Splenomegaly, hypersplenism and coagulation abnormalities in liver disease

Hepatic Failure

The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery.

In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study

BACKGROUND Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. MATERIAL AND METHODS All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. RESULTS A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506-0.6 and 0.539-0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601-0.664 and 0.596-0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627-0.69 and 0.607-0.692, respectively. CONCLUSIONS APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.

Laparoscopic splenic vessels ligation as a treatment of hypersplenism and thrombocytopenia in children

BACKGROUND

Splenectomy and partial splenic embolization as the surgical approach in the treatment of hypersplenism and thrombocytopenia have been reported. However, there are still some disadvantages in the application of these techniques. In this article, we propose a new technique for the treatment of hypersplenism and thrombocytopenia in children and report our preliminary experience.

METHODS

From Aug 2014 to Dec 2014, four children with hypersplenism and three children with idiopathic thrombocytopenic purpura were treated in our hospital. Laparoscopic splenic vessels ligation was performed in all patients. The gastric wall was suspended to expose the pancreatic tail and spleen, and the splenic artery was ligated at the superior border of the pancreas. The splenic venous branches were dissected and ligated at the splenic hilum using the Hem-o-lok.

RESULTS

The laparoscopic splenic vessels ligation was successfully performed in all patients. The average operative time was 126 min (range 120-150 min). No patient required transfusion, and the length of hospital stay varied from 4 to 11 days (mean 6.6 days). The patients were followed up for 6-10 months (mean 8.5 months). The complete blood counts were within normal range. The size of spleen decreased postoperatively. The partial splenic infarction and the reduction in splenic blood flow were confirmed in all patients by postoperative ultrasound and CT.

CONCLUSIONS

The laparoscopic splenic vessels ligation is a feasible option for treating hypersplenism and thrombocytopenia in children.

Relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis

Background

Schistosomiasis is a tropical disease. Patients who develop hepatosplenic schistosomiasis have clinical findings including periportal fibrosis, portal hypertension, cytopenia, splenomegaly and gastrointestinal hemorrhage.

Objective

The aim of this study was to analyze the hemostatic and hematologic findings of patients with schistosomiasis and correlate these to the size of the spleen.

Methods

Fifty-five adults with hepatosplenic schistosomiasis and 30 healthy subjects were selected through a history of contact with contaminated water, physical examination and ultrasound characteristics such as periportal fibrosis and splenomegaly in the Gastroenterology Service of the Universidade Federal de Pernambuco. Blood samples were collected to determine liver function, blood counts, prothrombin (international normalized ratio), partial thromboplastin time and fibrinogen and D-Dimer levels using the Pentra 120 hematological analyzer (HORIBA/ABX), Density Plus (test photo-optical Trinity Biotech, Ireland) and COBAS analyzer 6000 (Roche). Furthermore, the longitudinal size of the spleen was measured by ultrasound (Acuson X analyzer 150, Siemens). The Student t-test, the Fisher test and Pearson's correlation were used to analyze the results with statistical significance being set for a p-value < 0.05.

Results

The mean age was higher for the Study Group than for the Control Group (54 ± 13.9 vs. 38 ± 12.7 years). The average longitudinal diameter of the spleen was 16.9 cm (Range: 12.3-26.3 cm). Anemia is a common finding in patients with schistosomiasis (36.3%). The mean platelet and leukocyte counts of patients were lower than for the Control Group (p-value < 0.001). Moreover, the international normalized ratio (1.42 vs. 1.04), partial thromboplastin time (37.9 vs. 30.5 seconds) and D-Dimer concentration (393 vs. 86.5 ng/mL) were higher for the Study Group compared to the Control Group.

Conclusion

This study suggests that hematological and hemostatic abnormalities are associated with splenomegaly, hypersplenism and portal hypertension.

Radiofrequency ablation for treatment of hypersplenism: A feasible therapeutic option

We present a case of a patient with hypersplenism secondary to portal hypertension due to hepato-splenic schistosomiasis, which was accompanied by severe and refractory thrombocytopenia. We performed spleen ablation and measured the total spleen and ablated volumes with contrast-enhanced computed tomography and volumetry. No major complications occurred, thrombocytopenia was resolved, and platelet levels remained stable, which allowed for early treatment of the patient’s underlying disease. Previous work has shown that splenic radiofrequency ablation is an attractive alternative treatment for hypersplenism induced by liver cirrhosis. We aimed to contribute to the currently sparse literature evaluating the role of radiofrequency ablation (RFA) in the management of hypersplenism. We conclude that splenic RFA appears to be a viable and promising option for the treatment of hypersplenism.

Human platelets and their capacity of binding viruses: meaning and challenges?

Blood platelets are first aimed at ensuring primary hemostasis. Beyond this role, they have been acknowledged as having functions in the maintenance of the vascular arborescence and, more recently, as being also innate immune cells, devoted notably to the detection of danger signals, of which infectious ones. Platelets express pathogen recognition receptors that can sense bacterial and viral moieties. Besides, several molecules that bind epithelial or sub-endothelial molecules and, so forth, are involved in hemostasis, happen to be able to ligate viral determinants, making platelets capable of either binding viruses or even to be infected by some of them. Further, as platelets express both Fc-receptors for Ig and complement receptors, they also bind occasionally virus-Ig or virus-Ig-complement immune complexes. Interplays of viruses with platelets are very complex and viral infections often interfere with platelet number and functions. Through a few instances of viral infections, the present review aims at presenting some of the most important interactions from pathophysiological and clinical points of view, which are observed between human viruses and platelets.

Endothelial Gab1 deficiency aggravates splenomegaly in portal hypertension independent of angiogenesis

Certain pathological changes, including angiogenesis, actively contribute to the pathogenesis of splenomegaly in portal hypertension (PH), although the detailed molecular and cellular mechanisms remain elusive. In this study, we demonstrated that endothelial Grb-2-associated binder 1 (Gab1) plays a negative role in PH-associated splenomegaly independent of angiogenesis. PH, which was induced by partial portal vein ligation, significantly enhanced Gab1 expression in endothelial cells in a time-dependent manner. Compared with controls, endothelium-specific Gab1 knockout (EGKO) mice exhibited a significant increase in spleen size while their PH levels remained similar. Pathological analysis indicated that EGKO mice developed more severe hyperactive white pulp and fibrosis in the enlarged spleen but less angiogenesis in both the spleen and mesenteric tissues. Mechanistic studies showed that the phosphorylation of endothelial nitric oxide synthase (eNOS) in EGKO mice was significantly lower than in controls. In addition, the dysregulation of fibrosis and inflammation-related transcription factors [e.g., Krüppel-like factor (KLF) 2 and KLF5] and the upregulation of cytokine genes (e.g., TNF-α and IL-6) were observed in EGKO mice. We thus propose that endothelial Gab1 mediates multiple pathways in inhibition of the pathogenesis of splenomegaly in PH via prevention of endothelial dysfunction and overproduction of proinflammatory/profibrotic cytokines.

Thrombocytopenia, Platelet Transfusion, and Outcome Following Liver Transplantation

Thrombocytopenia affects patients undergoing liver transplantation. Intraoperative platelet transfusion has been shown to independently influence survival after liver transplantation at 1 and 5 years. We examined the impact of thrombocytopenia and intraoperative platelet transfusion on short-term graft and overall survival after orthotopic liver transplantation (OLT). A total of 399 patients undergoing first OLT were studied. Graft and overall survival in patients with different degrees of thrombocytopenia and with or without intraoperative platelet transfusion were described. The degree of thrombocytopenia prior to OLT did not affect graft or overall survival after transplant. However, graft survival in patients receiving platelets was significantly reduced at 1 year (P= .023) but not at 90 days (P= .093). Overall survival was significantly reduced at both 90 days (P= .040) and 1 year (P= .037) in patients receiving platelets. We conclude that a consistently lower graft and overall survival were observed in patients receiving intraoperative platelet transfusion.

Eltrombopag in chronic hepatitis C

Chronic hepatitis C is a public health problem worldwide. Unfortunately, not all patients may benefit from antiviral therapy due to thrombocytopenia. Its causes are represented by portal hypertension and platelet sequestration in the spleen, decreased serum levels or activity of thrombopoietin, the bone marrow suppression induced by hepatitis C virus and a possible adverse effect of interferon. Thrombopoietin receptor analogs may contribute to increase platelet counts in these patients. Eltrombopag binds to another region of the thrombopoietin receptor compared to endogenous thrombopoietin and stimulates the proliferation and maturation of megakaryocytes and the platelet production in a dose-dependent manner. Eltrombopag has proven its effectiveness for the treatment of patients with primary immune thrombocytopenia. Its indication for other hemopathies or situations (like thrombocytopenia secondary to chemo- or radiotherapy, acute leukemia, myelodysplastic syndroms, acquired and hereditary bone marrow failure, and platelet donors) is under study. Eltrombopag may be particularly useful in patients with advanced chronic hepatitis or liver cirrhosis who require antiviral treatment. We present a minireview on the results of treatment with eltrombopag in patients chronically infected with hepatitis C virus, highlighting the benefits and mentioning possible adverse effects. In some studies eltrombopag increased the number of virological responses after clasical antiviral treatment of patients with chronic hepatitis C and reduced the transfusional requirements of those who had to be subjected to invasive surgery. Eltrombopag is a solution for many of these patients, which allows them receiving antiviral therapy and sometimes getting a sustained virological response, but they must be well monitored to prevent possible thromboembolic or bone marrow complications or liver failure occurrence.

Partial splenic artery embolization in cirrhotic patients

Splenomegaly is a common sequela of cirrhosis, and is frequently associated with decreased hematologic indices including thrombocytopenia and leukopenia. Partial splenic artery embolization (PSE) has been demonstrated to effectively increase hematologic indices in cirrhotic patients with splenomegaly. This is particularly valuable amongst those cirrhotic patients who are not viable candidates for splenectomy. Although PSE was originally developed decades ago, it has recently received increased attention. Presently, PSE is being utilized to address a number of clinical concerns in the setting of cirrhosis, including: decreased hematologic indices, portal hypertension and its associated sequela, and splenic artery steal syndrome. Following PSE patients demonstrate significant increases in platelets and leukocytes. Though progressive decline of hematologic indices occur following PSE, they remain improved as compared to pre-procedural values over long-term follow-up. PSE, however, is not without risk and complications of the procedure may occur. The most common complication of PSE is post-embolization syndrome, which involves a constellation of symptoms including fever, pain, and nausea/vomiting. The rate of complications has been shown to increase as the percent of total splenic volume embolized increases. The purpose of this review is to explore the current literature in regards to PSE in cirrhotic patients and to highlight their techniques, and statistically summarize their results and associated complications.

Low-dose splenic irradiation in symptomatic congestive splenomegaly: report of five cases with literature data

Background

To show effectiveness of low-dose splenic irradiation in symptomatic congestive splenomegaly.

Methods

Five patients were referred to our department for symptomatic congestive splenomegaly within three years. Primary diseases were autoimmune hepatitis with liver cirrhosis (n = 2), cystic fibrosis (n = 1), granulomatous liver disease (n = 1) and Werlhof disease with liver cirrhosis (n = 1). Mean age was 54 years (range: 36–67). Patients received splenic irradiation with a total dose of 3 Gy (single dose: 0.5 Gy). One patient was re-irradiated after long-term failure with the same treatment schedule.

Results

In four patients long term relief of splenic pain could be observed during the follow-up time of median 20 (range: 2–36) months. Four patients showed haematological response after irradiation with an increase of erythrocytes, leucocytes and/or platelets. A slightly decrease in spleen size was found in two patients.

Conclusions

Low-dose splenic irradiation in symptomatic congestive splenomegaly is feasible and perhaps as effective as in lympho-and myeloproliferative malignancies regarding pain relief and haematological response.

Overview of platelet physiology: its hemostatic and nonhemostatic role in disease pathogenesis

Platelets are small anucleate cell fragments that circulate in blood playing crucial role in managing vascular integrity and regulating hemostasis. Platelets are also involved in the fundamental biological process of chronic inflammation associated with disease pathology. Platelet indices like mean platelets volume (MPV), platelets distributed width (PDW), and platelet crit (PCT) are useful as cheap noninvasive biomarkers for assessing the diseased states. Dynamic platelets bear distinct morphology, where α and dense granule are actively involved in secretion of molecules like GPIIb , IIIa, fibrinogen, vWf, catecholamines, serotonin, calcium, ATP, ADP, and so forth, which are involved in aggregation. Differential expressions of surface receptors like CD36, CD41, CD61 and so forth have also been quantitated in several diseases. Platelet clinical research faces challenges due to the vulnerable nature of platelet structure functions and lack of accurate assay techniques. But recent advancement in flow cytometry inputs huge progress in the field of platelets study. Platelets activation and dysfunction have been implicated in diabetes, renal diseases, tumorigenesis, Alzheimer's, and CVD. In conclusion, this paper elucidates that platelets are not that innocent as they keep showing and thus numerous novel platelet biomarkers are upcoming very soon in the field of clinical research which can be important for predicting and diagnosing disease state.

Impact of sustained virus elimination on natural anticoagulant activity in patients with chronic viral hepatitis C

Previous studies have reported reduced synthesis of various hemostatic factors in patients with chronic liver disease. Whether changes in plasma levels of these proteins reflect recovered liver synthetic function following virological eradication therapy has not been approved yet. The aim of the study was to determine the impact of sustained viral suppression achieved with pegylated interferon alpha and ribavirin on hemostatic parameters including natural anticoagulants in patients with chronic hepatitis C. The following coagulation screening tests were obtained in thirty patients with chronic viral hepatitis C before and after completion of antiviral treatment: activated partial thromboplastin time, prothrombin time, plasma fibrinogen and natural anticoagulant proteins antithrombin III, protein C (PC) and total protein S (PS) activity. Only patients who achieved durable virus suppression were included. The mean PC and PS levels were significantly lower in patients with chronic viral hepatitis C before antiviral therapy than in healthy controls (79.04 ± 16.19 % vs. 109.92 ± 21.33% and 54.04 ± 16.11% vs. 87.60 ± 8.15%, respectively; (p<0.001). Mean levels of PC exhibited a significant increase by 14.69 % after the completion of antiviral treatment (93.73 ± 14.18%, p<0.001) as well as PS levels, which significantly increased by 21.46% (75.50 ± 15.43, p<0.001) when compared with pre-treatment values. No remarkable fluctuations in other hemostatic parameters were noted. Protein C and protein S are sensitive markers of hepatocyte synthetic impairment and are valuable markers in monitoring the efficacy of antiviral treatment in chronic hepatitis C patients. Larger studies are needed to confirm our results.

Effects of portal hypertension on contractility of rat spleen

Portal hypertension induces changes in vascular responses to vasoconstrictors. However, the effects of portal hypertension on splenic contraction have not previously been investigated. In partial portal vein ligated (PVL) and sham-operated rats, we examined the splenic contractile responses to cumulative concentrations of noradrenaline and KCl. In PVL rats, the potency of noradrenaline in producing splenic contraction was significantly increased (pEC50 of 5.88 ± 0.08), as compared to sham (5.40 ± 0.06; p<0.001). In the presence of prazosin (10(-8)M), there was a significant rightward shift in the noradrenaline concentration response curve but the shift was greater for PVL, so that in the presence of prazosin there was no significant difference between PVL and sham animals in the potency of noradrenaline. Prazosin produced a significantly greater shift of noradrenaline potency in spleen from PVL (pKB of 8.88 ± 0.06) (n=6) than from sham animals (8.51 ± 0.08, n=6), demonstrating that the α1-adrenoceptor mediated component is greater in spleen from PVL. In the presence of prazosin (10(-8)M) the residual response is non-α1-adrenoceptor mediated, presumably α2-adrenoceptor mediated, and this response did not differ between sham and PVL. The maximum splenic contraction did not significantly differ between sham and PVL rats for either agonist. In conclusion, noradrenaline potency in contracting the rat spleen was significantly increased in tissues from PVL rats. The increased potency of prazosin suggests a greater predominance of α1-adrenoceptors in spleen of PVL rats, as prazosin has lower potency at α2-adrenoceptors.

Hemostatic dysfunction is increased in patients with hepatosplenic schistosomiasis mansoni and advanced periportal fibrosis

BACKGROUND

Schistosomiasis mansoni is an endemic parasitic disease and a public health problem in Northeast Brazil. In some patients, hepatic abnormalities lead to periportal fibrosis and result in the most severe clinical form, hepatosplenic schistosomiasis. This study aimed to evaluate whether abnormal blood coagulation and liver function tests in patients with hepatosplenic schistosomiasis (n = 55) correlate with the severity of their periportal fibrosis.

METHODOLOGY/PRINCIPAL FINDINGS

Blood samples were used for liver function tests, hemogram and prothrombin time (International Normalized Ratio, INR). The blood coagulation factors (II, VII, VIII, IX and X), protein C and antithrombin IIa (ATIIa), plasminogen activator inhibitor 1 (PAI-1) and D-dimer were measured by photometry or enzyme linked immunosorbent assay. Hyperfibrinolysis was defined on the basis of PAI-1 levels and a D-dimer concentration greater than a standard cut-off of 483 ng/mL. Standard liver function tests were all abnormal in the patient group compared to healthy controls (n = 29), including raised serum transaminases (p<0.001) and lower levels of albumin (p = 0.0156). Platelet counts were 50% lower in patients, while for coagulation factors there was a 40% increase in the INR (p<0.001) and reduced levels of Factor VII and protein C in patients compared to the controls (both p<0.001). Additionally, patients with more advanced fibrosis (n = 38) had lower levels of protein C compared to those with only central fibrosis (p = 0.0124). The concentration of plasma PAI-1 in patients was one-third that of the control group (p<0.001), and D-dimer levels 2.2 times higher (p<0.001) with 13 of the 55 patients having levels above the cut-off.

CONCLUSION/SIGNIFICANCE

This study confirms that hemostatic abnormalities are associated with reduced liver function and increased liver fibrosis. Of note was the finding that a quarter of patients with hepatosplenic schistosomiasis and advanced periportal fibrosis have hyperfibrinolysis, as judged by excessive levels of D-dimer, which may predispose them to gastrointestinal bleeding.

The role of eltrombopag in the management of hepatitis C virus-related thrombocytopenia

Eltrombopag is a 2nd generation thrombopoietin-receptor agonist. It binds with the thrombopoietin-receptors found on the surfaces of the megakaryocytes & increases platelet production. Many recent studies have suggested a potential role for this novel agent in the treatment of thrombocytopenia associated with hepatitis-C infection. Studies have shown that adjunct treatment with Eltrombopag can help avoid dose reductions/withdrawals of pegylated interferon secondary to thrombocytopenia. It may also have a role in priming up platelet levels to help initiate antiviral therapy. Similarly, chronic liver disease patients with thrombocytopenia who need to undergo an invasive procedure may be potential candidates for short two-week courses of eltrombopag in the periprocedural period to help reduce the risk of bleeding. Besides the price (deemed very expensive and probably not cost-effective), there are some legitimate concerns about the safety profile of this novel agent (most importantly, portal vein thrombosis, bone marrow fibrosis and hepatotoxicity). In this article, the potential role of eltrombopag in the context of hepatitis C virus (HCV)-related thrombocytopenia is reviewed. To write this article, a MEDLINE search was conducted (1990 to November 2012) using the search terms “eltrombopag,” “HCV,” and “thrombocytopenia.”

Disruption of splenic circulation using microbubble-enhanced ultrasound and prothrombin: a preliminary study

The spleen is a solid organ in which splenomegaly frequently develops and to which abdominal blunt trauma occurs. In this study, we demonstrated the potential therapeutic effect of microbubble-enhanced ultrasound (MEUS) combined with prothrombin to disrupt splenic circulation. A high-pressure-amplitude therapeutic ultrasound (TUS) device was used to treat 36 surgically exposed spleens in healthy New Zealand rabbits. Eighteen spleens were treated with either MEUS (n = 9) or MEUS combined with prothrombin (n = 9). The other 18 spleens were treated with TUS only or sham ultrasound exposure and served as the controls. The TUS was operated at a frequency of 831 kHz and a peak negative pressure of 4.8 MPa. Prothrombin was administered intravenously at 20 IU/kg. Contrast-enhanced ultrasound (CEUS) and acoustic quantification were performed to assess splenic blood perfusion. We found significant blood perfusion slowdown and drop-off in the MEUS-treated spleens. The peak intensity dropped from 20.2 ± 2.70 dB to 11.6 ± 4.58 dB immediately after treatment. The spleens treated with the combination of MEUS and prothrombin showed consistently poor perfusion within 1 h. In histologic examination of the MEUS-treated spleens, we found significant dilatation of splenic sinuses, hemorrhage, interstitial edema and thrombosis. This study demonstrated that the vascular effects induced by microbubble-enhanced, high-pressure ultrasound can slow down or block blood perfusion in the rabbit spleen. Prothrombin helps to enhance and extend the effects for up to 1 h.

Experimental studies and clinical experiences on treatment of secondary hypersplenism with extracorporeal high-intensity focused ultrasound

The aim of this study is to investigate the efficacy and safety of extracorporeal high-intensity focused ultrasound (HIFU) in treatment of hypersplenism. Fifteen adult dogs, weighing 13-18 kg were divided into three groups: sham group, SVL group undergoing splenic vein ligation (SVL) after laparotomy, and SVL + HIFU group receiving SVL followed by extracorporeal HIFU. Pathologic and hematologic analyses were performed. We also reviewed the clinical data of 19 patients with secondary hypersplenism caused by liver cirrhosis or hepatocellular carcinoma who underwent extracorporeal HIFU. Extracorporeal HIFU significantly diminished the volume of the spleen of animals, coupled with occurrence of coagulation necrosis and fibrosis in the target area. Both platelet and red blood cell counts were significantly restored by HIFU intervention. Similarly, HIFU treatment improved the hematologic parameters in patients with hypersplenism, and no major complications were encountered. Extracorporeal HIFU intervention is effective and safe in managing secondary hypersplenism.

Coated transjugular intrahepatic portosystemic shunt does not improve thrombocytopenia in patients with liver cirrhosis

BACKGROUND/AIM

Thrombocytopenia is a common complication of chronic liver disease. The theory of portal decompression to improve thrombocytopenia due to hypersplenism has led to the study of transjugular intrahepatic portosystemic shunt (TIPS) as a potential therapy. However, there is a paucity of data and results have been conflicting. The aim of this study was to determine whether platelet counts improved in cirrhotic patients after placement of the new polytetrafluoroethylene (PTFE)-coated TIPS, developed in 2004.

METHODS

This is a retrospective cohort study of 68 patients with chronic liver disease who underwent a TIPS procedure. One-hundred twenty controls who did not undergo a TIPS procedure were matched on average for age, sex, race, model for end-stage liver disease (MELD) score, and etiology of liver disease. Platelet and hemoglobin counts were recorded during the month prior to the TIPS procedure (baseline) and over the following 12-14 months or until transplanted or death.

RESULTS

While platelet counts improved during the first 3 months after TIPS with a mean increase of 11.25 × 103/μL (p = 0.064), they returned to baseline (pre-TIPS) with mean platelets of 91.31 × 103 μL by 12-14 months in comparison with a mild decrease of 10.2 × 103 μL in platelet counts in the control group from 100.4 × 103 μL to 90.2 × 103 (p = 0.119). There was also no significant correlation between platelet counts and etiology of liver disease, age, race, gender, or MELD score. Hemoglobin counts were found to have a small increase of 0.657 g/dL over the 12-14 month course in the TIPS group, which was statistically significant (p = 0.003).

CONCLUSION

There does not appear to be a significant improvement in thrombocytopenia in cirrhotic patients after TIPS placement, despite advances in TIPS stents. However, there may be a mild improvement in anemia after TIPS implantation.

Brain surgery in patients with liver cirrhosis

OBJECT

Liver cirrhosis was identified as an independent predictor of poor outcomes in patients suffering trauma and in those undergoing major surgeries. The aim of this study was to report the authors' experiences treating patients with cirrhosis who undergo brain surgeries.

METHODS

Between 2004 and 2009, 121 consecutive patients with cirrhosis underwent 144 brain procedures. Patients were categorized as Child-Turcotte-Pugh (referred to as "Child") Class A, B, or C. The patient profiles, including the severity of cirrhosis, reason for surgery, complications, and prognosis factors, were analyzed.

RESULTS

In this retrospective study, the overall surgical complication rate for patients with cirrhosis was 52.1% and the mortality rate was 24.3%. For patients with acute traumatic brain injury (TBI), the complication, rebleeding, and mortality rates reached 84.4%, 68.8%, and 37.5%, respectively. Surgery for TBI was a significant risk factor for postoperative complications (p = 0.0002) and postoperative hemorrhage (p < 0.0001). Otherwise, according to the Child classification, the complication rate increased in a stepwise fashion from 38.7% to 60% to 84.2%, the rebleeding rate from 29.3% to 48.0% to 63.2%, and the mortality rate from 5.3% to 38% to 63.2% for Child A, B, and C, respectively. The Child classification was associated with higher risk of complications-Child B vs A OR 2.84 (95% CI 1.28-6.29), Child C vs A OR 5.39 (95% CI 1.32-22.02). It was also associated with risk of death-Child C vs A OR 30.43 (95% CI 7.71-120.02), Child B vs A OR 10.88 (95% CI 3.42-34.63).

CONCLUSIONS

Liver cirrhosis is a poor comorbidity factor for brain surgery. The authors' results suggest that the Child classification used independently is a poor prognostic factor; in addition, grave outcomes were observed in patients with TBI.

Rifaximin improves thrombocytopenia in patients with alcoholic cirrhosis in association with reduction of endotoxaemia

BACKGROUND

Thrombocytopenia is a major haematological disorder of cirrhosis with unclear pathogenesis. Endotoxaemia resulting from intestinal bacterial overgrowth could reduce platelet counts directly or through cytokine release.

AIMS

To correlate endotoxaemia with platelet counts and study the effects of intestinal decontamination with rifaximin on thrombocytopenia in relation to changes in endotoxin and cytokine concentrations in patients with alcoholic cirrhosis.

METHODS

Platelet counts, plasma endotoxin levels and serum interleukin-1 (IL-1), interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) levels were measured in 23 thrombocytopenic cirrhotic patients (platelet count<150 000/μl) before and after 4-week treatment with rifaximin 1200 mg/d (n = 13) or no treatment (n = 10) and at baseline in 10 cirrhotic patients without thrombocytopenia; spleen size was measured at baseline in all patients.

RESULTS

Endotoxin and IL-6 levels were significantly higher in patients with thrombocytopenia than in those without thrombocytopenia (2.76 ± 0.69 vs. 0.64 ± 0.09 EU/ml; P < 0.001 and 24.26 ± 3.38 vs. 2.66 ± 0.74 pg/ml; P = 0.001 respectively). Platelet counts were inversely correlated with endotoxin levels (r = -0.589; P = 0.003), Child-Pugh score (r = -0.625; P = 0.001), IL-6 levels (r = -0.464; P = 0.02) and spleen size (r = -0.455; P = 0.02) in patients with thrombocytopenia. Following rifaximin, platelet counts increased significantly (83 100 ± 9700 vs. 99 600 ± 11 200/μl; P = 0.006) in line with significant reductions in endotoxin (1.28 ± 0.41 vs. 2.54 ± 0.86 EU/ml; P = 0.005), IL-1 (3.1 ± 0.5 vs. 4.4 ± 1.2 pg/ml; P = 0.04), IL-6 (12.8 ± 2.5 vs. 21.1 ± 4.2 pg/ml; P = 0.01) and TNF-α (3.6 ± 1.3 vs. 5.8 ± 1.7; P = 0.02) levels. Platelet count changes were correlated with the changes in endotoxin (r = 0.573; P = 0.04), TNF-α (r = 0.554; P = 0.05) and IL-6 (r = 0.495; P = 0.07) levels.

CONCLUSIONS

Rifaximin improves cirrhosis-related thrombocytopenia and this could be related with the reduction of endotoxaemia.

Increased immunohistochemical expression of YKL-40 in the spleen of patients with portal hypertension

YKL-40 has been identified as a growth factor in connective tissue cells and also a migration factor in vascular smooth muscle cells. To a large extent, the increase of serum YKL-40 is attributed to liver fibrosis and asthma. However, the relationship of the expression and clinical/prognostic significance of YKL-40 to the splenomegaly of patients with portal hypertension is unclear. In the present study, the expression of YKL-40 was studied by immunohistochemistry in 48 splenomegaly tissue samples from patients with portal hypertension and in 14 normal spleen specimens. All specimens were quickly stored at -80°C after resection. Primary antibodies YKL-40 (1:150 dilution, rabbit polyclonal IgG) and MMP-9 (1:200 dilution, rabbit monoclonal IgG) and antirabbit immunoglobulins (HRP K4010) were used in this study. The relationship of clinicopathologic features with YKL-40 is presented. The expression of YKL-40 indicated by increased immunochemical reactivity was significantly up-regulated in splenomegaly tissues compared to normal spleen tissues. Overexpression of YKL-40 was found in 68.8% of splenomegaly tissues and was significantly associated with Child-Pugh classification (P = 0.000), free portal pressure (correlation coefficient = 0.499, P < 0.01) and spleen fibrosis (correlation coefficient = 0.857, P < 0.01). Further study showed a significant correlation between YKL-40 and MMP-9 (correlation coefficient = -0.839, P < 0.01), indicating that YKL-40 might be an accelerator of spleen tissue remodeling by inhibiting the expression of MMP-9. In conclusion, YKL-40 is an important factor involved in the remodeling of spleen tissue of portal hypertension patients and can be used as a therapeutic target for splenomegaly.

Platelet production and destruction in liver cirrhosis

BACKGROUND & AIMS

Thrombocytopenia is common in liver cirrhosis (LC) but the mechanisms are not fully understood. The purpose of our work was to evaluate platelet kinetics in LC with different etiologies by examining platelet production and destruction.

METHODS

Ninety-one consecutive LC patients (36 HCV, 49 alcoholics, 15 HBV) were enrolled. As controls, 25 subjects with idiopathic thrombocytopenic purpura, 10 subjects with aplastic anemia, and 40 healthy blood donors were studied. Plasma thrombopoietin (TPO) was measured by ELISA. Reticulated platelets (RP) were determined using the Thiazole Orange method. Plasma glycocalicin (GC) was measured using monoclonal antibodies. Platelet associated and serum antiplatelet antibodies were detected by flow cytometry. B-cell monoclonality in PBMC was assessed by immunoglobulin fingerprinting.

RESULTS

Serum TPO was significantly lower in LC (29.9±18.1 pg/ml) compared to controls (82.3±47.6 pg/ml). The GC levels were higher in LC (any etiology) than in healthy cases. Conversely, the absolute levels of RP were lower in LC (any etiology) than in healthy controls. The platelet-associated and serum anti-platelet antibodies were higher in HCV+ LC compared to healthy subjects (p<0.0064), alcoholic LC (p<0.018), and HBV+ LC (p<0.0001). B-cell monoclonality was found in 27% of the HCV+LC, while it was not found in HBV+ or alcoholic LC.

CONCLUSIONS

Patients with LC present decreased plasma TPO, accelerated platelet turnover, and reduced platelet production. This indicates that LC thrombocytopenia is a multifactorial condition involving both increased platelet clearance and impaired thrombopoiesis.

Endotoxaemia in the pathogenesis of cytopenias in liver cirrhosis. Could oral antibiotics raise blood counts?

Cytopenias are frequently observed in patients with cirrhosis and are associated with increased morbidity. In particular, thrombocytopenia can impact routine care of patients with cirrhosis by potentially postponing or interfering with diagnostic and therapeutic procedures including liver biopsy and medically indicated or elective surgery. The pathogenesis of cytopenias in cirrhosis remains largely unknown. Historically, the concept of hypersplenism has long been associated with the cirrhosis-related hematological disorders but was never proven. On the other hand, intestinal bacterial overgrowth and altered gut permeability in cirrhotic patients lead to increased translocation of bacteria and endotoxin into the portal circulation. The impaired phagocytic function of the reticuloendothelial system together with the portosystemic shunting allow endotoxin to reach the systemic circulation and high concentrations of circulating endotoxin are found in cirrhotic patients even with no clinical evidence of infection and correlate with the severity of liver disease. Endotoxin activates monocytes and promotes the release of proinflammatory cytokines. Indeed, serum levels of interleukin-1, interleukin-6, tumor necrosis factor-α, and interferon-γ are elevated in patients with cirrhosis in proportion to the severity of liver disease. Endotoxaemia stimulates the vascular production of nitric oxide (NO) directly or indirectly via the cytokine cascade, and correlates with serum NO metabolite levels in cirrhosis. Several lines of evidence strongly suggest that endotoxaemia may reduce peripheral blood counts either directly or through the release of cytokines and NO. Previous studies in experimental models of cirrhosis and cirrhotic patients have demonstrated that long-term administration of oral antibiotics such as trimethoprim-sulfamethoxazole, norfloxacin, and rifaximin can reduce bacterial translocation and circulating levels of endotoxin, TNF-α, IL-6, and NO. We hypothesize that endotoxaemia plays a pivotal role in the pathogenesis of cytopenias in cirrhosis and that intestinal decontamination could raise peripheral blood counts by the suppression of endotoxaemia and the inhibition of cytokine and NO production.

Risk factors for portal venous thrombosis after splenectomy in patients with cirrhosis and portal hypertension (Br J Surg 2010; 97: 910-916)

Background

Portal venous thrombosis (PVT) is a potentially fatal complication following splenectomy. Its mechanisms and risk factors are poorly understood, especially in patients with cirrhosis and portal hypertension. This study investigated risk factors for PVT following splenectomy in such patients.

Methods

All consecutive patients with cirrhosis who underwent splenectomy in Kyushu University Hospital between 1998 and 2004 were included in this retrospective study. They were divided into two groups based on the presence or absence of postoperative PVT. Preoperative and operative factors were compared, and the relationships between formation of PVT and its independent variables were analysed. In some cases, portal venous flow was measured before and after splenectomy using duplex Doppler ultrasonography.

Results

PVT developed after surgery in 17 (24 per cent) of 70 patients studied. Multivariable analysis showed that increased splenic vein diameter and low white cell count were significant independent risk factors for PVT. Portal venous flow after splenectomy was greatly reduced in the PVT group, but not in patients without PVT.

Conclusion

Large splenic vein diameter and low white cell count are independent risk factors for PVT after splenectomy in patients with cirrhosis and portal hypertension.

Splenectomy and antiviral treatment for thrombocytopenic patients with chronic hepatitis C virus infection

Thrombocytopenic patients with chronic hepatitis C virus (HCV) infection are poor candidates for antiviral treatment with interferon (IFN), but no standard treatment for thrombocytopenia has yet been established. We evaluated the safety of splenectomy and its efficacy for the initiation and continuation of antiviral therapy. From March 2003 to April 2006, 10 patients (mean age 62.5 years) with HCV-related cirrhosis, low platelet count (<==106 000/mm(3)) and splenomegaly (spleen size >==10 cm) underwent splenectomy. Platelet counts significantly increased at 4-8 weeks after splenectomy [pre: 64 200 +/- 6900/mm(3)vs post 209 000 +/- 40 600/mm(3) (P = 0.004)]. No severe operative complications were observed. All patients subsequently received antiviral therapy. Of the eight patients who were infected with HCV genotype 1 and had a high viral load (>==100 KIU/mL), four received combination therapy with pegylated IFNalpha-2b plus ribavirin, and the other four received standard IFNalpha-2b plus ribavirin. One patient infected with HCV genotype 2 and another with HCV genotype 1 and a low viral load (<100 KIU/mL) were treated with pegylated IFNalpha-2a. Six patients achieved sustained virologic response (SVR). Among four patients who failed to achieve SVR, one was given retreatment with pegylated IFN plus ribavirin, and the other three received low-dose long-term IFN therapy. Although this study was small, the treatment results were similar to those for patients without thrombocytopenia and suggested that splenectomy would not reduce the antiviral efficacy of IFNalpha-based treatment.

Expression of NALP3 in the spleen of mice with portal hypertension

This study examined the mRNA expression of NALP3 in the spleen of the mice with hypersplenism due to portal hypertension (PH). The mouse hypersplenism models were established by oral administration of tetrachloromethane (2 mL/kg/week for 12 weeks by oral gavage). All the mice were randomly divided into a control group and an experimental group. The blood routine test was conducted, spleen index was calculated and spleen was histologically examined. Portal vein sera were taken for detection of the level of uric acid. The mRNA expressions of NALP3 and IL-1beta in the spleen were detected by reverse transcriptase-polymerase chain reaction (RT-PCR). The results showed that the platelet count was significantly lower in the experimental group [(674 + or - 102) x 10(9)/L] than in the control group [(1307 + or - 181) x 10(9)/L] (P<0.05), while the spleen index was significantly higher [(9.83 + or - 1.36) microg/g] in the experimental group than in the control group [(4.11 + or - 0.47) microg/g] (P<0.05). The histopathological changes of spleen followed the pattern of congestive splenomegaly. No significant difference was found in the uric acid level in the portal vein between the control group and the experiment group. The mRNA expressions of NALP3 and IL-1beta were up-regulated significantly in the spleen in the experimental group as compared with those in the control group (P<0.05). It was concluded that NALP3 and IL-1beta may play important roles in the pathogenesis of hypersplenism.

[Splenomegaly and thrombocytopenia in patients with liver cirrhosis]

BACKGROUND/AIM

Splenomegaly is a frequent finding in patients with liver cirrhosis and portal hypertension and may cause hypersplenism. The occurrence of thrombocytopenia in those patients can be considered as an event with multiple etiologies. Two mechanisms may act alone or synergistically with splenic sequestration. One is central which involves either myelosuppression because of hepatitis viruses or the toxic effects of alcohol abuse on the bone marrow. The second one involves the presence of antibodies against platelets. It also depends upon the stage and etiology of liver disease. The aim of the study was to investigate a correlation between the platelet count and spleen size and the risk factors for thrombocytopenia in patients with liver cirrhosis.

METHODS

We studied 40 patients with decompensated liver cirrhosis who were hospitalized in the Department of Gastroenterohepatology. The liver function was graded according to Child Pugh score. Spleen size was defined ultrasonografically on the basis of craniocaudal length. Suspicion of portal hypertension was present when longitudinal spleen length was more than 11 cm. Thrombocytopenia was determined by platelet count under 150,000/mL.

RESULTS

We did not find any significant correlation between hepatic dysfunction and spleen size (p = 0.9), and between hepatic dysfunction and thrombocytopenia (p = 0.17). Our study did not find any significant correlation between spleen size and peripheral platelet count (p = 0.5), but we found a significant correlation between thrombocytopenia and etiology of cirrhosis - decreased platelet count was more common among patients with cirrhosis of alcoholic etiology than in other etiologies of cirrhosis (p = 0.001).

CONCLUSION

According to our study, liver cirrhosis, portal hypertension and thrombocytopenia could be present even in the absence of enlarged spleen suggesting the involvement of other mechanisms of decreasing platelet account.

Relevance of the mTOR signaling pathway in the pathophysiology of splenomegaly in rats with chronic portal hypertension

BACKGROUND & AIMS

Splenomegaly is a frequent hallmark of portal hypertension that, in some cases, can be very prominent and cause symptoms like abdominal pain, splenic infarction, and cytopenia. This study characterizes the pathogenetic mechanisms leading to spleen enlargement in portal hypertensive rats and focuses on mTOR pathway as a potential modulator of splenomegaly in portal hypertension.

METHODS

Characterization of splenomegaly was performed by histological, hematological, immunohistochemical and Western blot analyses in rats with portal hypertension induced by portal vein ligation, and compared with sham-operated animals. The contribution of the mTOR signaling pathway to splenomegaly was determined in rats with fully developed portal hypertension and control rats by treatment with rapamycin or vehicle.

RESULTS

Our results illustrate that splenomegaly in portal hypertensive rats arises as a consequence of the interplay of several factors, including not only spleen congestion, as traditionally thought, but also enlargement and hyperactivation of the splenic lymphoid tissue, as well as increased angiogenesis and fibrogenesis. Since mTOR signaling plays a central role in immunological processes, angiogenesis and fibrogenesis, we next determined the involvement of mTOR in splenomegaly. Interestingly, mTOR signaling was overactivated in the spleen of portal hypertensive rats, and mTOR blockade by rapamycin profoundly ameliorated splenomegaly, causing a 44% decrease in spleen size. This effect was most likely accounted for the inhibitory action of rapamycin on lymphocyte proliferation, neovascularization and fibrosis.

CONCLUSIONS

These findings shed light on the pathogenesis of splenomegaly in portal hypertension, and identify mTOR signaling as a potential target for therapeutic intervention in this disease.

Role of partial splenic arterial embolization for hypersplenism in patients with liver cirrhosis and thrombocytopenia

BACKGROUND

Hypersplenism is traditionally treated by surgical splenectomy. Transcatheter ablation of splenic parenchyma is an alternative treatment modality.

METHODS

We evaluated the efficacy and safety of partial splenic arterial embolization in 10 patients with chronic liver disease and hypersplenism with thrombocytopenia (platelet count <80,000/microL).

RESULTS

At six months follow up, median (range) platelet counts (134.5 [71.5-164] x 10(3)/microL) were significantly higher than those before treatment (33.5 [23-39] x 10(3)/microL; p<0.05]). All patients developed post-embolization syndrome. Left-sided pleural effusion and increase in amount or new development of ascites occurred in six and five patients, respectively.

CONCLUSIONS

Our data suggest that partial splenic arterial embolization leads to an increase in platelet count in patients with thrombocytopenia due to chronic liver disease and hypersplenism. However, it is often associated with complications.

Thrombocytopenia and its Related Factors: A Hospital-based, Cross-sectional Study

Introduction: The objective of this study was to explore the association between thrombocytopenia and its related factors. Materials and Methods: This was a hospital-based, cross-sectional study. We retrospectively analysed the medical records of all patients who received periodic health examinations at a medical centre located at Taichung in Taiwan between 2000 and 2004. In all, 5585 subjects were included for further analysis. A complete physical examination, laboratory survey and abdominal ultrasonography were performed on each subject. The t-test, chi-square test and multivariate logistic regression analysis were used. Results: The subjects consisted of 3123 men (55.9%) and 2462 women (44.1%). The mean age was 49.4 ± 12.3 years (range, 20 to 87). The overall prevalence of thrombocytopenia was found to be 0.5%, higher in men than in women (0.6% vs 0.4%, P = 0.504). After controlling for the other covariates, multivariate logistic regression analysis exhibited that the factors significantly related to thrombocytopenia were increasing age (OR, 1.04; 95% CI, 1.004-1.08), anti-HCV positive (OR, 5.24; 95% CI, 2.08-13.20), liver cirrhosis (OR, 7.93; 95% CI, 2.28-27.62), and splenomegaly (OR, 18.86; 95% CI, 6.86-51.87). Conclusion: It is advisable to further check the hepatic status, if thrombocytopenia is noted. Key words: Hepatitis C, Liver cirrhosis, Splenomegaly, Thrombocytopenia

Considerations in the management of hepatitis C virus-related thrombocytopenia with eltrombopag

Thrombocytopenia is a common clinical problem in HCV-infected cases. Multiple studies have consistently shown a rise in platelet count following a successful HCV treatment thus proving a cause-effect relationship between the two. Although, many therapeutic strategies have been tried in the past to treat HCV-related thrombocytopenia (e.g. interferon dose reductions, oral steroids, intravenous immunoglobulins, splenectomy etc), the success rates have been variable and not always reproducible. After the cessation of clinical trials of PEG-rHuMGDF due to immunogenecity issues, the introduction of non-immunogenic second-generation thrombopoietin-mimetics (eltrombopag and Romiplostim) has opened up a novel way to treat HCV-related thrombocytopenia. Although the data is still sparse, eltrombopag therapy has shown to successfully achieve the primary endpoint platelet counts of >/=50,000/muL in phase II& III, randomized, double-blind, placebo-controlled trials. Likewise, though it is premature to claim safety of this drug especially in high-risk patient groups, reported side effects in the published literature were of insufficient severity to require discontinuation of the drug. Based on the current and emerging evidence, a review of the pharmacologic basis, pharmacokinetics, therapeutic efficacy, safety profile and future considerations of eltrombopag in the context of HCV-related thrombocytopenia is given in this article. A MEDLINE search was conducted (1990 to August 2009) using the search terms eltrombopag, HCV, thrombocytopenia.

Thrombocytopenia, an important interfering factor of antiviral therapy and hepatocellular carcinoma treatment for chronic liver diseases

In patients with chronic liver diseases, thrombocytopenia is a common manifestation which interferes with antiviral therapy for hepatitis C virus (HCV), and with hepatocellular carcinoma (HCC) treatment. While thrombopoietin-receptor agonist is expected to improve thrombocytopenia for patients with chronic liver diseases in 2-3 weeks, there is still a lack of fundamental data about short-term variations in the natural course of platelet count in cirrhotic patients, and the impact of thrombocytopenia on antiviral therapy for HCV-infected patients and patients being treated for HCC. The aims of this study are to investigate sequential changes in platelet count and the impact of thrombocytopenia on antiviral therapy and HCC treatment in patients with chronic liver diseases. A total of 726 chronic liver disease patients were enrolled in this study. Changes of platelet count were examined during a 4-week follow-up. Risk of discontinuation or reduction of peginterferon dosage was evaluated in HCV patients with moderate thrombocytopenia (5-10x10(4)/microL). Risk of platelet transfusion or splenectomy was evaluated in HCC patients with severe thrombocytopenia (<5x10(4)/microL). No significant changes of platelet count were observed in cirrhotic patients with thrombocytopenia during a 4-week follow-up. The rate of discontinuation or reduction in dosage of peginterferon was 85.2% (23/27) in patients with moderate thrombocytopenia. Risk of discontinuation or reduction of peginterferon dosage was 3.4-times higher in HCV patients with thrombocytopenia than in those without thrombocytopenia. In HCC patients with severe thrombocytopenia, the frequency of platelet transfusion or splenectomy during HCC treatment was 57.9% (22/38). Risk of platelet transfusion or splenectomy in HCC patients with thrombocytopenia was 57.9-times higher than in those without thrombocytopenia. In conclusion, we demonstrated no significant variation in the short-term natural course of platelet count in cirrhotic patients. In chronic liver disease patients with moderate and severe thrombocytopenia, about 85% of patients treated with peginterferon, and 60% of patients receiving HCC treatments suffered from thrombocytopenia-related limitations, respectively.

Role of hematopoietic growth factors as adjuncts in the treatment of chronic hepatitis C patients

Drug-induced hematotoxicity is the most common reason for reducing the dose or withdrawing ribavirin (RBV) and interferon (IFN) therapy in chronic hepatitis C, which leads to the elimination of a possible cure for the patient. Traditionally, severe anemia and neutropenia have been considered as absolute contraindications to start antiviral therapy. This has not however, been the case since the advent of adjunct therapy with hematopoietic growth factors (erythropoietin (EPO) and granulocyte-colony stimulating factor (G-CSF)). Some recent landmark studies have used this adjunct therapy to help avoid antiviral dose reductions. Although the addition of this adjunct therapy has been shown to significantly increase the overall cost of the treatment, this extra cost is worth bearing if the infection is cured at the end of the day. Although more studies are needed to refine the true indications of this adjunct therapy, determine the best dose regimen, quantify the average extra cost and determine whether or not the addition of this therapy increases the sustained virological response rates achieved, the initial reports are encouraging. Therefore, although not recommended on a routine basis, some selected patients may be given the benefits of these factors. This article reviews the current literature on this subject and makes a few recommendations to help develop local guidelines.

Spontaneous intracranial hemorrhage in cirrhotic patients

OBJECTIVE

The major characteristics of spontaneous intracranial hemorrhage (SICH) in cirrhotic patients have not been completely defined. Cirrhotic patients with SICH were thus analyzed in an effort to better understand the risk factors for SICH and predict patient outcomes.

PATIENTS AND METHODS

From 1997 to 2006, 4515 hospitalized cirrhotic patients were recruited, with a focus on 36 cirrhotic patients with SICH who had no history of cerebral vascular accidents, head injuries, or cerebral arteriovenous malformations. The patient characteristics, severity of cirrhosis, location of the hematoma, and prognosis were analyzed.

RESULTS

Of the patients, 78% were males, 72% consumed alcohol, and 81% had a mild-to-moderate degree of cirrhosis. The overall incidence of SICH was related to the etiology of cirrhosis as follows: virus-related cirrhosis (0.3%), alcohol-related cirrhosis (1.9%), and combined virus- and alcohol-related cirrhosis (3%). The outcome of patients with SICH was associated with the size of the hematoma (P<0.005), the initial Glasgow Coma Scale score (P<0.05), the Child-Pugh classification (P=0.05), and the serum total bilirubin level (P<0.05).

CONCLUSION

SICH occurs primarily in young males with mild-to-moderate alcoholic cirrhosis of the liver. The etiology of cirrhosis is related to the incidence of SICH, but not to the patient outcome. The severity of liver cirrhosis is associated with patient outcome, but not the incidence of SICH.

Eltrombopag for thrombocytopenia in patients with cirrhosis associated with hepatitis C

BACKGROUND

Eltrombopag is a new, orally active thrombopoietin-receptor agonist that stimulates thrombopoiesis. We evaluated its ability to increase platelet counts and facilitate treatment for hepatitis C virus (HCV) infection in patients with thrombocytopenia associated with HCV-related cirrhosis.

METHODS

Seventy-four patients with HCV-related cirrhosis and platelet counts of 20,000 to less than 70,000 per cubic millimeter were randomly assigned to receive eltrombopag (30, 50, or 75 mg daily) or placebo daily for 4 weeks. The primary end point was a platelet count of 100,000 per cubic millimeter or more at week 4. Peginterferon and ribavirin could then be initiated, with continuation of eltrombopag or placebo for 12 additional weeks.

RESULTS

At week 4, platelet counts were increased to 100,000 per cubic millimeter or more in a dose-dependent manner among patients for whom these data were available: in 0 of the 17 patients receiving placebo, in 9 of 12 (75%) receiving 30 mg of eltrombopag, in 15 of 19 (79%) receiving 50 mg of eltrombopag, and in 20 of 21 (95%) receiving 75 mg of eltrombopag (P<0.001). Antiviral therapy was initiated in 49 patients (in 4 of 18 patients receiving placebo, 10 of 14 receiving 30 mg of eltrombopag, 14 of 19 receiving 50 mg of eltrombopag, and 21 of 23 receiving 75 mg of eltrombopag) while the administration of eltrombopag or placebo was continued. Twelve weeks of antiviral therapy, with concurrent receipt of eltrombopag or placebo, were completed by 36%, 53%, and 65% of patients receiving 30 mg, 50 mg, and 75 mg of eltrombopag, respectively, and by 6% of patients in the placebo group. The most common adverse event during the initial 4 weeks was headache; thereafter, the adverse events were those expected with interferon-based therapy.

CONCLUSIONS

Eltrombopag therapy increases platelet counts in patients with thrombocytopenia due to HCV-related cirrhosis, thereby permitting the initiation of antiviral therapy. (ClinicalTrials.gov number, NCT00110799.)

Introduction: thrombocytopenia in chronic liver disease -- treatment implications and novel approaches

BACKGROUND

Thrombocytopenia is a common hematologic toxicity among patients with chronic liver disease.

AIM

To give a brief overview of thrombocytopenia and its effects on patients with chronic liver disease.

RESULTS

Thrombocytopenia is generally mild to moderate in severity and can thus be managed relatively easily. Severe thrombocytopenia (platelet count <50,000 /microL), however, may present significant challenges to patient management. Thrombocytopenia can increase the risk of bleeding associated with invasive or surgical procedures. Therefore, while perhaps less widely appreciated than the impact of anemia or neutropenia, effective prevention and management of thrombocytopenia is also critical for patients with liver disease.

CONCLUSIONS

This supplement to Alimentary Pharmacology & Therapeutics provides a comprehensive review of the significance of thrombocytopenia in patients with chronic liver disease, its pathophysiology and relationship to coagulation disorders, impact on clinical care and resource utilization, and novel therapies that may be able to supplant platelet transfusions.

Review article: thrombocytopenia in chronic liver disease

BACKGROUND

Thrombocytopenia is a common finding in advanced liver disease. It is predominantly a result of portal hypertension and platelet sequestration in the enlarged spleen, but other mechanisms may contribute. The liver is the site of thrombopoietin (TPO) synthesis, a hormone that leads to proliferation and differentiation of megakaryocytes and platelet formation. Reduced TPO production further reduces measurable serum platelet counts.

AIM

This paper describes the scope of thrombocytopenia in chronic liver disease and assesses the clinical impact in this patient population.

METHODS

A medline review of the literature was performed pertaining to thrombocytopenia and advanced liver disease. This data is compiled into a review of the impact of low platelets in liver disease.

RESULTS

The incidence of thrombocytopenia, its impact on clinical decision making and the use of platelet transfusions are addressed. Emerging novel therapeutics for thrombocytopenia is also discussed.

CONCLUSIONS

Thrombocytopenia is a common and challenging clinical disorder in patients with chronic liver disease. New therapeutic options are needed to safely increase platelet counts prior to invasive medical procedures as well as to counteract therapies that further exacerbate low platelets, such as interferon. An ideal compound would be orally available and safe, with rapid onset of action.

Partial Splenic Embolization: Successful treatment of hypersplenism, secondary to biliary cirrhosis and portal hypertension in cystic fibrosis

Partial Splenic Embolization (PSE) is a non-surgical treatment for hypersplenism. It has been reported only in a limited number of patients with Cystic Fibrosis (CF). We report a case of a female cystic fibrosis patient who developed hypersplenism at the age of 14 and underwent PSE. Long term results over a period of 14 years after the procedure are presented.

Comparison of two different percutaneous splenic artery interventions in the treatment of hypersplenism: preliminary report

BACKGROUND

Splenomegaly and hypersplenism occur in patients with chronic liver disease and liver transplant recipients. The traditional treatment for hypersplenism is surgical removal. Percutaneous interventional methods, such as partial splenic embolization, are alternatives to surgery for hypersplenism. This article gives preliminary findings for a new percutaneous technique in which a narrowed stent is placed in the splenic artery.

METHODS

The study focused on 10 patients (eight males and two females) who were treated for hypersplenism. Partial splenic embolization was performed in six patients (age range, 1-43 years) who were waiting for liver transplantation, and narrowed stents were placed in four patients (age range, 12-47 years) who had undergone either orthotopic two patients) or heterotopic two patients) liver transplantation. For embolization, the splenic artery was catheterized and polyvinyl alcohol particles were infused to the distal branches, reducing blood flow in the spleen by 40% to 50%. In the other cases, a narrowed stent was deployed to the middle portion of the splenic artery.

RESULTS

Hypersplenism was successfully treated in all 10 cases. Compared with partial splenic embolization, placement of narrowed stents was associated with lower frequencies of postintervention fever and pain, shorter hospital stay, and decreased need for antibiotics. In addition to treating hypersplenism, narrowed-stent placement also completely resolved splenic artery steal syndrome in the two patients (orthotopic liver transplant recipients) with this condition.

CONCLUSION

Percutaneous placement of a narrowed stent in the splenic artery is a promising new technique for treating hypersplenism and splenic arterial steal syndrome.

Partial splenic embolization in patients with cirrhosis: efficacy, tolerance and long-term outcome in 32 patients

BACKGROUND

Although partial splenic embolization (PSE) has been proposed in patients with cirrhosis in cases when thrombocytopenia or neutropenia may cause clinical manifestations or if there are contra-indications to other therapeutic procedures, there are limited data on long-term outcome. We provide a retrospective review of results and the tolerance of all PSE procedures in patients with cirrhosis in our department.

PATIENTS AND METHODS

Thirty-two consecutive patients with cirrhosis were included over a 6 year period. Indications for PSE were as follows: (1) severe cytopenia preventing necessary antiviral treatment (n=14), percutaneous destruction of hepatocellular carcinoma (n=8) or major surgery (n=3), severe purpura (n=3); (2) painful splenomegaly (n=4). After superselective catheterization, embolization was performed with up to 50% reduction of splenic blood flow.

RESULTS

Thrombocyte and leucocyte counts increased markedly (185% and 51% at 1 month; 95% and 30% at 6 months). Thirty-one and 20 patients had platelet count >80,000/mm3 at months 1 and 6 vs only one before PSE. Overall, the aim of PSE was achieved in 27 patients (84%) (planned treatment: 20/25; disappearance of purpura and splenic pain: 7/7). Severe complications occurred in five patients (16%): transient ascites (n=2), splenic and/or portal vein thrombosis (n=2) that resolved after anticoagulation therapy, and splenic abscess (n=2) leading to death. These two patients had splenic necrosis >70%.

CONCLUSION

In patients with cirrhosis, PSE may resolve cytopenia and the clinical complications related to hypersplenism or splenomegaly. However, due to a high risk of severe complications, particularly splenic abscess, the indications of PSE should be very limited and the extent of necrosis should be strictly controlled during the PSE procedure.

Partial Splenic Embolization for the Treatment of Hypersplenism in Cirrhotic HIV/HCV Patients Prior to Pegylated Interferon and Ribavirin

Partial splenic embolization (PSE), a non-surgical treatment for hypersplenism, has also been reported to improve hepatic function. As severe thrombocytopaenia or leukopaenia contraindicate the use of combined therapy with pegylated interferons (PEG-IFNs) and ribavirin (RBV) in HCV-related cirrhosis, we evaluated, from July 2002 to October 2003, the safety and effectiveness of PSE as a procedure to allow therapy for HCV in three Child-Pugh class B cirrhotic patients with hypersplenism and HIV co-infection. HCV genotypes were 1b ( n=2) and 3a ( n=1). Severe thrombocytopaenia (in all) and leukopaenia (in two) precluded therapy for HCV. PSE was successfully performed in all with a mean infarcted area of 80%, leading to a significant increase in platelet and leukocyte counts that allowed therapy with weight-adjusted RBV and PEG-IFN-α-2b (patients 1 and 3) or 180 μg of PEG-IFN-α-2a (patient 2) 8 weeks after the procedure. Moderate pain, well controlled with conservative measures, followed PSE in 100% of cases, but during follow-up (mean 422 days) there were no infectious complications or liver decompensation episodes. Although preliminary, these results suggest the potential role of PSE in HIV/HCV-cirrhotic subjects with hypersplenism as a procedure to allow the use of combined PEG-IFN and RBV.

Preoperative preparation of patients with advanced liver disease

OBJECTIVE

To review the characteristic features of patients with advanced liver disease that may lead to increased perioperative morbidity and mortality rates.

DESIGN

Literature review.

RESULTS

Patients with end-stage liver disease are at high risk of major complications and death following surgery. The most common complications are secondary to acute liver failure and include severe coagulopathy, encephalopathy, adult respiratory distress syndrome, acute renal failure, and sepsis. The degree of malnutrition, control of ascites, level of encephalopathy, prothrombin time, concentration of serum albumin, and concentration of serum bilirubin predict the risk of complications and death following surgery. Other determinants of adverse outcome include emergency surgery, advanced age, and cardiovascular disease. Portal hypertension is a prominent feature of advanced liver disease, and it predisposes the patient to variceal hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and uncontrolled ascites. Portal hypertension can be ameliorated by percutaneous or surgical portasystemic shunting procedures. If well-defined contraindications are not present, patients with advanced liver disease should be evaluated for orthotopic liver transplantation from a cadaver donor or possible living-related liver transplantation.

CONCLUSIONS

Optimal preparation, which addresses the common features of advanced liver disease, may decrease the risk of complications or death following surgery. Preparation should include correcting coagulopathy, minimizing preexisting encephalopathy, preventing sepsis, and optimizing renal function.

Evaluation of a canine model of secondary hypersplenism induced by splenic vein ligation

AIM

To introduce and evaluate a canine model of secondary hypersplenism induced by splenic vein ligation.

METHODS

Eighteen healthy mongrel dogs were randomly divided into three groups. The first group (n = 4) underwent laparotomy, the second (n = 10) and third groups (n = 4) underwent laparotomy plus ligation of splenic vein and its collateral branches to induce congestive splenomegaly. At the end of the third week, splenectomy was performed in the third group. The blood cell counts for peripheral venous blood were determined weekly, and the radiographic and histopathological changes of spleen also obtained regularly.

RESULTS

The erythrocyte and platelet counts decreased in the first week, and were significantly lowered (erythrocyte count of (6.8 ± 1.2)×10¹²/L in control vs (5.1± 0.7)×10¹²/L in second group, P<0.01; and platelet counts of (398 ± 58)×10⁹/L vs (230 ± 86)109/L, P<0.05 respectively) at the end of 3rd week after splenic vein ligation thereafter sustained. The splenomegaly, erythrocytopenia and thrombocytopenia had remained over 9 weeks. No significant changes of the leukocyte counts were observed after splenic vein ligation throughout the experiment (P>0.05). The abnormal status of erythrocytopenia and thrombocytopenia was ameliolated by splenectomy, and the erythrocyte and platelet counts were similarly to the levels of the control group in the second week after splenectomy. After the end of 3rd week after splenic vein ligation, the splenic histopathological changes conformed to the changes of chronic congestive splenomagely.

CONCLUSION

The method of splenic vein ligation to induce experimental secondary hypersplenism is simple and effective. This is a relative ideal model for surgical or interventional therapy on hypersplenism.

Clinical application of serial operations with preserving spleen

AIM: To evaluate the clinical application of serial operations with preservation of spleen.

METHODS: Serial operations with preserving spleen were performed on 211 cases in our hospital from 1980 to 2000. The patient’s age ranged from 13 to 56 years, averaging 38 years. Diseases included splenic injury in 171 cases, portal hypertension in 9 cases, splenic cyst in 10 cases, and the lesion of pancreatic body and tail in 21 cases.

RESULTS: All the cases were cured, and 129 patients were followe dup from 3 mo to 3 years with the leukocyte phagocytosis test, detection of immunoglubin, CT, ^99mTc scanning and ultrasonography. The results were satisfactory.

CONCLUSION: The operations with preserving spleen were safe, feasible, and worth of clinical application.