What is the management approach for hypersplenism?

From the Guidelines

The management of hypersplenism should prioritize treating the underlying cause and addressing resulting cytopenias, with a focus on medical management using thrombopoietin receptor agonists, such as avatrombopag and lusutrombopag, as the preferred initial approach, as supported by the most recent evidence from 2024 1.

Key Considerations

• The presence of hypersplenism is often associated with advanced cirrhosis, and its management should be integrated into the broader picture of cirrhosis affecting homeostasis.
• A low platelet count per se is not suggested to predict the risk of bleeding in patients with cirrhosis, and rotational thromboelastometry may be superior to routine coagulation laboratory tests in predicting the risk of bleeding during high-risk procedures.
• The correction of a low platelet count is not recommended before low-risk procedures, and blood products should be used sparingly to avoid side effects.

Treatment Options

• Medical management using thrombopoietin receptor agonists, such as avatrombopag and lusutrombopag, is the preferred initial approach, as they have been shown to be superior to no treatment in avoiding platelet transfusion and rescue therapy 1.
• Splenectomy and partial splenic vein embolization are alternative options, but are not currently part of standard management strategies.
• After transplantation, portal pressure decreases rapidly, and thrombopoietin levels increase, usually resulting in normal platelet counts within 2 weeks.

Important Notes

• The management of hypersplenism should prioritize the patient's overall condition and the underlying cause of the splenic enlargement.
• The use of thrombopoietin receptor agonists requires careful consideration of the patient's individual needs and the potential risks and benefits of treatment.
• The most recent evidence from 2024 1 should be taken into account when making treatment decisions for patients with hypersplenism.

From the Research

Management Approach for Hypersplenism

The management approach for hypersplenism involves various treatment options, including:

• Etiological treatment: treating the underlying cause of hypersplenism 2
• Non-surgical treatment: using pharmacological agents to increase platelet counts 3
• Total splenectomy: surgical removal of the spleen, which is the most effective method but carries a significant risk of portal vein thrombosis 3
• Partial splenic artery embolization: a minimally invasive procedure that can increase platelet counts, but counts may return to baseline over time 3, 4
• Radiofrequency ablation: a method for treating hypersplenism, but its long-term effectiveness is unclear 3
• Liver transplantation: may be considered in some cases, especially when hypersplenism is caused by liver disease 2

Treatment Considerations

When deciding on a treatment approach, several factors should be considered, including:

• The underlying cause of hypersplenism
• The severity of symptoms and cytopenias
• The presence of other medical conditions, such as liver disease or portal hypertension
• The potential risks and benefits of each treatment option
• The individual patient's needs and preferences 2, 4

Comparison of Treatment Options

Studies have compared the efficacy and safety of different treatment options for hypersplenism, including:

• Partial splenic embolization (PSE) versus splenectomy (SP): PSE was associated with less operation time, less intraoperative blood loss, shorter hospital stay, and lower complication rate, but similar efficacy in improving postoperative platelet, white blood cell, and hemoglobin levels 4
• Splenectomy versus other treatment options: splenectomy is the most effective method, but it carries a significant risk of portal vein thrombosis and other complications 3