Hepatitis C Virus Recurrence and Idiopathic Thrombocytopenic Purpura after Liver Transplantation in Adult Patients: Role of Splenectomy

Acute thrombocytopenia after liver transplant: role of platelet activation, thrombopoietin deficiency and response to high dose intravenous IgG treatment

BACKGROUND/AIMS

Thrombocytopenia is common after liver transplantation due to platelet sequestration secondary to hypersplenism. The aim of this study was to further investigate the causes of this condition, as well as the response of thrombocytopenia to high dose intravenous immunoglobulins.

METHODS

We retrospectively studied 73 patients who underwent liver transplantation. Out of these 73 patients, 27 had severe thrombocytopenia and were treated with high dose intravenous immunoglobulin. Additionally, we retrospectively studied 8 patients undergoing liver transplantation.

RESULTS

Our data suggest that splenomegaly is not the only factor responsible for thrombocytopenia after liver transplantion and two additional phenomena, namely, reduced platelet production due to reduced thrombopoietin levels and sustained platelets activation take part in the pathogenesis of this condition. The infusion of high dose immunoglobulins induced a safe, prompt, complete and persistent resolution of severe thrombocytopenia in more than 70% of patients.

CONCLUSIONS

Based on these findings, treatment with high dose intravenous immunoglobulins should be considered in the management of severe thrombocytopenia after liver transplant, although additional randomized trials are warranted.

Immune thrombocytopenic purpura following liver transplantation: a case series and review of the literature

Thrombocytopenia is common among liver transplant candidates and recipients. The aim of our study was to determine the incidence and outcome of new-onset immune-mediated thrombocytopenic purpura (ITP) following liver transplantation at a single center. Among the 256 liver transplant recipients with an International Classification of Diseases, Ninth Edition code for thrombocytopenia, 8 cases of new-onset ITP were identified, leading to an overall incidence of 0.7% in 1,105 consecutive liver transplant recipients over a 15-year period. All 8 patients were Caucasian, 5 (63%) were male, and the median age at ITP onset was 54 years (range, 15-63). The median platelet count at presentation was 3,500 cells/mL (range, 1,000-12,000) and liver disease was due to hepatitis C (38%), primary sclerosing cholangitis (38%), and cryptogenic cirrhosis (25%). The median time from transplant to ITP onset was 53.5 months (range, 1.9-173). Three of the 6 patients tested (50%) had cell-bound antiplatelet antibodies, 1 patient had an underlying hematological malignancy, and none of the organ donors had a history of ITP. Corticosteroids and/or immunoglobulin infusions were effective in 4 patients. However, serial rituximab infusions were required in 4 patients with persistent thrombocytopenia, and 3 of them eventually required splenectomy to induce disease remission. At a median follow-up of 19.7 months, 7 long-term survivors remain in remission with a median platelet count of 267,000 cells/mL. In conclusion, new-onset ITP is an infrequent but important cause of severe thrombocytopenia in liver transplant recipients. Corticosteroids and immunoglobulin infusions were effective in 50% while the remainder of patients required rituximab infusions or eventual splenectomy for long-term disease remission.