemorrhage, clinically evidenced by the Grey Turner's and Cullen's signs. Haemorrhage was confirmed radiologically by CT. The patient was managed in an intensive care facility and treated with multiple blood products, including packed red blood cells, fresh frozen plasma and cryoprecipitates. However, as his clinical condition deteriorated, he required surgical intervention by incision and drainage, followed by evacuation. Early identification of coagulopathy and aggressive treatment are essential in these cases of cirrhosis to avoid unfavourable outcomes.

The Prognostic Values of Neutrophil-to-lymphocyte Ratio and Platelet-to-Lymphocyte Ratio at Baseline in Predicting the In-hospital Mortality in Black African Patients with Advanced Hepatocellular Carcinoma in Palliative Treatment: A Comparative Cohort Study

Background

The prognostic values of the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) in predicting the in-hospital mortality of Black African patients with advanced hepatocellular carcinoma (HCC) in palliative treatment is unknown.

Aim

To determine the prognostic value of NLR and PLR compared with that of Child–Turcotte–Pugh (CTP), model for end-stage liver disease (MELD) scores and the Barcelona clinic liver cancer staging system (BCLC).

Methods

The cutoffs, accuracies and association with the mortality of these prognostic scores were determined using a time-dependent area under receiver operating characteristic curves (AUC), the log rank test and Cox proportional hazards ratio.

Results

A total of 104 patients with advanced HCC (median age=49.5 years, males=58.7%) were enrolled. All were hospitalized for an enlarged liver mass of at least 15.4 cm in size in the right thoracic quadrant. Overall, 46 (44.2%) patients died in hospital during follow-up. Patients with NLR >2.5 (log rank test=7.11, p=0.01) or PLR >92 (log rank test=5.63, p=0.02) had poor survival. Factors associated with the in-hospital mortality were the MELD score (p=0.01), NLR (p=0.03) and hemoglobin level (p=0.02). NLR exhibits better and stable accuracy in predicting the in hospital mortality at time points of 30 (AUC=0.618), 60 (AUC=0.680) and 90 (AUC=0.613) days of follow-up, compared with CTP, MELD scores, BCLC and PLR. However, PLR displayed an enhanced accuracy over 90 days of follow up (AUC=0.688).

Conclusion

NLR is useful in predicting the in-hospital mortality in Black African patients with advanced stage HCC in clinical practice. NLR and PLR may be used concomitantly for long-term follow-up.

Dual Effects of Large Spleen Volume After Splenectomy for the Patients With Chronic Liver Disease

Background

After splenectomy in patients with chronic liver disease, a large spleen was reported to be not only a risk factor of portal/splenic vein thrombosis (PSVT), but also a prediction for favorable improvement of liver function. This study aimed to evaluate the risk of PSVT and the improvement of liver function after splenectomy, with special attention to spleen volume (SV).

Methods

This studied included 50 patients who underwent splenectomy with diagnosed chronic liver disease between January 2005 and December 2017. After evaluation of risk factors for PSVT the cut-off value of SV for predicting PSVT was determined. According to the cut-off value of SV, 50 patients were divided into 2 groups: small-volume group (SVG) and large-volume group (LVG). Postoperative liver functions were compared between the 2 groups.

Results

Twenty-eight patients developed PSVT. Larger SV was the most significant independent risk factor for PSVT. The cut-off value of SV was 520 mL. Preoperatively, LVG had significantly higher total bilirubin, and MELD (model for end-stage liver disease) score, and had significantly higher rates of pancytopenia than SVG. Postoperatively, compared to SVG, platelet count, choline esterase, and total cholesterol in LVG were significantly increased.

Conclusion

After splenectomy in the patients with chronic liver disease, large SV is an independent risk factor for PSVT, with a clear benefit in improving liver function, if PSVT is properly diagnosed and managed.

Consequences of Perioperative Serotonin Reuptake Inhibitor Treatment During Hepatic Surgery

BACKGROUND AND AIMS

Platelet-stored serotonin critically affects liver regeneration in mice and humans. Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenalin reuptake inhibitors (SNRIs) reduce intraplatelet serotonin. As SSRIs/SNRIs are now one of the most commonly prescribed drugs in the United States and Europe and given serotonin's impact on liver regeneration, we evaluated whether perioperative use of SSRIs/SNRIs affects outcome after hepatic resection.

APPROACH AND RESULTS

Consecutive patients undergoing hepatic resection (n = 754) were retrospectively included from prospectively maintained databases from two European institutions. Further, an independent cohort of 495 patients from the United States was assessed to validate our exploratory findings. Perioperative intake of SSRIs/SNRIs was recorded, and patients were followed up for postoperative liver dysfunction (LD), morbidity, and mortality. Perioperative intraplatelet serotonin levels were significantly decreased in patients receiving SSRI/SNRI treatment. Patients treated with SSRIs/SNRIs showed a higher incidence of morbidity, severe morbidity, LD, and LD requiring intervention. Associations were confirmed in the independent validation cohort. Combined cohorts documented a significant increase in deleterious postoperative outcome (morbidity odds ratio [OR], 1.56; 95% confidence interval [CI], 1.07-2.31; severe morbidity OR, 1.86; 95% CI, 1.22-2.79; LD OR, 1.96; 95% CI, 1.23-3.06; LD requiring intervention OR, 2.22; 95% CI, 1.03-4.36). Further, multivariable analysis confirmed the independent association of SSRIs/SNRIs with postoperative LD, which was closely associated with postoperative 90-day mortality and 1-year overall survival.

CONCLUSIONS

We observed a significant association of perioperative SSRI/SNRI intake with adverse postoperative outcome after hepatic resection. This indicates that SSRIs/SNRIs should be avoided perioperatively in patients undergoing hepatic resections.

Exploring the Link Between Platelet Numbers and Vascular Homeostasis Across Early and Late Stages of Fibrosis in Hepatitis C

BACKGROUND

Thrombocytopenia is a hallmark of advanced liver disease. Platelets, growth factors (GFs), and vascular integrity are closely linked factors in disease pathogenesis, and their relationship, particularly in early disease stages, is not entirely understood. The aim was to compare circulating platelets, growth factors, and vascular injury markers (VIMs) in hepatitis C-infected (HCV) patients with early fibrosis and cirrhosis.

METHODS

Retrospective evaluation of serum GFs and VIMs by ELISA were evaluated from twenty-six HCV patients. Analytes from an earlier time-point were correlated with MELD at a later time-point.

RESULTS

Platelets and GFs decreased, and VIMs increased with fibrosis. Platelets correlated positively with PDGF-AA, PDGF-BB, TGFB1, EGF, and P-selectin, and negatively with ICAM-3 and VCAM-1. P-selectin showed no correlations with VIMs but positively correlated with PDGF-AA, PDGF-BB, TGFB1, and EGF. Soluble VCAM-1 and ICAM-3 were linked to increasing fibrosis, liver enzymes, and synthetic dysfunction. Higher VCAM-1 and ICAM-3 and lower P-selectin at an earlier time-point were linked to higher MELD score at a later time-point.

CONCLUSION

In chronic HCV, progressive decline in platelets and growth factors with fibrosis and their associations suggest that platelets are an important source of circulating GFs and influence GF decline with fibrosis. Enhanced markers of vascular injury in patients with early fibrosis suggest an earlier onset of endothelial dysfunction preceding cirrhosis. Associations of VIMs with platelets suggest a critical link between platelets and vascular homeostasis. Circulating markers of vascular injury may not only have prognostic importance but emphasize the role of vascular dysfunction in liver disease pathogenesis (NCT00001971).

Prognostic value of aspartate aminotransferase to platelet ratio index as a noninvasive biomarker in patients with hepatocellular carcinoma: a meta-analysis

Background

The aspartate aminotransferase-to-platelet ratio index (APRI) has been correlated with clinical outcome in patients with hepatocellular carcinoma (HCC), but controversial results were obtained with previous studies. This study was aimed to evaluate the prognostic value of the APRI in patients with HCC.

Materials and methods

A literature survey was conducted by searching PubMed, Web of Science, Cochrane library, Embase, Wanfang, and National Knowledge Infrastructure for publications released prior to March 1, 2018. Pooled hazard ratios (HRs) with 95% CIs were calculated to assess the association between the APRI and HCC prognosis using Stata SE 12.0 software.

Results

Analysis was performed on a total of 15 articles that included 5,051 patients. The pooled results showed that APRI was significantly associated with overall survival for patients with HCC (HR =1.62, 95% CI: 1.23–2.01). Furthermore, HCC patients with higher APRI were at significantly greater risk of short recurrence-free survival (HR =1.83, 95% CI: 1.48–2.18) and poor disease-free survival (HR =1.46, 95% CI: 1.26–1.66).

Conclusions

APRI could serve as a promising and noninvasive marker for predicting HCC prognosis.

Perioperative safety analysis of transcatheter arterial chemoembolization for hepatocellular carcinoma patients with preprocedural leukopenia or thrombocytopenia

Patients with hepatocellular carcinoma (HCC) exhibit a high incidence of concomitant cirrhosis with leukopenia and/or thrombocytopenia. In the present study, perioperative changes in the white blood cell (WBC) and platelet (PLT) counts and associated complications were investigated to assess the safety of transcatheter arterial chemoembolization (TACE) for HCC patients with preprocedural leukopenia or thrombocytopenia. The records of 1,461 HCC patients who received TACE between January 2012 and December 2013 were retrospectively reviewed. The incidence of complications during the perioperative period and changes in the WBC and PLT counts were recorded. A Chi-squared test was used to evaluate the associations between postoperative infection and preprocedural WBC count and between bleeding at the puncture site and preprocedural PLT count. The WBC count of the majority of the patients increased within 3 days and returned to the preprocedural level within 30 days after TACE. The PLT count decreased within 3 days and returned to the preprocedural level within 30 days after TACE. The major complications were liver decompensation (n=66), puncture site bleeding (n=45), infection (n=33), severe thrombocytopenia (n=8), upper gastrointestinal bleeding (n=6), tumor bleeding (n=4) and agranulocytosis (n=3). A Chi-squared test revealed that postoperative infection was not associated with preprocedural WBC count and puncture site bleeding was not associated with decreased PLT count due to hypersplenism. Therefore, TACE was found to be safe for HCC patients with preprocedural thrombocytopenia or leukopenia due to hypersplenism, with a low incidence of major complications during the perioperative period.

Stratified aspartate aminotransferase-to-platelet ratio index accurately predicts survival in hepatocellular carcinoma patients undergoing curative liver resection

The aspartate aminotransferase-to-platelet ratio index has been reported to predict prognosis of patients with hepatocellular carcinoma. This study examined the prognostic potential of stratified aspartate aminotransferase-to-platelet ratio index for hepatocellular carcinoma patients undergoing curative liver resection. A total of 661 hepatocellular carcinoma patients were retrieved and the associations between aspartate aminotransferase-to-platelet ratio index and clinicopathological variables and survivals (overall survival and disease-free survival) were analyzed. Higher aspartate aminotransferase-to-platelet ratio index quartiles were significantly associated with poorer overall survival (p = 0.002) and disease-free survival (p = 0.001). Multivariate analysis showed aspartate aminotransferase-to-platelet ratio index to be an independent risk factor for overall survival (p = 0.018) and disease-free survival (p = 0.01). Patients in the highest aspartate aminotransferase-to-platelet ratio index quartile were at 44% greater risk of death than patients in the first quartile (hazard ratio = 1.445, 95% confidence interval = 1.081 - 1.931, p = 0.013), as well as 49% greater risk of recurrence (hazard ratio = 1.49, 95% confidence interval = 1.112-1.998, p = 0.008). Subgroup analysis also showed aspartate aminotransferase-to-platelet ratio index to be an independent predictor of poor overall survival and disease-free survival in patients positive for hepatitis B surface antigen or with cirrhosis (both p < 0.05). Similar results were obtained when aspartate aminotransferase-to-platelet ratio index was analyzed as a dichotomous variable with cutoff values of 0.25 and 0.62. Elevated preoperative aspartate aminotransferase-to-platelet ratio index may be independently associated with poor overall survival and disease-free survival in hepatocellular carcinoma patients following curative resection.

Hepatitis B infection is associated with an increased incidence of thrombocytopenia in healthy adults without cirrhosis

The association between HBV infection and incident thrombocytopenia among subjects without cirrhosis or splenomegaly is unknown. Therefore, we sought to elucidate the association between HBV infection and the development of thrombocytopenia in a large cohort of apparently healthy men and women. A cohort study was performed in 122 200 participants without liver cirrhosis or splenomegaly who underwent comprehensive health examinations and were followed until December 2014. HBV infection was defined by the presence of hepatitis B surface antigen (HBsAg) at baseline. Thrombocytopenia was defined as a platelet count <150 000/μL. Cox proportional hazard models were used to estimate adjusted hazard ratios with 95% confidence intervals (CIs) for incident thrombocytopenia. HBsAg was positive in 4857 of 122 200 subjects (4.0%) at baseline. During 883 983 person-years of follow-up, 2037 incident cases of thrombocytopenia were identified (incident rate 2.3 per 1000 person-years). HBsAg-positive subjects had a higher incidence of thrombocytopenia than did healthy controls (11.2 vs 1.9 per 1000 person-years, respectively). The multivariate-adjusted hazard ratio (95% CI) for incident thrombocytopenia comparing HBsAg-positive to HBsAg-negative subjects was 5.71 (5.10-6.38). Strong associations between HBsAg positivity and thrombocytopenia were consistently observed across prespecified subgroups. In this large cohort study of an apparently healthy population, HBsAg positivity was strongly and independently associated with incident thrombocytopenia, indicating that mechanisms of thrombocytopenia other than portal hypertension may exist in healthy HBV carriers.

Thrombocytopenia in the Intensive Care Unit Setting

Thrombocytopenia is a commonly encountered labora tory abnormality in the intensive care unit setting. Al though moderate degrees of thrombocytopenia may be dismissed as clinically trivial, severe thrombocytopenia can have catastrophic consequences. This review di vides the potential pathogenesis of thrombocytopenia into three pathophysiological categories: (1) produc tive, (2) consumptive, and (3) distributional. The im portant etiologies and appropriate therapies for throm bocytopenia in each of these categories are discussed. We have attempted to emphasize the underlying patho genic mechanisms as well as highlight the diagnostic dilemmas likely to be faced by intensive care unit physi cians. Although this review stresses those thrombocyto penic disorders most likely to be encountered in the intensive care unit, chronic etiologies of thrombocy topenia are also discussed because preexistent throm bocytopenia will further complicate the care of any acutely ill intensive care unit patient.

AST to Platelet Ratio Index Predicts Mortality in Hospitalized Patients With Hepatitis B-Related Decompensated Cirrhosis

Aspartate aminotransferase to platelet ratio index (APRI) has originally been considered as a noninvasive marker for detecting hepatic fibrosis in patients with chronic hepatitis B and C. APRI has been used for predicting liver-related mortality in patients with chronic hepatitis C virus infection or alcoholic liver disease. However, whether APRI could be useful for predicting mortality in chronic hepatitis B virus (HBV) infection remains unevaluated. This study aims to address this knowledge gap. A total of 193 hospitalized chronic HBV-infected patients (cirrhosis, n = 100; noncirrhosis, n = 93) and 88 healthy subjects were retrospectively enrolled. All patients were followed up for 4 months. Mortality that occurred within 90 days of hospital stay was compared among patients with different APRI. APRI predictive value was evaluated by univariate and multivariate regression embedded in a Cox proportional hazards model. APRI varied significantly in our cohort (range, 0.16-10.00). Elevated APRI was associated with increased severity of liver disease and 3-month mortality in hospitalized patients with HBV-related cirrhosis. Multivariate analysis demonstrated that APRI (odds ratio: 1.456, P < 0.001) and the model for end-stage liver disease score (odds ratio: 1.194, P < 0.001) were 2 independent markers for predicting mortality. APRI is a simple marker that may serve as an additional predictor of 3-month mortality in hospitalized patients with HBV-related decompensated cirrhosis.

Platelet count combined with right liver volume and spleen volume measured by magnetic resonance imaging for identifying cirrhosis and esophageal varices

AIM: To determine whether the combination of platelet count (PLT) with spleen volume parameters and right liver volume (RV) measured by magnetic resonance imaging (MRI) could predict the Child-Pugh class of liver cirrhosis and esophageal varices (EV).

METHODS: Two hundred and five cirrhotic patients with hepatitis B and 40 healthy volunteers underwent abdominal triphasic-enhancement MRI and laboratory examination of PLT in 10⁹/L. Cirrhotic patients underwent endoscopy for detecting EV. Spleen maximal width (W), thickness (T) and length (L) in mm together with spleen volume (SV) and RV in mm³ were measured by MRI, and spleen volume index (SI) in mm³ was obtained by W × T × L. SV/PLT, SI/PLT and RV × PLT/SV (RVPS) were calculated and statistically analyzed to assess cirrhosis and EV.

RESULTS: SV/PLT (r = 0.676) and SI/PLT (r = 0.707) increased, and PLT (r = -0.626) and RVPS (r = -0.802) decreased with the progress of Child-Pugh class (P < 0.001 for all). All parameters could determine the presence of cirrhosis, distinguish between each class of Child-Pugh class, and identify the presence of EV [the areas under the curve (AUCs) = 0.661-0.973]. Among parameters, RVPS could best determine presence and each class of cirrhosis with AUCs of 0.973 and 0.740-0.853, respectively; and SV/PLT could best identify EV with an AUC of 0.782.

CONCLUSION: The combination of PLT with SV and RV could predict Child-Pugh class of liver cirrhosis and identify the presence of esophageal varices.

Abnormal platelet kinetics are detected before the occurrence of thrombocytopaenia in HBV-related liver disease

BACKGROUND & AIMS

Thrombocytopaenia is a frequent feature in patients with HBV-related liver disease. Its underlying mechanism is not fully understood. Multiple factors might contribute to the development of thrombocytopaenia. In this study, we investigated the reticulated platelets (RP), glycocalicin (GC), serum thrombopoietin (TPO) and platelet glycoprotein (GP) in different stages of the disease.

METHODS

One hundred and fourteen patients with HBV-related liver disease (30 with chronic hepatitis B (CHB), 20 patients in Child A without thrombocytopaenia, 19 patients in Child A with thrombocytopaenia, 45 in Child B/C with thrombocytopaenia) and 25 normal controls (NC) were enrolled. Liver cirrhosis (LC) was classified according to modified Child-Turcotte-Pugh (CTP) score. Serum TPO levels and GC were measured by ELISA. RP and platelet glycoprotein (GP) expression were detected by flow cytometry.

RESULTS

The TPO levels of patients with LC were significantly lower than that of controls, even in patients of Child A without thrombocytopaenia group. Serum TPO level was positively correlated (r = 0.65, p < 0.01) with serum albumin in Child B/C group. Both the RP percentages and the glycocalicin index (GCI) levels were significantly higher in patients groups including CHB and Child A without thrombocytopaenia than that of normal controls. A negative correlation existed in HBV DNA copies and the GPs% in patients with CHB and Child A without thrombocytopaenia.

CONCLUSION

Abnormal platelet production, destruction and platelet-specific glycoproteins levels were detected before the occurrence of thrombocytopaenia in HBV-related liver disease, indicating that multiple mechanisms might play roles in thrombocytopaenia in HBV-infected patients.

Causes of thrombocytopenia in chronic hepatitis C viral infection

We retrospectively studied 89 patients with chronic hepatitis C virus (HCV) infection, including 50 chronic hepatitis (CH) cases, 18 liver cirrhosis (LC) cases, and 21 LC with hepatocellular carcinoma (LC + HCC) cases, with regard to various factors related with thrombocytopenia. The platelet count decreased with the stage advancement of liver diseases. Multiple regression analysis revealed that splenomegaly and von Willebrand factor (vWF) were explanatory variables that correlated with thrombocytopenia. Splenomegaly appears to be the most responsible factor, although there are a considerable number of thrombocytopenic cases without splenomegaly, suggesting other factors may also be responsible. The vWF level is inversely correlated with the platelet count. Soluble thrombomodulin, a marker of endothelial dysfunction, increases with the advancement of liver fibrosis. It is positively correlated with vWF and inversely with the platelet count. Our present results imply that vascular endothelial dysfunction is also involved in thrombocytopenia during chronic HCV infection.

Platelet production and destruction in liver cirrhosis

BACKGROUND & AIMS

Thrombocytopenia is common in liver cirrhosis (LC) but the mechanisms are not fully understood. The purpose of our work was to evaluate platelet kinetics in LC with different etiologies by examining platelet production and destruction.

METHODS

Ninety-one consecutive LC patients (36 HCV, 49 alcoholics, 15 HBV) were enrolled. As controls, 25 subjects with idiopathic thrombocytopenic purpura, 10 subjects with aplastic anemia, and 40 healthy blood donors were studied. Plasma thrombopoietin (TPO) was measured by ELISA. Reticulated platelets (RP) were determined using the Thiazole Orange method. Plasma glycocalicin (GC) was measured using monoclonal antibodies. Platelet associated and serum antiplatelet antibodies were detected by flow cytometry. B-cell monoclonality in PBMC was assessed by immunoglobulin fingerprinting.

RESULTS

Serum TPO was significantly lower in LC (29.9±18.1 pg/ml) compared to controls (82.3±47.6 pg/ml). The GC levels were higher in LC (any etiology) than in healthy cases. Conversely, the absolute levels of RP were lower in LC (any etiology) than in healthy controls. The platelet-associated and serum anti-platelet antibodies were higher in HCV+ LC compared to healthy subjects (p<0.0064), alcoholic LC (p<0.018), and HBV+ LC (p<0.0001). B-cell monoclonality was found in 27% of the HCV+LC, while it was not found in HBV+ or alcoholic LC.

CONCLUSIONS

Patients with LC present decreased plasma TPO, accelerated platelet turnover, and reduced platelet production. This indicates that LC thrombocytopenia is a multifactorial condition involving both increased platelet clearance and impaired thrombopoiesis.

Abnormal hematological indices in cirrhosis

Abnormalities in hematological indices are frequently encountered in cirrhosis. Multiple causes contribute to the occurrence of hematological abnormalities. Recent studies suggest that the presence of hematological cytopenias is associated with a poor prognosis in cirrhosis. The present article reviews the pathogenesis, incidence, prevalence, clinical significance and treatment of abnormal hematological indices in cirrhosis.

Liver protection in the perioperative setting

With recent advances in surgical and anaesthetic management, clinical medicine has responded to societal expectations and the number of operations in patients with a high-risk of perioperative liver failure has increased over the last decades. This review will outline important pathophysiological alterations common in patients with pre-existing liver impairment and thus highlight the anaesthetic challenge to minimise perioperative liver insults. It will focus on the intraoperative balancing act to reduce blood loss while maintaining adequate liver perfusion, the various anaesthetic agents used and their specific effects on hepatic function, perfusion and toxicity. Furthermore, it will discuss advances in pharmacological and ischaemic preconditioning and summarise the results of recent clinical trials.

Evaluation of platelet kinetics in patients with liver cirrhosis: similarity to idiopathic thrombocytopenic purpura

BACKGROUND

Thrombocytopenia is a common manifestation of liver cirrhosis (LC), but its underlying mechanism is not fully understood. The purpose of the present paper was to evaluate the platelet kinetics in LC patients by examining several non-invasive convenient markers.

METHODS

Fifty-seven LC patients, 32 patients with idiopathic thrombocytopenic purpura (ITP), 12 with aplastic anemia (AA), and 29 healthy individuals were studied. Plasma thrombopoietin was measured by enzyme-linked immunosorbent assay. Absolute reticulated platelet (RP) count and plasma glycocalicin were used as indices for thrombopoiesis, and the indices for platelet turnover were the RP proportion and the plasma glycocalicin normalized to the individual platelet count (GCI).

RESULTS

There was no difference in thrombopoietin levels between LC patients and healthy controls. The RP proportion and GCI were significantly higher and the absolute RP count and glycocalicin significantly lower in LC patients than in healthy controls. These markers in ITP and LC patients were comparable, but significantly different from those in AA patients. The bone marrow megakaryocyte density in LC and ITP patients was similar, and significantly higher than in AA patients.

CONCLUSIONS

Cirrhotic thrombocytopenia is a multifactorial condition involving accelerated platelet turnover and moderately impaired thrombopoiesis. Thrombopoietin deficiency is unlikely to be the primary contributor to cirrhotic thrombocytopenia.

Hemostatic defects in end stage liver disease

End stage liver disease results in a complex and variably severe failure of hemostasis that predisposes to abnormal bleeding. The diverse spectrum of hemostatic defects includes impaired synthesis of clotting factors, excessive fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction. Hemostasis screening tests are used to assess disease severity and monitor the response to therapy. Correction of hemostatic defects is required in patients who are actively bleeding or require invasive procedures. Fresh frozen plasma, cryoprecipitate, and platelet transfusion remain the mainstays of therapy until larger trials confirm the safety and efficacy of recombinant factor VIIa in this population.

Which patients with primary biliary cirrhosis or primary sclerosing cholangitis should undergo endoscopic screening for oesophageal varices detection?

BACKGROUND

Recent guidelines from an AASLD Single Topic Symposium suggest that patients with cirrhosis, including those with primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC), should be screened for oesophageal varices when the platelet count is <140,000/mm3.

AIM

To determine the validity of these guidelines in clinical practice in patients with PBC or PSC.

METHODS

Retrospective review of individuals undergoing screening upper endoscopy for oesophageal varices at a single centre. Oesophageal varices were reported as being present or absent.

RESULTS

A total of 235 patients with chronic liver disease, including 86 patients with PBC (n=79) or PSC (n=7), 104 patients with chronic viral hepatitis, and 45 with non-alcoholic cirrhosis of differing aetiologies, underwent a single screening endoscopy between 1996 and 2001. Oesophageal varices were detected in 26 (30%) of the PBC/PSC group, 38 (37%) of the viral hepatitis group, and 21 (47%) of the "other" group. Applying multiple logistic regression analysis to the data in the group with PBC/PSC, platelets <200,000/mm3 (odds ratio (OR) 5.85 (95% confidence interval (CI) 1.79-19.23)), albumin <40 g/l (OR 6.02 (95% CI 1.78-20.41)), and serum bilirubin >20 micromol/l (OR 3.66 (95% CI 1.07-12.47)) were shown to be independent risk factors for oesophageal varices. Prothrombin time was unhelpful. The values at these cut offs were not useful in predicting oesophageal varices in the other groups.

CONCLUSION

We conclude that current guidelines recommended by the AASLD Single Topic symposium are invalid in our cohort of patients with PBC and PSC. Patients with a platelet count <200,000/mm3, an albumin level <40 g/l, and a bilirubin level >20 micromol/l should be screened for oesophageal varices.

Intraoperative changes in blood coagulation and the effectiveness of ulinastatin during liver resection

The blood coagulation status of 16 patients undergoing liver resection was monitored by thrombelastograph (TEG). Coagulation test by TEG was performed at three different times: before and one hour after induction of anesthesia and after liver resection. The four variables such as r (reaction time), k (coagulation velocity), ma (maximum amplitude) and me (maximum elasticity) were measured. In 8 patients, Ulinastatin was not administered during the operation and FFP was transfused after the second measurement of TEG (group I). The other 8 patients were administered totally 300,000 units of Ulinastatin after induction until the second measurement of TEG, thereafter FFP was transfused (group II). The TEG showed poor preoperative coagulation state in both groups. In group I, TEG variables showed coagulopathy was exacerbated significantly during liver resection. In group II TEG variables showed no significant changes during operation. Between the two groups there were statistical differences in the TEG variables during the operation. The TEG was useful for monitoring coagulation function during liver resection. It was impossible to improve TEG data by only replacement of FFP. Ulinastatin was useful in normalizing the coagulation function and in preventing the changes in TEG measurements during liver resection.

Role of elevated platelet-associated immunoglobulin G and hypersplenism in thrombocytopenia of chronic liver diseases

BACKGROUND AND AIM

Thrombocytopenia typically worsens with the progression of liver disease and can become a major clinical complication. Several mechanisms that contribute to thrombocytopenia have been proposed, including hypersplenism accompanied by increased platelet sequestration, platelet destruction mediated by platelet-associated immunoglobulins (PAIgG), and diminished platelet production stimulated by thrombopoietin (TPO). The purpose of the present study was to evaluate the role of each of these mechanisms in patients with liver disease-associated thrombocytopenia.

METHODS

Twenty-nine patients with liver cirrhosis (LC), 20 of whom were hepatitis C virus (HCV)-seropositive, 29 chronic hepatitis (CH) patients, 24 of whom were HCV-seropositive, and 16 control patients without liver or hematopoetic disease were enrolled in this study. Serum TPO levels, PAIgG, and liver-spleen volumes were determined and correlation analyses were performed.

RESULTS

No differences in serum TPO levels were observed among the three groups. The PAIgG levels were significantly elevated in CH and LC patients (mean +/- SD: 56.5 +/- 42.3 and 144.6 +/- 113.6 ng/107 cells, respectively) compared with the controls (18.9 +/- 2.5 ng/107 cells, P < 0.001 for both). Spleen volume was significantly higher only in LC (428 +/- 239) compared with CH (141 +/- 55) and control (104 +/- 50 cm3) (P < 0.001), while liver volume was not significantly different between the three groups. Correlation analyses demonstrated a significant negative correlation between platelet count with PAIgG (r = - 0.517, P < 0.001) and spleen volume (r = - 0.531, P < 0.001), and no relationship between platelet count and serum TPO level (r = 0.076).

CONCLUSIONS

Serum TPO level may not be directly associated with thrombocytopenia in patients with chronic hepatitis and liver cirrhosis. In contrast, spleen volume and PAIgG are associated with thrombocytopenia in such patients, suggesting that hypersplenism and immune-mediated processes are predominant thrombocytopenic mechanisms.

A role of autoantibody-mediated platelet destruction in thrombocytopenia in patients with cirrhosis

Thrombocytopenia is a common manifestation in patients with liver cirrhosis (LC), but its underlying mechanism remains controversial. This study examined the role of anti-platelet autoimmunity in cirrhotic thrombocytopenia by determining the autoantibody response to GPIIb-IIIa, a major platelet surface autoantigen recognized by anti-platelet antibodies in patients with idiopathic thrombocytopenic purpura (ITP). Circulating B cells producing anti-GPIIb-IIIa antibodies as well as platelet-associated and plasma anti-GPIIb-IIIa antibodies were examined in 72 patients with LC, 62 patients with ITP, and 52 healthy controls. In vitro anti-GPIIb-IIIa antibody production was induced in cultures of peripheral blood mononuclear cells (PBMCs) by stimulation with GPIIb-IIIa. The frequency of anti-GPIIb-IIIa antibody-producing B cells in patients with LC was significantly greater than in healthy controls (10.9 +/- 6.2 vs. 0.4 +/- 0.3/10(5) PBMCs; P <.0001) and was even higher than the frequency in patients with ITP (8.2 +/- 5.2; P =.007). Anti-GPIIb-IIIa antibodies in the patients with LC and ITP were mainly present on the surfaces of circulating platelets rather than in the plasma in an unbound form. Furthermore, PBMCs from patients with LC and ITP produced anti-GPIIb-IIIa antibodies on antigenic stimulation with GPIIb-IIIa in vitro, and the specific antibodies produced had the capacity to bind normal platelet surfaces. In conclusion, the similar profile of the anti-GPIIb-IIIa autoantibody response in patients with LC and ITP suggests that autoantibody-mediated platelet destruction may contribute at least in part to cirrhotic thrombocytopenia.

Recombinant human interleukin-11 improves thrombocytopenia in patients with cirrhosis

To elucidate the hematopoietic activity of recombinant human interleukin-11 (rhIL-11, [Neumega, Cambridge, MA]) in patients with cirrhosis and thrombocytopenia, we administered rhIL-11 at 50 microg/kg/d subcutaneously to 10 patients for 10 days with a 30-day follow-up period. All treated patients (n = 9) experienced a gradual, yet significant increase in their platelet count above the baseline value (P < or =.01) reaching the peak value (median, 93,000/microL; range, 60,000-206,000/microL) at a median of 13 days (range, 6-23 days). Eight patients (89%) had a significant increase of > or =50% over the baseline value (P <.05). Moreover, further increases to > or =60,000/microL, > or =80,000/microL, and > or =100,000/microL were observed in 100%, 78%, and 33% of the patients, respectively. A subsequent decline in platelet count was observed at a median of 19 days (range, 7-26 days) after the occurrence of peak concentration. A significant increase in neutrophil count was also demonstrated starting on the third day of treatment (P < or =.01). Concurrent with an increase in the serum level of fibrinogen, transaminase levels declined significantly during treatment period, while bilirubin levels continued to drop for up to 20 days after the initiation of treatment (P <.05). The most frequent effects were due to plasma volume expansion, including conjunctival redness and edema. In conclusion, rhIL-11 can improve platelet counts in patients with early cirrhosis and these patients could benefit from rhIL-11 treatment. However, given the high frequency of regimen-related toxicity, the use of rhIL-11 in patients with cirrhosis should be administered with caution.

Noninvasive prediction of cirrhosis in C282Y-linked hemochromatosis

The aim of the present study was to examine the predictive accuracy of noninvasive clinical and biochemical variables associated with cirrhosis among patients with C282Y homozygous hemochromatosis. Sixteen clinical and laboratory variables were recorded at the time of diagnosis in 193 Canadian C282Y homozygous patients. All patients underwent percutaneous liver biopsy and 27 (14%) had biopsy specimen-proven cirrhosis. Prediction of cirrhosis was assessed first by univariate regression analysis. Variables significantly related to cirrhosis were then evaluated by stepwise linear multivariate regression. Receiver operating characteristic curve analysis of the most informative variables from multivariate analysis was then used to devise a clinically applicable index for the noninvasive prediction of cirrhosis. This index was then validated in 162 C282Y homozygous patients in France. Ferritin, blood platelets, and aspartate transaminase (AST) level were selected for the clinical index. The combination of ferritin levels of 1,000 microg/L or greater, platelet levels of 200 x 10(9)/L or less, and AST levels above the upper limit of normal led to a correct diagnosis of cirrhosis in 77% of Canadian patients. In the French patients, this led to a correct diagnosis of cirrhosis in 90%. In conclusion, in C282Y homozygous patients, a combination of easily measured laboratory variables (ferritin, platelets, AST) can be used to make the diagnosis of cirrhosis in approximately 81% of cases, reducing the need for liver biopsy.

Clinical predictors of large esophagogastric varices in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, especially in Asia. Gastrointestinal bleeding due to esophagogastric variceal hemorrhage is one of the leading causes of death in HCC patients. The aim of study was to determine whether clinical variables were predictive of the presence of large esophagogastric varices (EGV) before performing endoscopy. Three hundred and four HCC patients who received endoscopy were enrolled and studied retrospectively. Univariate and stepwise logistic regression analysis were used to evaluate associations between the presence of large EGV and patient characteristics. There were 248 patients with small or no EGV and 56 patients with large EGV. The optimal critical values determined by a receiver operating characteristic curve for platelet count and albumin level were 135,000/mm3 and 3.5 g/dl, respectively. Stepwise logistic regression analysis demonstrated that splenomegaly [odds ratio (OR): 9.72; confidence interval (CI): 3.75-25.17], portal vein thrombosis (OR: 2.73; CI: 1.50-4.97), low platelet count (<135,000/mm3) (OR: 3.78; CI: 2.07-6.90) and low albumin level (<3.5 g/dl) (OR: 3.44; CI: 1.73-6.82) were significant, independent predictors for large EGV. Large EGV also could be independently predicted by Child-Pugh classification, splenomegaly (OR: 4.93; CI: 1.87-13.01), or portal vein thrombosis (OR: 2.37; CI: 1.28-4.39) while excluding the non-cirrhotic patients. In conclusion, splenomegaly, low platelet count (<135,000/mm3), and low albumin level (<3.5 g/dl) are clinical predictors to stratify HCC patients at risk of developing large EGV. Besides factors related to liver cirrhosis, portal vein thrombosis is also an important predictor for HCC patients with large EGV.

Transient thrombopoietin peak after liver transplantation for end-stage liver disease

Knowledge about synthesis of thrombopoietin (TPO) by human liver cells is now well established and makes the study of TPO serum levels and interdependency with platelet concentrations important before and after liver transplantation. We followed these variables in 14 patients suffering from primary biliary cirrhosis (group A), 10 with hepatitis B (group B) and nine with hepatitis C (group C) infections, as well as 11 patients suffering from alcoholic cirrhosis (group D). In the pretransplant serum samples, TPO levels and platelet counts revealed median values (range) of 112.75 pg/ml (5.0-349.3) in group A, 67.8 pg/ml (14.8-249.9) in B, 68.6 pg/ml (31.4-147.3) in C and 57.9 pg/ml (25.2-264.2) in D for TPO, and 138 x 10(9)/l (36-243) in A, 48 x 10(9)/l (22-129) in B, 105 x 10(9)/l (32-176) in C and 109 x 10(9)/l (33-285) in D for platelets, the latter levels being abnormally reduced. Within 2-3 d of transplantation, the TPO levels started to increase to transient peaks of mostly 5-10 times baseline, which were followed by continuous correction of thrombocytopenia. Splenomegaly was identified to be an important co-factor of thrombocytopenia in groups A and D. We conclude that decreased TPO production in patients with end-stage liver diseases is reverted by orthotopic liver transplantation.

Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease

OBJECTIVE

Recently it has been recommended that all cirrhotic patients without previous variceal hemorrhage undergo endoscopic screening to detect varices and that those with large varices should be treated with beta-blockers (American College of Gastroenterology guidelines). However, endoscopic screening only of patients at highest risk for varices may be the most cost effective.

METHODS

Ninety-eight patients without a history of variceal hemorrhage underwent esophagogastroduodenoscopy as part of a liver transplant evaluation. Univariate/multivariate analysis was used to evaluate associations between the presence of varices and patient characteristics including etiology of liver disease, Child-Pugh class, physical findings (spider angiomata, splenomegaly, and ascites), encephalopathy, laboratory parameters (prothrombin time, albumin, bilirubin, BUN, creatinine, and platelets), and abdominal ultrasound findings (portal vein diameter/flow, splenomegaly, and ascites).

RESULTS

The causes of cirrhosis among the 67 men and 31 women (mean age, 48 yr) included 28% Hepatitis C/alcoholism, 25% Hepatitis C, 13% alcoholism, 9% primary sclerosing cholangitis/primary biliary cirrhosis, 9% cryptogenic, 6% Hepatitis B, 1% Hepatitis B and C, and 9% other. Patients were Child-Pugh class A 34%, B 51%, and C 15%. Endoscopic findings included esophageal varices in 68% of patients (30% were large), gastric varices in 15%, and portal hypertensive gastropathy in 58%. Platelet count <88,000 was the only parameter identified by univariate/multivariate analysis (p < 0.05) as associated with the presence of large esophageal varices (odds ratio 5.5; 95% confidence interval 1.8-20.6) or gastric varices (odds ratio 5; 95% confidence interval 1.4-23).

CONCLUSIONS

Platelet count <88,000 is associated with the presence of esophagogastric varices. A large prospective study is needed to verify and validate these findings and may allow identification of a group of patients who would most benefit from endoscopic screening for varices.

Bleeding problems in patients with liver disease. Ways to manage the many hepatic effects on coagulation

Liver disease is associated with a wide variety of abnormalities of the coagulation system and often with severe bleeding. Knowledge of the effects of liver disease and its complications on the various clotting factors may be useful in differential diagnosis. Therapy is difficult but should be approached in a stepwise fashion, with attention to the potential hazards of each intervention. The coagulation system and its interrelationship with liver function can be complex. To ensure the best care of patients with liver disease and bleeding, primary care physicians should not hesitate to enlist the assistance of specialists in clotting disorders and a reliable coagulation laboratory.

Platelet-associated IgM elevated in patients with chronic hepatitis C contains no anti-platelet autoantibodies

We investigated whether thrombocytopenia in patients with chronic hepatitis C is due to anti-platelet autoantibodies. Platelet-associated IgG (PAIgG) and platelet-associated IgM (PAIgM) were measured by direct immunofluorescent flow cytometric analysis. Elevation of PAIgM level was detected in 70% of chronic hepatitis C patients, while only a mild elevation of PAIgG level was detected in 32% of the cases. The elevation of PAIgM values in these patients was comparable to that in patients with chronic immune thrombocytopenic purpura (ITP). However, elevated PAIgM was also found in both patients with and without thrombocytopenia, and no correlation was found between PAIgM and platelet count. Eluted PAIgM did not react with normal platelets in all cases with a positive PAIgM value, indicating that eluted PAIgM contained no detectable anti-platelet antibodies. During alpha-interferon therapy, the level of PAIgM increased in association with the decrease in platelet counts in 75% of the cases; however, eluted PAIgM at any day point never reacted with platelets from normal donors. PAIgM was elevated in patients with chronic hepatitis C, but contained no detectable anti-platelet autoantibodies. Thrombocytopenia in these patients is not due to anti-platelet autoantibodies.

Platelet autoantibodies in patients with chronic liver disease

The thrombocytopenia in chronic liver disease (CLD) has been attributed mainly to hypersplenism, although other factors such as reduced mean life span with increased platelet turnover have also been demonstrated. Immunological abnormalities have been described in the pathogenesis and progression of CLD. In this sense, many studies have reported elevated levels of platelet associated IgG (PAIgG) in patients with CLD, and it has been suggested that PAIgG could represent true antiplatelet antibody. In this study we used a glycoprotein (GP)-specific immunoassay (MACE) to determine whether PAIgG or circulating antiplatelet antibodies, reacted against the GPIIb/IIIa or GPIb/IX complexes, in patients with CLD. Thirty-six patients with CLD of diverse etiology were studied (20 female, mean age 53 years, range 38-75 years). 23 out of 36 patients (64%) had anti-GP antibodies in MACE. Particularly, 12 had anti-GPIb, 4 anti-GPIIb/IIIa, and 7 had both types of autoantibodies. The existence of these anti-GP antibodies was not related with the blood platelet count or etiology of CLD. These data show that in patients with CLD of diverse origin, there is a high prevalence of autoantibodies reacting specifically with platelet membrane GP, which constitutes the first evidence of the specific nature of platelet-bound IgG in CLD. These findings suggest that in patients with CLD, an immune mechanism may participate in inducing or aggravating the thrombocytopenia.

Quantification of thrombelastographic changes after blood component transfusion in patients with liver disease in the intensive care unit

Thrombelastography (TEG) can be used to monitor hemostasis and guide transfusion therapy during orthotopic liver transplantation. However, data are limited regarding the type and quantity of blood components necessary for TEG-guided blood component transfusion in coagulopathic critically ill patients with liver disease. We evaluated changes in four thrombelastogram variables (reaction time, thrombin constant time, alpha angle, and maximum amplitude) in whole blood samples after 74 separate blood component transfusions in 60 critically ill patients with a coagulopathy and liver disease. Only platelets significantly improved TEG variables in patients who received a single type of blood component. Each unit of platelets decreased the reaction and thrombin constant time by 0.43 (P < 0.05) and 0.82 (P < 0.005) min, respectively, increased the alpha angle by 1.5 degrees (P < 0.005), and the maximum amplitude by 1.4 mm (P < 0.005). In patients who received multiple blood components, cryoprecipitate decreased the thrombin constant time by 0.56 min/U (P < 0.05), and each unit of platelets decreased the thrombin constant time by 0.39 min (P < 0.005), and increased the alpha angle and maximum amplitude by 0.63 degrees (P < 0.05) and 0.99 mm (P < 0.005), respectively. We conclude that platelet transfusions, alone or in combination with other blood components, are most effective for improving abnormal TEG variables in coagulopathic critically ill patients with liver disease.

Adenine nucleotide metabolism of blood platelets in human liver cirrhosis

The adenylate energy charge of human platelets was measured in normal subjects and cirrhotic patients using a method by labelling the adenine nucleotide pool of platelets with radioactive adenine. Using the above method, it was demonstrated that a reliable value for the adenylate energy charge can be obtained from platelet rich plasma containing more than 10(4) platelets per microliter after 30 minutes incubation. A significant difference was found in the distribution of adenine nucleotide metabolites between normal subjects and cirrhotic patients. However, no significant difference was found in the adenylate energy charge between two groups. These results indicate that energy metabolism of platelets is impaired to some extent in liver cirrhosis.

Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation

The blood coagulation system of 66 consecutive patients undergoing consecutive liver transplantations was monitored by thrombelastograph and analytic coagulation profile. A poor preoperative coagulation state, decrease in levels of coagulation factors, progressive fibrinolysis, and whole blood clot lysis were observed during the preanhepatic and anhepatic stages of surgery. A further general decrease in coagulation factors and platelets, activation of fibrinolysis, and abrupt decrease in levels of factors V and VIII occurred before and with reperfusion of the homograft. Recovery of blood coagulability began 30-60 min after reperfusion of the graft liver, and coagulability had returned toward baseline values 2 hr after reperfusion. A positive correlation was shown between the variables of thrombelastography and those of the coagulation profile. Thrombelastography was shown to be a reliable and rapid monitoring system. Its use was associated with a 33% reduction of blood and fluid infusion volume, whereas blood coagulability was maintained without an increase in the number of blood product donors.

Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation

The blood coagulation system of 66 consecutive patients undergoing consecutive liver transplantations was monitored by thrombelastograph and analytic coagulation profile. A poor preoperative coagulation state, decrease in levels of coagulation factors, progressive fibrinolysis, and whole blood clot lysis were observed during the preanhepatic and anhepatic stages of surgery. A further general decrease in coagulation factors and platelets, activation of fibrinolysis, and abrupt decrease in levels of factors V and VIII occurred before and with reperfusion of the homograft. Recovery of blood coagulability began 30-60 min after reperfusion of the graft liver, and coagulability had returned toward baseline values 2 hr after reperfusion. A positive correlation was shown between the variables of thrombelastography and those of the coagulation profile. Thrombelastography was shown to be a reliable and rapid monitoring system. Its use was associated with a 33% reduction of blood and fluid infusion volume, whereas blood coagulability was maintained without an increase in the number of blood product donors.

Kinetics and in vivo distribution of 111-In-labelled autologous platelets in chronic hepatic disease: mechanisms of thrombocytopenia

The kinetics and distribution in vivo of autologous 111-In-labelled platelets were studied in 20 patients with chronic hepatic disease. The patients, 16 of whom were thrombocytopenic, exhibited a shortened platelet mean life time, a reduced platelet recovery and a normal platelet turnover, the latter 2 of which were positively correlated to the platelet count. Platelet in vivo recovery was negatively correlated to the spleen volume. In accordance with this, scintigraphic studies revealed that the spleen was the major organ of platelet sequestration and destruction, the role of the liver being almost negligible. Signs of platelet destruction in the bone marrow were also found. Our results indicate that splenic platelet pooling and accelerated platelet destruction, accompanied by inability of the bone marrow to compensate for the thrombocytopenia are the main causes of the thrombocytopenia accompanying chronic hepatic disease.

Platelet dynamics in chronic liver disease using the 111Indium oxine label

Platelet dynamics in chronic liver disease have been studied using 111Indium-8-hydroxyquinolone (111In-oxine) as a platelet label. In 20 patients, mainly with alcoholic cirrhosis, the platelet mean life span was reduced in 12 and the splenic platelet pool increased, often markedly so, in 15. However, the platelet count was not significantly related to mean bile span, the splenic platelet pool, or spleen size. Whereas splenic platelet pool size is related to spleen size in most of the haematological 'big-spleen' syndromes, this did not apply to those patients with chronic liver disease. Technically, 111In-oxine is a more appropriate platelet label than 51Cr in ill and thrombocytopenic patients with liver disease.