Nationwide survey in Japan regarding splenectomy/partial splenic embolization for interferon treatment targeting hepatitis C virus-related chronic liver disease in patients with low platelet count

Partial Splenic Embolization in a Patient with Hemophilia A and Severe Thrombocytopenia: A Case Report

We report a patient with hemophilia A who underwent partial splenic embolization (PSE) for severe thrombocytopenia secondary to portal hypertension-induced splenomegaly, resulting in a stable long-term quality of life. The patient was diagnosed with hemophilia A and unfortunately contracted human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) from blood products. He subsequently developed progressive splenomegaly due to portal hypertension from chronic HCV, resulting in severe thrombocytopenia. PSE was performed because he had occasional subcutaneous bleeding and needed to start interferon (IFN) and ribavirin (RBV) treatment for curing his HCV infection at that time. His platelet counts increased, and no serious adverse events were observed. Currently, he continues to receive outpatient treatment, regular factor VIII (FVIII) replacement therapy for hemophilia A, and antiretroviral therapy for HIV infection. Vascular embolization has been reported to be an effective and minimally invasive treatment for bleeding in hemophilia patients. PSE also provided him with a stable quality of life without the side effects of serious infections and thrombocytopenia relapses. We conclude that PSE is a promising therapeutic option for patients with hemophilia A.

Effects of Helicobacter pylori Eradication on the Platelet Count in Hepatitis C Virus-Infected Patients

BACKGROUND

Helicobacter pylori (H. pylori) infection is associated with a low platelet count in patients with immune thrombocytopenic purpura (ITP). While eradication of H. pylori is an established therapy for increasing the platelet count in ITP patients, it is unclear whether or not eradication will similarly affect the platelet counts in patients with chronic liver diseases (CLDs). We herein examined the effect of H. pylori eradication on the platelet counts in hepatitis C virus (HCV)-related CLD patients.

METHODS

A total of 65 patients were enrolled, and the H. pylori-positive patients were treated to eradicate H. pylori. The eradication of H. pylori was assessed using a ¹³C-urea breath test 4 weeks after the completion of the therapy. In addition to the general laboratory variables of HCV-infected patients, including platelet counts, the prothrombin time (PT), and liver function markers (AST, ALT, total bilirubin, alkaline phosphatase, and albumin), we also investigated the presence of splenomegaly via ultrasonography. The platelet counts were measured at 1, 3, and 6 months after the final eradication therapy in order to assess the success of H. pylori eradication.

RESULTS

Of the 65 patients with HCV-related CLD, 30 were found to be H. pylori-positive. The oral treatment regimen succeeded in eliminating H. pylori in 19 patients. These H. pylori-eradicated patients included eight males and 11 females, and 15 (78.9%) had liver cirrhosis. Regarding the patients who failed to achieve H. pylori eradication, their platelet counts did not markedly differ between pre- and post-treatment. Regarding the patients with H. pylori eradication, the platelet counts tended to increase 6 months after the treatment (9.2 ± 2.9 × 10³/μL vs. 10.1 ± 3.7 × 10³/μL, P = 0.085). We also found that the platelet count was significantly increased after the eradication in patients without splenomegaly (9.8 ± 2.8 ×10³/μL vs. 11.0 ± 3.7 ×10³/μL, P = 0.040). Regarding the seven patients whose platelet count increased by more than 20 × 10³/μL after anti-H. pylori treatment, most (6/7, 85.7%) did not have splenomegaly.

CONCLUSION

H. pylori eradication may increase the platelet count in HCV-positive patients, particularly those without splenomegaly.

Telaprevir-based triple therapy following partial splenic arterial embolization for chronic hepatitis C with thrombocytopenia can reduce carcinogenesis and improve hepatic function reserve

Thrombocytopenia in patients with chronic hepatitis C negatively impacts interferon (IFN)-based treatment. The aim of this study was to evaluate the efficacy and safety of telaprevir (TVR)-based triple therapy including IFN for patients who have undergone partial splenic arterial embolization (PSE). Ten patients with thrombocytopenia who were infected with hepatitis C virus (HCV) genotype 1b received 12 weeks of TVR in combination with 24 weeks of pegylated interferon (PEG-IFN)α2b and ribavirin following PSE. A sustained virological response (SVR) was seen in 9 of the 10 patients who could be assessed. Early relapse was seen in 1 patient who had the IL-28B minor allele and a null response to pretreatment. The α-fetoprotein levels of the patients decreased from 17.94±7.30 ng/ml prior to PSE to 4.33±2.41 ng/ml at 6 months after triple therapy (P=0.08). Furthermore, serum albumin levels improved significantly from 3.68±0.49 g/dl pre-PSE to 4.13±0.34 g/dl at 12 months after triple therapy (P=0.043). PSE contributed to the treatment success of triple therapy, particularly for patients who were either treatment-naïve, had a history of relapse or the IL28B major allele. This strategy can reduce carcinogenesis and improve hepatic function reserve.

Effect of spleen operation on antiviral treatment in hepatitis C virus-related cirrhotic patients

AIM: To investigate the impact of spleen operation (SO) on interferon-α (IFN-α)-based antiviral treatment in patients with hepatitis C virus (HCV)-related cirrhosis.

METHODS: Studies were systematically identified by searching electronic databases including MEDLINE, Cochrane Library, Elsevier, and Embase up to September 30, 2013, and relevant clinical studies were reviewed. Sustained virological response (SVR) rate and adherence to therapy were taken as the endpoints of interest.

RESULTS: A total of 603 patients from 16 studies were included in the systematic review. Of 372 patients who underwent SO followed by antiviral treatment, the total SVR rate was 39.5%. SVR was associated with HCV genotypes 2/3 (OR = 10.84; 95%CI: 5.47-21.47; P < 0.00001). IFN-α dose needed to be reduced in 29.4%, and IFN-α-based therapy was discontinued in 11.5% of patients. Analysis of controlled studies showed that SVRs were achieved in 34.1% of patients with SO and 31.1% of patients without SO. SO had no effect on the SVR rate in cirrhotic patients with genotype 1 HCV infection (OR = 1.28; 95%CI: 0.51-3.22; P = 0.60), but improved the SVR rate in patients with genotypes 2/3 infection, though the difference was not significant (OR = 0.36; 95%CI: 0.13-1.02; P = 0.05).

CONCLUSION: SO combined with IFN-α-based antiviral therapy may be suitable in cirrhotic patients with genotypes 2/3 HCV infection, but not in those with genotype 1 infection.

Prognostic effect of response to interferon therapy after laparoscopic splenectomy among patients with marked thrombocytopenia and hepatitis C virus-related cirrhosis

BACKGROUND/PURPOSE

Laparoscopic splenectomy enables patients with marked thrombocytopenia and hepatitis C virus (HCV)-related cirrhosis to receive sufficient interferon-based therapy. The purpose of this study was to evaluate whether the response to interferon after laparoscopic splenectomy contributes to the survival of cirrhotic patients with marked thrombocytopenia.

METHODS

Eighty-seven patients with marked thrombocytopenia and HCV-related cirrhosis who met the inclusion criteria were enrolled. Of the 87 patients, 65 underwent laparoscopic splenectomy for IFN therapy, and 22 patients declined laparoscopic splenectomy and IFN therapy. Finally, 61 patients received IFN therapy after splenectomy, and 26 patients did not receive IFN therapy.

RESULTS

The numbers of patients in the sustained virological response (SVR) group, the transient response (TR) group, the no response (NR) group, and the no interferon (IFN) group were 25, 12, 24, and 26, respectively. Seven-year survival in the SVR group, the TR group, NR group, and the no IFN group was 86, 76, 44, and 42%, respectively. When the response group was defined as the SVR or TR group, survival was significantly higher for the response group than for the other groups. However, there was no significant difference between survival in the NR and no IFN groups. On multivariate analysis, independent factors related to survival were the response to interferon, the presence of esophageal varices, and a history of treatment for hepatocellular carcinoma.

CONCLUSION

A good response to interferon after splenectomy was associated with a favorable prognosis. Therefore, prediction of the efficacy of IFN therapy is crucial before splenectomy.

Thrombocytopenia in pegylated interferon and ribavirin combination therapy for chronic hepatitis C

BACKGROUND

This study aimed to examine the therapeutic effect and prognostic indicators of pegylated interferon (PEG-IFN) and ribavirin (RBV) combination therapy in thrombocytopenic patients with chronic hepatitis C, hepatitis C virus (HCV)-related cirrhosis, and those who underwent splenectomy or partial splenic embolization (PSE).

METHODS

Of 326 patients with HCV-related chronic liver disease (252 with genotype 1b and 74 with genotype 2a/2b) treated with PEG-IFN/RBV, 90 were diagnosed with cirrhosis.

RESULTS

Regardless of the degree of thrombocytopenia, the administration rate was significantly higher in the splenectomy/PSE group compared to the cirrhosis group. However, in patients with genotype 1b, the sustained virological response (SVR) rate was significantly lower in the cirrhosis and the splenectomy/PSE groups compared to the chronic hepatitis group. No cirrhotic patients with platelets less than 80,000 achieved an SVR. Patients with genotype 2a/2b were more likely to achieve an SVR than genotype 1b. Prognostic factors for SVR in patients with genotype 1b included the absence of esophageal and gastric varices, high serum ALT, low AST/ALT ratio, and the major homo type of the IL28B gene. Splenectomy- or PSE-facilitated induction of IFN in patients with genotype 2a/2b was more likely to achieve an SVR by an IFN dose maintenance regimen. Patients with genotype 1b have a low SVR regardless of splenectomy/PSE. In particular, patients with a hetero/minor type of IL28B did not have an SVR.

CONCLUSIONS

Splenectomy/PSE for IFN therapy should be performed in patients expected to achieve a treatment response, considering their genotype and IL28B.