Prognostic Factors for Immune Thrombocytopenic Purpura Remission after Laparoscopic Splenectomy: A Cohort Study

The Current Role and Relevance of a Splenectomy in Immune Thrombocytopenic Purpura Patients-A Single-Center Experience

Background and objectives: Immune thrombocytopenic purpura (ITP) is a rare hematological disorder characterized by an autoimmune-mediated decline in platelet count in peripheral blood. Over the years, its treatment has evolved, leading to a decline in the role of splenectomy, which was previously used as a second-line therapy. This study aims to evaluate the effects of spleen removal on the progression of the disease, regardless of the surgical procedure, by presenting a single-center experience. Materials and Methods: We retrospectively reviewed the medical records of all ITP patients who underwent splenectomy and were admitted to the Hematology Clinic of Timișoara Emergency City Hospital between January 1988 and June 2024. A total of 217 ITP patients who underwent splenectomy were identified over a 37-year period. Demographic data, postoperative complications, and responses to splenectomy were analyzed over a median follow-up period of 93.86 ± 104.25 months, ranging from 6 to 423 months. Results: Among the 217 patients included in the study, 155 (71.42%) were female and 62 (28.58%) were male, with a mean age of 38.47 ± 16.12 years. During the follow-up period, a significant decrease in the number of splenectomies was observed (p < 0.001). The overall morbidity rate was 14.28%. The overall response rate after splenectomy was 85.71%, with 158 patients (72.81%) achieving a complete response and 28 (12.90%) achieving a partial response. However, 28 (15.05%) of the responsive patients experienced relapse during follow-up and required additional medical therapy. Analyzing the association between comorbidities and relapse after splenectomy, the presence of diabetes (OR = 6.90, 95% CI: 2.87-16.58), hepatic diseases (OR = 64.60, 95% CI: 19.60-212.91), immune thyroid disorders (OR = 8.37, 95% CI: 2.09-33.46), and obesity (OR = 10.22, 95% CI: 3.41-30.60) were identified as risk factors for relapse using univariate analysis. Conclusions: Splenectomy remains the treatment with the best long-term outcomes compared to other therapies. However, concerns about early and late complications following splenectomy, along with advancements in modern ITP treatments, have led to a significant decline in the number of splenectomies performed. In univariate analyses, female gender, age over 40, and the presence of diabetes, hepatic diseases, obesity, or immune thyroid disorders were found to be risk factors for relapse following splenectomy. In the logistic regression analysis adjusted for age and sex, obesity and steatosis were significantly associated with an increased risk of relapse after splenectomy in women over 40 years of age.

Health-related quality of life and complications of corticosteroid treatment in patients with immune thrombocytopenia in two teaching hospitals in Ethiopia: a cross-sectional study

Background

The treatment of immune thrombocytopenia (ITP) is a major clinical challenge and has a significant impact on health-related quality of life (HRQoL), and prolonged use of corticosteroids may have a negative impact on HRQoL.

Objectives

To evaluate the impact of ITP on HRQoL and complications of corticosteroid treatment in patients with ITP in two teaching hospitals in Ethiopia.

Methods

The institution-based cross-sectional study was conducted from November 15, 2022, to March 15, 2023, to recruit 214 study participants during the study period (4 months). The ITP Life Quality Index (ILQI) in the Amharic version was used to assess the impact of ITP. Linear regression analysis models were also used, and a p-value of less than 0.05 was generally considered statistically significant.

Results

Regarding treatment, the majority 172 (80.4%) of study participants were taking prednisolone only, and 143 (66.8%) of study participants had at least one side effect of corticosteroids during the entire treatment period. Predictive factors for a higher impact of ITP on HRQoL; all correlated variables explained 36.5% (adjusted R-squared = 0.365, p < 0.0001) of the variance and had a moderate impact on HRQoL. Furthermore, predictive factors for an increasingly higher impact of ITP on HRQoL were the development of emotionally related corticosteroid side effects (β = 0.392, 95% CI: 5.160-9.961, p < 0.001), the presence of fatigue during the assessment (β = 0.326, 95% CI: 4.394-9.475, p < 0.001), patients not taking cotrimoxazole prophylaxis treatment (β = 0.236, 95% CI: 2.236-6.570, p < 0.001), living far from the hematology clinic (outside Addis Ababa) (β = 0166, 95% CI: 1.107-5.114 p = 0.003), having epistaxis and/or wet purpura (mucosal bleeding) (β = 0.191, 95% CI: 0.091-4.259, p = 0.001), and skin symptoms (petechiae and ecchymosis) (β = 0.041, 95% CI: 0.091-4.259 p = 0.041) during diagnosis.

Conclusion

The impact of ITP on their energy levels and work life was high compared to the impact of ITP on daily life. The side effects of corticosteroids also affect the HRQoL of ITP patients.

Treatment outcomes and adherence to treatment in patients with immune thrombocytopenia in two Ethiopian teaching hospitals: a retrospective cohort study

The treatment of immune thrombocytopenia (ITP) is challenging and treatment outcomes depend on numerous unknown and patient-specific factors. Corticosteroids are the cornerstone of ITP treatment, but they are associated with many side effects. In this retrospective cohort study, treatment outcomes and treatment adherence in patients with ITP were investigated in 214 ITP patients from November 15, 2022 to March 15, 2023. Multinomial regression analysis models were used to identify predictive factors for treatment outcomes. A p value of less than 0.05 was considered statistically significant. Most study participants were female 161 (75.5%), and the majority 172 (80.4%) of them were taking prednisolone only. In terms of treatment adherence, 178 (83.2%) of the study participants adhered well to their ITP medications. The complete response rate at 3 months was 139 (65.0%). Predictive factors for partial response were increased negative impact of ITP on health-related quality of life (AOR = 1.221, 95% CI 1.096-1.360), being treated at Tikur Abessa Sepcialazed Hospital (AOR = 0.431, 95% CI 0.197-0.941) and the presence of heavy menstrual bleeding (AOR = 2.255, 95% CI 0.925-5.497) compared to patients with complete response. Hepatitis B virus-infected ITP patients (AOR = 0.052, 95% CI 0.004-0.621) were also a predictive factor for no response compared to complete response.

Novel Therapies to Address Unmet Needs in ITP

Primary immune thrombocytopenia (ITP) is an autoimmune disorder that causes low platelet counts and subsequent bleeding risk. Although current corticosteroid-based ITP therapies are able to improve platelet counts, up to 70% of subjects with an ITP diagnosis do not achieve a sustained clinical response in the absence of treatment, thus requiring a second-line therapy option as well as additional care to prevent bleeding. Less than 40% of patients treated with thrombopoietin analogs, 60% of those treated with splenectomy, and 20% or fewer of those treated with rituximab or fostamatinib reach sustained remission in the absence of treatment. Therefore, optimizing therapeutic options for ITP management is mandatory. The pathophysiology of ITP is complex and involves several mechanisms that are apparently unrelated. These include the clearance of autoantibody-coated platelets by splenic macrophages or by the complement system, hepatic desialylated platelet destruction, and the inhibition of platelet production from megakaryocytes. The number of pathways involved may challenge treatment, but, at the same time, offer the possibility of unveiling a variety of new targets as the knowledge of the involved mechanisms progresses. The aim of this work, after revising the limitations of the current treatments, is to perform a thorough review of the mechanisms of action, pharmacokinetics/pharmacodynamics, efficacy, safety, and development stage of the novel ITP therapies under investigation. Hopefully, several of the options included herein may allow us to personalize ITP management according to the needs of each patient in the near future.

Primary Immune Thrombocytopenia: Novel Insights into Pathophysiology and Disease Management

Immune thrombocytopenia (ITP) is an autoimmune disorder defined by a significantly reduced number of platelets in blood circulation. Due to low levels of platelets, ITP is associated with frequent bruising and bleeding. Current evidence suggests that low platelet counts in ITP are the result of multiple factors, including impaired thrombopoiesis and variations in immune response leading to platelet destruction during pathological conditions. Patient outcomes as well as clinic presentation of the disease have largely been shown to be case-specific, hinting towards ITP rather being a group of clinical conditions sharing common symptoms. The most frequent characteristics include dysfunction in primary haemostasis and loss of immune tolerance towards platelet as well as megakaryocyte antigens. This heterogeneity in patient population and characteristics make it challenging for the clinicians to choose appropriate therapeutic regimen. Therefore, it is vital to understand the pathomechanisms behind the disease and to consider various factors including patient age, platelet count levels, co-morbidities and patient preferences before initiating therapy. This review summarizes recent developments in the pathophysiology of ITP and provides a comprehensive overview of current therapeutic strategies as well as potential future drugs for the management of ITP.