Can liver disease cause thrombocytopenia (low platelet count)?

From the Guidelines

Yes, liver disease can cause low platelets, a condition known as thrombocytopenia, primarily due to hypersplenism and decreased thrombopoietin production, as evidenced by the most recent study in 2024 1. This occurs through several mechanisms, including the liver's reduced production of thrombopoietin, the hormone that stimulates platelet production in bone marrow, and portal hypertension leading to hypersplenism, which traps platelets in the spleen. Additionally, advanced liver disease may trigger immune-mediated destruction of platelets or impair their production. The severity of thrombocytopenia typically correlates with the progression of liver disease, with platelet counts often falling below 100,000 per microliter in advanced cases. Key points to consider include:

• Hypersplenism is a common feature in patients with advanced cirrhosis, affecting all hematological cell lines but most notably causing thrombocytopenia 1.
• The presence of a low platelet count should be integrated into the broader picture of cirrhosis affecting both homeostasis, and it is not suggested to predict the risk of bleeding in patients with cirrhosis per se 1.
• Rotational thromboelastometry may be superior to routine coagulation laboratory tests in predicting the risk of bleeding during high-risk procedures, including liver transplantation 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 like fluid overload 1.
• For high-risk procedures or in the presence of bleeding, platelet transfusion can work synergistically with local hemostatic means, and thrombopoietin receptor agonists like avatrombopag and lusutrombopag should be considered as alternatives 1. It is essential to monitor platelet levels regularly in patients with liver disease, as severe thrombocytopenia may increase bleeding risk and require medical intervention such as platelet transfusions in emergency situations or before invasive procedures.

From the FDA Drug Label

Thrombotic/thromboembolic complications may result from increases in platelet counts with ALVAIZ. Consider the potential for an increased risk of thromboembolism when administering ALVAIZ to patients with known risk factors for thromboembolism (e.g., Factor V Leiden, ATIII deficiency, antiphospholipid syndrome, chronic liver disease). In two controlled clinical trials in patients with chronic hepatitis C and thrombocytopenia, 3% (31/955) treated with eltrombopag experienced a thrombotic event compared with 1% (5/484) on placebo. The majority of events were of the portal venous system (1% in patients treated with eltrombopag versus less than 1% for placebo) The risk of portal venous thrombosis was increased in thrombocytopenic patients with chronic liver disease treated with 75 mg of eltrombopag once daily for 2 weeks in preparation for invasive procedures. Thrombotic/thromboembolic complications may result from increases in platelet counts with Nplate use. Portal vein thrombosis has been reported in patients with chronic liver disease receiving Nplate.

Liver disease can be associated with low platelets (thrombocytopenia), as seen in patients with chronic hepatitis C and chronic liver disease. However, the provided text does not directly state that liver disease causes low platelets. It does mention that patients with chronic liver disease are at increased risk of thrombotic events, including portal vein thrombosis, when treated with certain medications. 2 3

From the Research

Liver Disease and Low Platelets

• Liver disease, particularly chronic liver disease, can lead to thrombocytopenia, a condition characterized by low platelet counts 4, 5, 6.
• Thrombocytopenia in chronic liver disease patients can create clinical challenges, such as an increased risk of bleeding during invasive procedures 5, 6.
• The pathophysiology of thrombocytopenia in chronic liver disease is complex and involves multiple factors, including splenic sequestration, decreased thrombopoietin production, and portal hypertension 6.

Treatment Options for Thrombocytopenia in Liver Disease

• Eltrombopag, a thrombopoietin receptor agonist, has been shown to increase platelet counts in patients with chronic liver disease and thrombocytopenia 4, 5, 7.
• Avatrombopag, another thrombopoietin receptor agonist, has been approved for the treatment of thrombocytopenia in patients with chronic liver disease prior to an invasive procedure 8.
• These medications can help reduce the need for platelet transfusions and decrease the risk of bleeding during procedures 5, 8.

Risks and Benefits of Treatment

• The use of thrombopoietin receptor agonists, such as eltrombopag and avatrombopag, can be associated with risks, including thromboembolic events and potential decompensation of chronic liver disease 5, 7.
• However, these medications have also shown promising results in increasing platelet counts and reducing the need for platelet transfusions in patients with chronic liver disease and thrombocytopenia 4, 5, 6, 8.