Thrombocytopenia in chronic liver disease: Physiopathology and new therapeutic strategies before invasive procedures

Prevalence, Characteristics, and Outcomes of Infective Endocarditis Readmissions in Patients With Variables Associated With Liver Disease in the United States

Infective endocarditis (IE) is common in patients with liver disease. Outcomes of IE in patients with liver disease are limited. We aimed to investigate IE outcomes in patients with variables associated with liver disease in the USA. We used the 2017 National Readmission Database to identify index admission of adults with IE, based on the International Classification of Disease, 10th revision codes. The primary outcome was 30-day readmission. Secondary outcomes were mortality and predictors of hospital readmission. We identified 40,413 IE admissions. Patients who were readmitted were more likely to have a history of HCV (19.4 vs 12.3%, P < .001), hyponatremia (25 vs 21%, P < .001), and thrombocytopenia (20.3 vs 16.3%, P < .001). After adjusting for age, hypertension, heart failure, diabetes mellitus, and end stage renal disease, hyponatremia (odds ratio (OR) 1.25; 95% confidence intervals [CI]: 1.17-1.35; P < .001) and thrombocytopenia (OR 1.16; 95% CI: 1.08-1.24; P < .001) correlated with higher odds of 30-day readmission. Mortality was higher among patients with hyponatremia (29 vs 22%, P < .001), thrombocytopenia (29 vs 17%, P < .001), coagulopathy (12 vs 5%, P < .001), cirrhosis (6 vs 4%, P < .001), ascites (7 vs 3%, P < .001), liver failure (18 vs 3%, P < .001), and portal hypertension (3 vs 1.5%, P < .001).

Multiple Dimensions of using Mesenchymal Stem Cells for Treating Liver Diseases: From Bench to Beside

Liver diseases impose a huge burden worldwide. Although hepatocyte transplantation has long been considered as a potential strategy for treating liver diseases, its clinical implementation has created some obvious limitations. As an alternative strategy, cell therapy, particularly mesenchymal stem cell (MSC) transplantation, is widely used in treating different liver diseases, including acute liver disease, acute-on-chronic liver failure, hepatitis B/C virus, autoimmune hepatitis, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, alcoholic liver disease, liver fibrosis, liver cirrhosis, and hepatocellular carcinoma. Here, we summarize the status of MSC transplantation in treating liver diseases, focusing on the therapeutic mechanisms, including differentiation into hepatocyte-like cells, immunomodulating function with a variety of immune cells, paracrine effects via the secretion of various cytokines and extracellular vesicles, and facilitation of homing and engraftment. Some improved perspectives and current challenges are also addressed. In summary, MSCs have great potential in the treatment of liver diseases based on their multi-faceted characteristics, and more accurate mechanisms and novel therapeutic strategies stemming from MSCs will facilitate clinical practice.

Elevated Erythritol: A Marker of Metabolic Dysregulation or Contributor to the Pathogenesis of Cardiometabolic Disease?

Erythritol is a non-nutritive sugar replacement that can be endogenously produced by humans. Witkowski et al. reported that elevated circulating erythritol is associated with adverse cardiovascular events in three independent cohorts, demonstrated in vitro and ex vivo that erythritol promotes platelet activation, and showed faster clotting time in mice injected with erythritol. It was concluded that erythritol fosters enhanced thrombosis. This narrative review presents additional evidence that needs to be considered when evaluating these data and conclusions. We conducted a search of all studies related to erythritol exposure with focus on those that reported vascular health outcomes. Patients with chronically elevated erythritol levels due to inborn errors of metabolism do not exhibit higher platelet activation or thrombosis risk. Most long-term studies in which animals consumed high levels of erythritol do not support its role in platelet activation and thrombosis formation. Clinical data on the effects of chronic intake of erythritol are limited. Erythritol may be merely a marker of dysregulation in the Pentose Phosphate Pathway caused by impaired glycemia. However, this suggestion and the findings of Witkowski et al. need to be further examined. Clinical trials examining the long-term effects of erythritol consumption on cardiometabolic outcomes are required to test the causality between dietary erythritol and cardiometabolic risk. Until supportive data from these trials are available, it cannot be concluded that dietary erythritol promotes platelet activation, thrombosis, and cardiometabolic risk.

Assessing Thrombocytopenia and Chronic Liver Disease in Southeast Asia: A Multicentric Cross-Sectional Study

Background This multicentric cross-sectional study aimed to examine the prevalence of thrombocytopenia (TCP) and investigate the various causes of chronic liver disease (CLD) across 15 Southeast Asian (India, Pakistan, and Bangladesh) tertiary care centers over a three-month period. The study focused on assessing the fibrosis index (FI) and Model for End-Stage Liver Disease (MELD)-sodium (Na) score's capacity to grade and predict the progression and outcomes of patients with already diagnosed CLD. Methods The cross-sectional study enrolled 377 CLD patients. The study utilized admission registries from 15 tertiary care hospitals in Southeast Asia, spanning from April 2023 to June 2023. Various descriptive variables were collected, including gender, tobacco use (specifically, chewed tobacco), underlying etiology, presence of anemia, leukopenia, pancytopenia, infectious state, and liver cirrhosis diagnosed via traditional ultrasonography. This study examined liver failure indicators, including alanine transaminase levels, compensation status, TCP, and liver transplant (LT) listing. The MELD-Na score was the focus of frequency and percentage analysis. MELD-Na and FI medians and standard deviations were provided. Results The study of 377 patients with CLD found that TCP was present in 4% of patients and leukopenia was present in 12% of patients. The risk of TCP was significantly higher in leukopenic patients (89.5%) than in non-leukopenic patients (52.5%) (p = 0.003). The most common CLD cause was undiagnosable (31%), followed by autoimmune (26%), hepatitis C virus (21%), hepatitis B virus (14%), and schistosomiasis (8%). The majority of patients (98%) had decompensated liver disease. Of the patients, 64% had TCP, while 36% did not. The illness severity indicators MELD score and FI had mean ± SD values of 16.89 ± 6.42 and 4.1 ± 1.06, respectively. Similarly, the prevalence of LT needs among traditional ultrasonography-diagnosed cirrhotic patients was 83.1%, compared to 59.6% among non-cirrhotic patients (p = 0.001). Conclusion Leukopenia and TCP may be linked, which may affect CLD treatment and prognosis in this population. Non-invasive indicators like the FI and MELD-Na score can detect liver fibrosis and severity without invasive procedures, enhancing patient management. These findings highlight the need to improve early diagnosis methods for CLD in Southeast Asia and raise awareness among clinicians about effective diagnostic strategies for non-infectious causes of CLD.

Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study

PURPOSE

To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation.

MATERIALS AND METHODS

Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L.

RESULTS

A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup.

CONCLUSIONS

TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L.

Value of XGBoost machine learning model for diagnosis of hepatitis B cirrhosis

BACKGROUND

The progression of chronic hepatitis B into cirrhosis is slow and easily ignored, and the construction of a noninvasive diagnostic model for cirrhosis based on routine clinical indicators has become a hot research topic. However, there is still a lack of machine learning models regarding the early diagnosis of cirrhosis.

AIM

To investigate the performance of the extreme gradient boosting (XGBoost) machine model in the diagnosis of hepatitis B cirrhosis.

METHODS

A retrospective analysis was performed on 1087 patients with chronic hepatitis B virus infection (CHBV) diagnosed for the first time at the Department of Infection, The First/Second Affiliated Hospital of Anhui Medical University from 2010 to 2018. The patients were divided into training and validation sets in a 3:1 ratio according to the randomization principle. Clinical data of all study participants were collected and prediction models were constructed using XGBoost machine learning model. Meanwhile, the aspartate aminotransferase/platelet ratio index (APRI) and fibrosis-4 index (FIB-4) scores were calculated and compared with the XGBoost machine learning model. Area under the curve (AUC) was used to assess the model discrimination, and calibration curve (CA) and decision curve analysis (DCA) were used to assess the model calibration and benefit.

RESULTS

A total of 1087 CHBV patients were included, including 817 in the training set and 270 in the validation set. There was no statistical difference between the training and validation sets for all predictor variables (P > 0.05). Cirrhosis occurred in 103 patients in the training set, and APRI and FIB-4 scores were significantly higher in cirrhotic patients than in non-cirrhotic patients (P < 0.05). The relative importance of platelets was the highest among all predictors. The AUCs of the model in the training and validation sets were 0.95 and 0.86 (P < 0.05), respectively, and the Kappa values were 0.78 and 0.74, which suggested that the model was reproducible. CA curve analysis indicated that the model predicted a high degree of agreement with the true situation fit. DCA of the training and validation sets implied that the developed model could result in a high degree of benefit for patients. XGBoost machine learning model was significantly more efficient for the diagnosis of cirrhosis than APRI and FIB-4 scores.

CONCLUSION

The XGBoost machine learning model constructed in this study based on common clinical information of CHBV patients has an excellent performance for the diagnosis of cirrhosis and deserves further clinical promotion.

Thrombocytopenia (TCP), MELD Score, and Fibrosis Index (FI) Among Hospitalized Patients with Chronic Liver Disease (CLD) in Ma'abar City, Dhamar Governorate, Yemen: A Cross-Sectional Study

Purpose

This study sought to assess the prevalence of thrombocytopenia (TCP), underlying aetiologies of chronic liver disease, and the grading and prognostic systems for chronic liver disease (CLD) using non-invasive biomarkers: the Fibrosis index and the Model for End-Stage Liver Disease-Na (MELD-Na) Score, respectively.

Patients and Methods

This was a 15-month multi-centric cross-sectional study of 105 patients with chronic liver disease (CLD). The study was conducted using Sept 2019 to Nov 2020 admission records of CLD patients from Ma'abar City in Dhamar Governorate, Yemen.

Results

A total of 63 (60%) and 42 (40%) patients were identified as thrombocytopenic and non-thrombocytopenic, respectively. The means ± SD of the MELD score and FI were 19 ± 7.302 and 4.1 ± 1.06. TCP prevalence among leukopenic and non-leukopenic patients was 89.5% and 53.5%, respectively (P = 0.004). Likewise, the prevalence of traditional-ultrasonography-diagnosed cirrhotic patients needing liver transplantation (LT) was 82.3% versus 61.3% among corresponding non-cirrhotic patients (P = 0.000).

Conclusion

The prevalence of TCP among the participants of this study was similar to the global rate. However, the prevalence of decompensation was much higher among CLD patients than that found elsewhere, highlighting a need to improve methods for the early diagnosis of CLD in Yemen. This study also identified problems with the diagnostic work-up for non-infectious aetiologies of CLD. The findings suggest the need to improve clinician awareness about effective diagnostic strategies for these aetiologies.

Prealbumin as a Predictor of Short-Term Prognosis in Patients with HBV-Related Acute-on-Chronic Liver Failure

Purpose

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a serious medical condition with a high short-term mortality rate, making accurate prognostic assessment essential for informed clinical decision-making. In this study, we aimed to develop a simple and effective prognostic model for predicting short-term mortality in patients with HBV-ACLF.

Patients and Methods

To achieve our objective, we enrolled both a cross-sectional cohort (n = 291) and a retrospective cohort (n = 185) in this study. We collected laboratory and clinical data from these cohorts and performed univariate and multivariate logistic regression analyses to identify independent predictors of short-term mortality. Subsequently, we developed a novel prognostic score for HBV-ACLF, which was validated and assessed using receiver operating characteristic (ROC) curve analysis to determine its performance.

Results

Our analysis revealed that the admission prealbumin (PAB) level was a robust independent predictor of 30-day mortality, with an area under the receiver operating characteristic (AUROC) of 0.760. Moreover, we developed the HIAPP score, a prognostic-score model based on PAB. The HIAPP score was significantly lower in survivors compared to non-survivors (-2.80±0.21 vs 0.97±0.41, P < 0.001). The HIAPP score's AUROC value was 0.899, which was found to be superior to the MELD score (AUROC = 0.795) and the CLIF-C ACLF score (AUC =0.781) and comparable to the COSSH-ACLF II score (AUC =0.825) for predicting 30-day mortality. These findings were also validated in a separate cohort, further supporting the utility of the HIAPP score as a prognostic tool for HBV-ACLF patients.

Conclusion

Our study identifies the admission PAB level as a simple and valuable predictive index for 30-day mortality in HBV-ACLF patients. Furthermore, the HIAPP score, which incorporates PAB, PLT, INR, HE, and age, is an easy-to-use and pragmatic prognostic score in predicting short-term mortality.

Effectiveness and Safety of Avatrombopag in Liver Cancer Patients with Severe Thrombocytopenia: Real-World Data and Challenges

Background

Avatrombopag has been approved in patients who have severe thrombocytopenia (<50 × 10⁹/L) and chronic liver disease (CLD) while receiving invasive procedures. The real-world application and effectiveness of avatrombopag in the subgroup patients with liver cancer remain unknown.

Methods

Liver cancer patients (including primary liver cancer and colorectal cancer liver metastasis) who had severe thrombocytopenia and received avatrombopag were retrospectively enrolled. Avatrombopag dose, peak and absolute platelet count increase, combination treatment with other thrombopoietic agents, responder (peak count ≥50 × 10⁹/L with absolute increase ≥20 × 10⁹/L) rate, and anticancer treatment effect were analyzed. Thrombosis and bleeding events were assessed.

Results

In total, 93 patients were enrolled, with 72 and 21 in the CLD and non-CLD groups, respectively. Patients with CLD had hepatitis B or C, larger spleen volume, and a higher cirrhosis degree. Baseline platelet counts were similar between two groups (median, 37.0 × 10⁹/L vs. 39.0 × 10⁹/L; P=0.594), while patients without CLD had higher peak platelet (median, 134.0 × 10⁹/L vs. 74.0 × 10⁹/L; P=0.015) and absolute increase (median, 101.0 × 10⁹/L vs. 41.0 × 10⁹/L; P=0.020) after avatrombopag treatment. The responder rate was higher in patients without CLD (100% vs. 76.4%; P=0.010). Combined avatrombopag with other thrombopoietic agents significantly increased platelet count; repeated use of avatrombopag produced similar effects with that of initial treatment. Concerning anticancer treatment effect, patients who responded to avatrombopag had a higher disease control rate. No thrombosis or hemorrhagic events were observed, even in patients with portal vein tumor thrombosis.

Conclusion

Avatrombopag was safe and effective and ensured successful implementation of anticancer treatment in liver cancer patients with severe thrombocytopenia, accompanied with or without CLD.