Does cirrhosis cause thrombocytopenia (low platelet count)?

From the Guidelines

Cirrhosis is a significant cause of thrombocytopenia, with approximately 80% of patients having platelet counts below the lower limit of normal 1. This condition occurs due to several mechanisms related to advanced liver disease. The primary causes include reduced production secondary to bone marrow suppression from underlying disease, reduced thrombopoietin production and/or activity, increased destruction, and possible sequestration in the spleen 1. Some key points to consider are:

• Thrombocytopenia is common in patients with cirrhosis, with severe thrombocytopenia (<50 × 10^9/L) being uncommon in ambulatory patients with compensated disease but increasing in those with decompensated disease and critical illness 1.
• Mechanisms for thrombocytopenia in cirrhosis include reduced production, increased destruction, and possible sequestration in the spleen 1.
• Evidence suggests that thrombocytopenia is not a predictor of procedural bleeding risk in patients with liver disease, possibly due to counteracting mechanisms such as increased levels of von Willebrand factor (VWF) and decreased ADAMTS-13 levels 1. The severity of thrombocytopenia often correlates with the progression of cirrhosis, and this low platelet count can increase bleeding risk, particularly in advanced cirrhosis, and may require monitoring and management as part of comprehensive cirrhosis care.

From the Research

Thrombocytopenia in Cirrhosis

• Thrombocytopenia is a common complication in liver disease, particularly in cirrhosis, and can adversely affect the treatment of liver cirrhosis 2.
• The major mechanisms for thrombocytopenia in liver cirrhosis are:
  • Platelet sequestration in the spleen
  • Decreased production of thrombopoietin in the liver 2, 3
• Other factors that can contribute to the development of thrombocytopenia in cirrhotic patients include:
  • Reduced activity of the hematopoietic growth factor thrombopoietin
  • Bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents
  • Antiviral treatment with interferon-based therapy 2
  • Increased destruction of platelets due to hypersplenism, autoimmune disease, and raised titers of antiplatelet immunoglobulin 4

Relationship between Thrombopoietin and Thrombocytopenia

• Some studies suggest that inadequate thrombopoietin production may be a major cause of thrombocytopenia in cirrhosis of the liver 3.
• However, other studies have found that serum thrombopoietin levels are actually higher in cirrhotic patients than in healthy controls, and that thrombopoietin has no contribution to the occurrence of thrombocytopenia in cirrhosis 5.
• The relationship between thrombopoietin and thrombocytopenia in cirrhosis is complex and not fully understood, with multiple factors contributing to the development of thrombocytopenia 4.

Treatment Options

• Several treatment options are available for severe thrombocytopenia in cirrhotic patients, including:
  • Platelet transfusion
  • Interventional partial splenic embolization
  • Surgical splenectomy 2
  • Thrombopoietin receptor agonists, such as romiplostim, eltrombopag, avatrombopag, and lusutrombopag 6