Can liver cirrhosis cause thrombocytopenia (low platelet count)?

From the Guidelines

Yes, liver cirrhosis can cause thrombocytopenia, which is a condition characterized by abnormally low platelet counts in the blood. This occurs through several mechanisms, including portal hypertension, which leads to an enlarged spleen (splenomegaly) that traps and destroys platelets, reducing their circulation in the bloodstream 1. Additionally, cirrhosis impairs the liver's ability to produce thrombopoietin, a hormone essential for platelet production in the bone marrow, and causes decreased production of clotting factors, further contributing to bleeding risks 1.

Mechanisms of Thrombocytopenia in Liver Cirrhosis

The severity of thrombocytopenia typically correlates with the progression of liver disease, with platelet counts often falling below 100,000/μL in advanced cirrhosis 1. Patients with cirrhosis-related thrombocytopenia may experience easy bruising, nosebleeds, bleeding gums, or more serious internal bleeding. The primary cause of thrombocytopenia in liver cirrhosis is portal hypertension, which leads to splenomegaly and subsequent platelet sequestration 1. Other mechanisms include reduced thrombopoietin production, myeloid toxicity, and anti-platelet antibodies 1.

Management of Thrombocytopenia in Liver Cirrhosis

Management focuses on treating the underlying liver disease and may include platelet transfusions before invasive procedures if counts are dangerously low 1. However, the use of platelet transfusions should be judicious, as they carry potential risks, including transfusion-related lung injury syndromes 1. Alternative therapies, such as thrombopoietin receptor agonists (e.g., avatrombopag and lusutrombopag), may be considered for patients with severe thrombocytopenia undergoing high-risk procedures 1.

Key Considerations

• The presence of a low platelet count should be integrated into the broader picture of cirrhosis affecting both homeostasis 1.
• A low platelet count per se is not suggested to predict the risk of bleeding in patients with cirrhosis 1.
• Rotational thromboelastometry may be superior to routine coagulation laboratory tests in predicting the risk of bleeding during high-risk procedures 1.
• 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 1.

From the Research

Liver Cirrhosis and Thrombocytopenia

• Liver cirrhosis can cause thrombocytopenia, which is a common complication in liver disease 2, 3, 4, 5, 6.
• The pathophysiology of thrombocytopenia in liver disease is multifactorial, including:
  • Splenomegaly and increased splenic sequestration of circulating platelets 3, 5.
  • Reduced hepatic synthesis of thrombopoietin, resulting in diminished platelet production and release from the bone marrow 2, 3, 5, 6.
  • Increased platelet destruction or consumption 3.

Mechanisms of Thrombocytopenia in Liver Cirrhosis

• The major mechanisms for thrombocytopenia in liver cirrhosis are:
  • Platelet sequestration in the spleen 2, 3, 5.
  • Decreased production of thrombopoietin in the liver 2, 3, 5, 6.
• Thrombopoietin is produced primarily in the liver and degraded by circulating platelets, and its role in the thrombocytopenia of liver cirrhosis is crucial 5, 6.

Treatment Options for Thrombocytopenia in Liver Cirrhosis

• Several treatment options are available for severe thrombocytopenia in cirrhotic patients, including:
  • Platelet transfusion 2.
  • Interventional partial splenic embolization 2, 5.
  • Surgical splenectomy 2.
  • Thrombopoietin agonists and targeted agents, such as avatrombopag and lusutrombopag 3, 4.