From the Guidelines
Low platelet count (thrombocytopenia) is commonly associated with cirrhosis, primarily due to portal hypertension leading to splenomegaly, which traps and destroys platelets, and impaired liver production of thrombopoietin. This occurs because cirrhosis causes portal hypertension, which leads to an enlarged spleen (splenomegaly) that traps and destroys platelets, reducing their numbers in circulation 1. Additionally, cirrhosis impairs the liver's ability to produce thrombopoietin, a hormone that stimulates platelet production in bone marrow. The severity of thrombocytopenia often correlates with the progression of cirrhosis, with platelet counts typically falling below 150,000 per microliter.
Some key points to consider in the management of thrombocytopenia in cirrhosis include:
- 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 and may accurately predict 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.
- Thrombopoietin receptor agonists like avatrombopag may be used in specific situations to temporarily increase platelet counts before procedures 1.
In terms of management, treating the underlying liver disease is the primary focus, and in severe cases with bleeding risk, platelet transfusions may be necessary, particularly before invasive procedures. Thrombopoietin receptor agonists like avatrombopag might be used in specific situations to temporarily increase platelet counts before procedures 1. It is essential to consider the potential benefits and risks of prophylactic blood transfusions, such as transfusion reactions and alloimmunization, and to manage clinical care in collaboration with an expert hematologist when necessary 1.
From the Research
Low Platelet Count and Cirrhosis
- Low platelet count, also known as thrombocytopenia, is a common complication of advanced liver disease or cirrhosis, with an incidence of up to 75% 2.
- The pathophysiology of thrombocytopenia in liver disease is multifactorial, including splenomegaly, reduced hepatic synthesis of thrombopoietin, and increased platelet destruction or consumption 2, 3.
Mechanisms of Thrombocytopenia in Cirrhosis
- Splenomegaly and subsequently increased splenic sequestration of circulating platelets contribute to thrombocytopenia in cirrhosis 2.
- Reduced hepatic synthesis of thrombopoietin, which stimulates megakaryocytopoiesis and thrombocytopoiesis, results in diminished platelet production and release from the bone marrow 2, 3.
- Increased platelet destruction or consumption also plays a role in thrombocytopenia in cirrhosis 2, 4.
Treatment of Thrombocytopenia in Cirrhosis
- Thrombopoietin receptor agonists, such as avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease undergoing invasive procedures 2, 5, 6.
- These agents have been shown to increase platelet counts and reduce the need for platelet transfusions in patients with cirrhosis and severe thrombocytopenia 5, 6.