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Takahashi K, Nagai S, Safwan M, Liang C, Ohkohchi N. Thrombocytopenia after liver transplantation: Should we care? World J Gastroenterol 2018; 24:1386-1397. [PMID: 29632420 PMCID: PMC5889819 DOI: 10.3748/wjg.v24.i13.1386] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/06/2018] [Accepted: 03/18/2018] [Indexed: 02/06/2023] Open
Abstract
Transient thrombocytopenia is a common phenomenon after liver transplantation. After liver transplantation (LT), platelet count decreases and reaches a nadir on postoperative days 3-5, with an average reduction in platelet counts of 60%; platelet count recovers to preoperative levels approximately two weeks after LT. The putative mechanisms include haemodilution, decreased platelet production, increased sequestration, medications, infections, thrombosis, or combination of these processes. However, the precise mechanisms remain unclear. The role of platelets in liver transplantation has been highlighted in recent years, and particular attention has been given to their effects beyond hemostasis and thrombosis. Previous studies have demonstrated that perioperative thrombocytopenia causes poor graft regeneration, increases the incidence of postoperative morbidity, and deteriorates the graft and decreases patient survival in both the short and long term after liver transplantation. Platelet therapies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist, platelet transfusion, splenectomy, and intravenous immunoglobulin treatment might have a potential for improving graft survival, however clinical trials are lacking. Further studies are warranted to detect direct evidence on whether thrombocytopenia is the cause or result of poor-graft function and postoperative complications, and to determine who needs platelet therapies in order to prevent postoperative complications and thus improve post-transplant outcomes.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Mohamed Safwan
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Chen Liang
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
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Von Willebrand Factor Deposition and ADAMTS-13 Consumption in Allograft Tissue of Thrombotic Microangiopathy-like Disorder After Living Donor Liver Transplantation: A Case Report. Transplant Proc 2017; 49:1596-1603. [PMID: 28651806 DOI: 10.1016/j.transproceed.2017.02.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/03/2017] [Accepted: 02/20/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) pathogenesis after living donor liver transplantation (LDLT) is thought to be caused by release of unusually large von Willebrand factor multimers (UL-vWFMs) resulting from sinusoidal endothelial cell damage and induction of platelet adhesion and aggregation. A decrease in a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs-13 (ADAMTS-13) that cleave UL-vWFMs might cause excessive UL-vWFMs activity and result in platelet thrombus formation. However, this phenomenon has not undergone a full pathologic assessment. PROCEDURES A 60-year-old man was diagnosed with hepatitis C-related end-stage cirrhosis. His son was the donor, and he underwent LDLT. On postoperative day 44, his laboratory findings met most TMA diagnostic criteria, and he was diagnosed with TMA-like disorder (TMALD). Localization of CD42b as a platelet marker, vWF, and ADAMTS-13 in allograft tissue of this patient were evaluated using immunohistochemistry. RESULTS CD42b expression was observed as platelet aggregates attached to hepatocytes or within the hepatocyte cytoplasm, a morphology called extravasated platelet aggregation (EPA). vWF expression was observed mainly as deposited compact clusters, and ADAMTS-13 expression resembled distinct dots throughout the liver tissue. CONCLUSION These findings suggest that EPA indicated sinusoidal endothelial cell damage followed by detachment, and vWF deposition resulted from UL-vWFM oversynthesis. ADAMTS-13 might be consumed in the allograft tissue to cleave UL-vWFMs, but ADAMTS-13 levels might be insufficient to cleave all the deposited UL-vWFMs. We present the case of an LDLT recipient diagnosed with TMALD using blood tests, which showed the presence of TMA pathogenesis in the allograft.
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Hayashi H, Takamura H, Ohbatake Y, Nakanuma S, Tajima H, Fushida S, Onishi I, Tani T, Shimizu K, Ohta T. Postoperative changes in neutrophil-to-lymphocyte ratio and platelet count: A simple prognostic predictor for adult-to-adult living donor liver transplantation. Asian J Surg 2017; 41:341-348. [PMID: 28365200 DOI: 10.1016/j.asjsur.2017.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/06/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVE The neutrophil-to-lymphocyte ratio (NLR) is a simple index that represents systemic inflammatory change. The number of platelets is also known to reflect both post-transplant graft regeneration and dysfunction. Thus, we aimed to investigate the usefulness of NLR and platelet number in predicting the clinical course after adult-to-adult living donor liver transplantation (AA-LDLT) in the acute postoperative period in recipients. METHODS Between January 1999 and December 2013, 61 patients underwent their first AA-LDLT at our institute. We retrospectively analyzed their clinical data, including NLR and number of platelets, until postoperative day 14, and evaluated their ability to predict prognosis after AA-LDLT. RESULTS The optimal cutoff values of postoperative maximum NLR and maximum platelets to predict prognosis were 50 and 80 × 103/μL, respectively. The 1- and 5-year survival rates were 87.5% and 79.1% in the normal maximum NLR group, respectively, and 46.2% for both in the high maximum NLR group (p = 0.0033). The 1- and 5-year survival rates, respectively, were 90.9% and 84.1% in the high maximum platelets group and 47.1% and 41.2% in the low maximum platelets group (p < 0.0001). In multivariate analysis, maximum NLR ≥ 50 and maximum platelets < 80 × 103/μL were independently associated with 1-year mortality. CONCLUSION A high NLR and a low platelet count during acute postoperative period might correlate with poor prognosis after AA-LDLT.
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Affiliation(s)
- Hironori Hayashi
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
| | - Hiroyuki Takamura
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
| | - Hidehiro Tajima
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
| | - Sachio Fushida
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
| | - Ichiro Onishi
- Department of Surgery, National Hospital Organization Kanazawa Medical Center, 1-1 Shimoishibiki-machi, Kanazawa, Ishikawa 920-8650, Japan
| | - Takashi Tani
- Department of Surgery, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-0865, Japan
| | - Koichi Shimizu
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama 930-8550, Japan
| | - Tetsuo Ohta
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
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Takahashi N, Usui M, Naitoh K, Wada H, Mastsui T, Kobayashi T, Matsumoto T, Uemoto S, Isaji S. Elevated Soluble Platelet Glycoprotein VI Levels in Patients After Living Donor Liver Transplantation. Clin Appl Thromb Hemost 2016; 23:274-281. [PMID: 26346441 DOI: 10.1177/1076029615604047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Plasma-soluble platelet glycoprotein VI (sGPVI) levels were examined in patients undergoing living donor liver transplantation (LDLT), and the relationship between platelet activation and thrombocytopenia was evaluated to understand the mechanism of thrombocytopenia in LDLT. Platelet counts were significantly higher in the donors compared to the recipient, and the plasma sGPVI levels increased in both groups after the operation. Regarding the relationship between the platelet counts and the sGPVI levels, the slope varied on different days, and it became negative on day 3, suggesting that the plasma sGPVI levels are related to platelet activation in LDLT. The frequency of complications was high in the nonsurvivors. The platelet counts were higher in the survivors than in the nonsurvivors on days 14 and 28. Although the plasma levels of sGPVI in the survivors increased after the operation, those in the nonsurvivors were high only on day 3. Although the ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 domain, member 13) levels were markedly reduced, von Willebrand factor (VWF) and VWF propeptide (VWFpp) were markedly elevated during LDLT. The antithrombin activity was significantly lower (day 14) and VWFpp (day 28) was significantly higher in the nonsurvivors than in the survivors. These findings suggest that platelet activation first occurs after LDLT, and it is high in the nonsurvivors on day 3. Thereafter, the hemostatic abnormality and vascular endothelial cell injuries may appear on days 14 and 28.
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Affiliation(s)
- Naoki Takahashi
- 1 Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Masanobu Usui
- 1 Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Katsuki Naitoh
- 2 Biology Laboratory, Discovery Research, Mochida Pharmaceutical Co, Ltd, Shizuoka, Japan
| | - Hideo Wada
- 3 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshiki Mastsui
- 1 Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Kobayashi
- 3 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeshi Matsumoto
- 4 Department of Blood Transfusion, Mie University Graduate School of Medicine, Mie, Japan
| | - Shinji Uemoto
- 5 Hepatobiliary Pancreatic and Transplantation Surgery, Kyoto University Graduate School, Kyoto, Japan
| | - Shuji Isaji
- 1 Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.2015.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Aota T, Wada H, Yamashita Y, Matsumoto T, Ohishi K, Suzuki K, Imai H, Usui M, Isaji S, Katayama N. The efficacy of the administration of recombinant human soluble thrombomodulin in patients with DIC. Int J Hematol 2015; 103:173-9. [PMID: 26590919 DOI: 10.1007/s12185-015-1899-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 01/08/2023]
Abstract
Efficacy of recombinant human soluble thrombomodulin (rhTM), which is frequently used to treat patients with disseminated intravascular coagulation (DIC), was compared with that of gabexate mesilate (GM), which was previously used routinely in the treatment of DIC patients in Japan. Although there was no significant difference in the resolution rates of the patients who were treated with rhTM and GM, the results of our analysis revealed that the mortality rate was significantly higher among infectious disease patients treated with GM than in those treated with rhTM. Levels of fibrinogen and fibrin degradation products (FDP), antithrombin (AT) activity, and thrombin AT complex (TAT) were significantly lower in the DIC patients with infectious diseases, while fibrinogen levels were high. FDP level, D-dimer, platelet count, PT ratio, and DIC score all showed significant improvement following rhTM treatment. There were no significant difference between survivors and non-survivors in terms of DIC score, FDP level, platelet count, AT activity, or in TAT, SF and PPIC levels before rhTM treatment. However, fibrinogen levels were significantly lower in non-survivors than in survivors. These results indicate that rhTM may be superior to GM for the treatment of DIC.
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Affiliation(s)
- Takumi Aota
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideo Wada
- Departments of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshiki Yamashita
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeshi Matsumoto
- Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kohshi Ohishi
- Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kei Suzuki
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroshi Imai
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Masanobu Usui
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
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De novo thrombotic microangiopathy after non-renal solid organ transplantation. Blood Rev 2014; 28:269-79. [DOI: 10.1016/j.blre.2014.09.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/02/2014] [Indexed: 12/14/2022]
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