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

Abstract

Chronic liver disease is characterized by several hematological derangements resulting in a complex and barely rebalanced haemostatic environment. Thrombocytopenia is the most common abnormality observed in these patients and recent advances have led to researchers focus the attention on the multifactorial origin of thrombocytopenia and on the key role of thrombopoietin (TPO) in its physiopathology. Severe thrombocytopenia (platelet count < 50000/μL) complicates the management of patients with chronic liver disease by increasing the potential risk of bleeding for invasive procedures, which may be therefore delayed or canceled even if lifesaving. In the very last years, the development of new drugs which exceed the limits of the current standard of care (platelet transfusions, either immediately before or during the procedure) paves the way to a new scenario in the management of this population of patients. Novel agents, such as the TPO-receptor agonists avatrombopag and lusutrombopag, have been developed in order to increase platelet production as an alternative to platelet transfusions. These agents have demonstrated a good profile in terms of efficacy and safety and will hopefully allow reducing limitations and risks associated with platelet transfusion, without any delay in scheduled interventions. Altogether, it is expected that patients with chronic liver disease will be able to face invasive procedures with one more string in their bow.

Novel Perspectives on Thrombopoietin Receptor Agonists Applications

“…[52][53][54][55][56][57][58][59][60][61][62][63][64][65][66] It is not certain whether these differences can be solely attributed to the type of TPO-RA that has been used; however, similar results, indicating low rates of thrombosis with avatrombopag, have also been reported in patients with CLD. 10 Hence, based on these results, avatrombopag may seem more preferable in SOT patients. Of note, recent guidelines by the International Society on Thrombosis and Haemostasis (ISTH) Subcommittee on Hemostasis and Malignancy suggest the use of ROMI over other TPO-RAs, whenever TPO-RAs are used for CIT, outside of the context of a clinical trial.…”

“…Importantly, these agents have also been met with a favorable safety profile and have low potential for drug-to-drug interactions. 10 Collectively, these results have laid the basis for further exploration of TPO-RAs in other thrombocytopenic settings. In this review, we discuss a broad spectrum of thrombocytopenic conditions where TPO-RAs could be incorporated as a treatment option, highlighting potent novel uses of these drugs, while we also discuss, in the context of drug repurposing, about novel findings of use of TPO-RAs in the case of infections.…”

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

“…1 Mild TCP, defined as a platelet count of 100,000–150,000/μL, and moderate TCP, defined as a platelet count of 50,000–100,000/μL, rarely contraindicate the management of haemostasis issues. 2 However, on considering the former measures in CLD patients including investigative invasive ones (such as liver biopsy). There is conflicting data about the platelet count of CLD patients with moderate-to-severe TCP needed to indicate platelet transfusion during invasive procedures.…”

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

“…Thrombocytopenia is common in patients with chronic liver disease (CLD) and worsens with the degree of liver cirrhosis [ 1 , 2 ]. This situation is more complicated in liver cancer, which is the sixth most frequent cancer types and the fourth leading cause of cancer-related mortality globally because invasive therapeutic procedures [ 3 ], including hepatectomy, radiofrequency ablation, and biopsy, carry additional hemorrhage risk.…”

“…Te characteristics of enrolled liver cancer patients grouped by the presence or absence of chronic liver disease.Values are median (range); # P value of the comparison between the CLD and non-CLD groups; †Mann-Whitney U test; * Pearson χ 2. tests or Fisher's exact test, as appropriate; abbreviations: CLD: chronic liver disease; HBV: hepatitis B virus; HCV; hepatitis C virus; TB: total bilirubin; ALT: alanine transaminase; AST: aspartate transaminase; ALBI score: albumin-bilirubin score; TPO: thrombopoietin; rhIL-11: recombinant human interleukin-11; P: positive; N: negative.…”