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Rasizadeh R, Ebrahimi F, Zamani Kermanshahi A, Daei Sorkhabi A, Sarkesh A, Sadri Nahand J, Bannazadeh Baghi H. Viruses and thrombocytopenia. Heliyon 2024; 10:e27844. [PMID: 38524607 PMCID: PMC10957440 DOI: 10.1016/j.heliyon.2024.e27844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Thrombocytopenia, characterized by a decrease in platelet count, is a multifaceted clinical manifestation that can arise from various underlying causes. This review delves into the intriguing nexus between viruses and thrombocytopenia, shedding light on intricate pathophysiological mechanisms and highlighting the pivotal role of platelets in viral infections. The review further navigates the landscape of thrombocytopenia in relation to specific viruses, and sheds light on the diverse mechanisms through which hepatitis C virus (HCV), measles virus, parvovirus B19, and other viral agents contribute to platelet depletion. As we gain deeper insights into these interactions, we move closer to elucidating potential therapeutic avenues and preventive strategies for managing thrombocytopenia in the context of viral infections.
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Affiliation(s)
- Reyhaneh Rasizadeh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Animal Biology, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran
| | - Fatemeh Ebrahimi
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Amin Daei Sorkhabi
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aila Sarkesh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javid Sadri Nahand
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Bannazadeh Baghi
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Koschade SE, Moser LM, Sokolovskiy A, Michael FA, Serve H, Brandts CH, Finkelmeier F, Zeuzem S, Trebicka J, Ferstl P, Ballo O. Bone Marrow Assessment in Liver Cirrhosis Patients with Otherwise Unexplained Peripheral Blood Cytopenia. J Clin Med 2023; 12:4373. [PMID: 37445409 DOI: 10.3390/jcm12134373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
We performed a retrospective single-center analysis to investigate the diagnostic yield of bone marrow puncture in patients with liver cirrhosis and cytopenia. Liver cirrhosis patients receiving bone marrow aspiration or biopsy for the diagnostic work-up of otherwise unexplained peripheral blood cytopenia at our institution between 2004 and 2020 were enrolled in this study. We evaluated findings from cytologic, histologic and immunologic assessment and final diagnostic outcomes. A total of 118 patients with a median age of 55 years and a median Child-Pugh score of B (8 points) were enrolled. The main etiologies of liver cirrhosis were viral hepatitis (B and C) or chronic alcohol consumption. The majority of patients (60%) exhibited concurrent anemia, leukocytopenia and thrombocytopenia. Bone marrow assessment revealed normal, unspecific or reactive alterations in 117 out of 118 patients (99%). One patient was diagnosed with myelodysplastic syndrome. Our findings suggest that peripheral blood cytopenia in patients with liver cirrhosis is rarely associated with a primary bone marrow pathology.
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Affiliation(s)
- Sebastian E Koschade
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Laura M Moser
- Department for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Artur Sokolovskiy
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Florian A Michael
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Christian H Brandts
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Jonel Trebicka
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
- Department of Internal Medicine B, University of Münster, 48149 Münster, Germany
| | - Philip Ferstl
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Olivier Ballo
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
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Tajiri K, Okada K, Ito H, Kawai K, Kashii Y, Tokimitsu Y, Muraishi N, Murayama A, Hayashi Y, Minemura M, Takahara T, Shimizu Y, Yasuda I. Long term changes in thrombocytopenia and leucopenia after HCV eradication with direct-acting antivirals. BMC Gastroenterol 2023; 23:182. [PMID: 37231349 DOI: 10.1186/s12876-023-02829-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/22/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Thrombocytopenia due to hypersplenism is a major complication of hepatitis C virus (HCV)-associated cirrhosis. HCV eradication improves these complications in some patients, but the long-term effects of HCV eradication on these complications remain unclear, especially in patients treated with direct acting antivirals (DAAs). The aim was to evaluate long term changes in thrombocytopenia and leucopenia after HCV eradication with DAAs. METHODS The present multicenter study retrospectively evaluated changes over 5 years in thrombocytopenia and leukocytopenia, as well as changes in liver fibrosis markers and spleen size, in 115 patients with HCV-cirrhosis treated with DAAs. RESULTS Thrombocytopenia and leukocytopenia were improved 4 weeks after DAA administration, with thrombocytopenia show further gradual improvement over the next year. Fib-4 index was markedly reduced 1 year after DAA, followed by subsequent gradual reduction over the next 4 years. Spleen size showed gradual annual reductions, with patients experiencing spleen size reduction characterized at baseline by bilirubinemia. CONCLUSIONS Rapid DAA-associated HCV eradication might lead to rapid disappearance of liver inflammation and bone marrow suppression due to HCV infection. HCV eradication may gradually improve portal hypertension, reducing spleen size.
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Affiliation(s)
- Kazuto Tajiri
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan.
| | - Kazuhiko Okada
- Gastroenterology, Toyama Red Cross Hospital, Toyama, 930-8562, Japan
| | - Hiroyuki Ito
- Gastroenterology, Takaoka Municipal Hospital, Takaoka, 933-8550, Japan
| | - Kengo Kawai
- Gastroenterology, Nanto Municipal Hospital, Nanto, 932-0211, Japan
| | - Yoshiro Kashii
- Gastroenterology, Saiseikai Toyama Hospital, Toyama, 931-8533, Japan
| | | | - Nozomu Muraishi
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
| | - Aiko Murayama
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
| | - Yuka Hayashi
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
| | - Masami Minemura
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
| | - Terumi Takahara
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
| | - Yukihiro Shimizu
- Gastroenterology, Nanto Municipal Hospital, Nanto, 932-0211, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, 2630 Sugitani, 930-0194, Japan
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Hatanaka T, Kakizaki S, Hiraoka A, Tada T, Hirooka M, Kariyama K, Tani J, Atsukawa M, Takaguchi K, Itobayashi E, Fukunishi S, Tsuji K, Ishikawa T, Tajiri K, Ochi H, Yasuda S, Toyoda H, Ogawa C, Nishimura T, Shimada N, Kawata K, Kosaka H, Tanaka T, Ohama H, Nouso K, Morishita A, Tsutsui A, Nagano T, Itokawa N, Okubo T, Arai T, Imai M, Naganuma A, Koizumi Y, Nakamura S, Joko K, Kaibori M, Iijima H, Hiasa Y, Kumada T. Comparative efficacy and safety of atezolizumab and bevacizumab between hepatocellular carcinoma patients with viral and non-viral infection: A Japanese multicenter observational study. Cancer Med 2023; 12:5293-5303. [PMID: 36226511 PMCID: PMC10028018 DOI: 10.1002/cam4.5337] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/12/2022] [Accepted: 09/26/2022] [Indexed: 11/08/2022] Open
Abstract
AIM This study compared the efficacy and safety of atezolizumab and bevacizumab (Atez/Bev) in patients with viral and non-viral infection in clinical settings. METHODS We conducted the retrospective cohort study of 323 BCLC stage B or C hepatocellular carcinoma (HCC) patients with Child-Pugh class A, and a performance status of 0 or 1 who started Atez/Bev from September 2020 to December 2021 at 22 institutions in Japan. Patients with viral infection was defined as those who were either serum anti-HCV- Ab or HBs-Ag-positive, while patients with non-viral infection was defined as those who were both serum anti-HCV Ab- and HBs-Ag-negative. We constructed a propensity-score-matched cohort to minimize the risk of observable potential confounders. RESULTS Propensity score matching produced 126 matched pairs for patients with viral versus non-viral infection. After matching, the significant differences in baseline demographic features did not exist between the two groups. The objective response rate was 20.6% and 24.6% in viral- and non-viral-related HCC patients, respectively, without a significant difference (p = 0.55). The disease control rate was not also significantly different (68.3% vs 69.0%, p = 1.00). The median progression-free survival was 7.0 months (95% confidence interval [CI] 6.0-9.6) and 6.2 months (95% CI 5.1-7.8) in patients with viral and non-viral infection, and the 12-month survival rates were 65.5% (95% CI 50.8-76.8) and 71.7% (95% CI 57.3-81.9) in those with viral and non-viral infection, respectively, which were not significantly different (p = 0.33, p = 0.38). No significant difference in treatment-related adverse events was found between the two groups. CONCLUSIONS Our etiology-based study demonstrated that Atez/Bev showed good efficacy and safety for HCC patient with non-viral infection as well as those with viral infection.
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Affiliation(s)
- Takeshi Hatanaka
- Department of Gastroenterology, Gunma Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Satoru Kakizaki
- Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Toshifumi Tada
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Himeji, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Kazuya Kariyama
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Joji Tani
- Department of Gastroenterology and Hepatology, Kagawa University, Kagawa, Japan
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Koichi Takaguchi
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Ei Itobayashi
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Shinya Fukunishi
- Premier Departmental Research of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiko Tsuji
- Center of Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Toru Ishikawa
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Kazuto Tajiri
- Department of Gastroenterology, Toyama University Hospital, Toyama, Japan
| | - Hironori Ochi
- Center for Liver-Biliary-Pancreatic Disease, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Satoshi Yasuda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Chikara Ogawa
- Department of Gastroenterology, Japanese Red Cross Takamatsu Hospital, Takamatsu, Japan
| | - Takashi Nishimura
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Noritomo Shimada
- Division of Gastroenterology and Hepatology, Otakanomori Hospital, Kashiwa, Japan
| | - Kazuhito Kawata
- Hepatology Division, Department of Internal Medicine II, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Takaaki Tanaka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Hideko Ohama
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Kazuhiro Nouso
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Hepatology, Kagawa University, Kagawa, Japan
| | - Akemi Tsutsui
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Takuya Nagano
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Norio Itokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Tomomi Okubo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Michitaka Imai
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Atsushi Naganuma
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Shinichiro Nakamura
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Himeji, Japan
| | - Kouji Joko
- Center for Liver-Biliary-Pancreatic Disease, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Masaki Kaibori
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Hiroko Iijima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Takashi Kumada
- Department of Nursing, Gifu Kyoritsu University, Ogaki, Japan
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5
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Omer S, Iftime A, Constantinescu I, Dina I. Low-Cost Predictors for Liver Function and Clinical Outcomes after Sustained Virological Response in Patients with HCV-Related Cirrhosis and Thrombocytopenia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010146. [PMID: 36676770 PMCID: PMC9865508 DOI: 10.3390/medicina59010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/14/2023]
Abstract
Background and Objectives: To find low-cost markers that can identify the hepatitis C virus cirrhotic patients that are at risk for long-term severe adverse liver effects (ascites, ascites or upper gastrointestinal bleeding, hepatocellular carcinoma), after treatment. There is established evidence for the benefits of treating hepatitis C virus cirrhotic patients, but there is still some need for clarification concerning the real impact on the long-term evolution after achieving sustained virological response; there is no general consensus in the literature about identifying the patients that do not improve post-treatment. Materials and Methods: Our retrospective analysis investigated the long-term (2 years) evolution of 46 patients with cirrhosis with thrombocytopenia, previously infected with VHC, treated and who obtained an SVR after DAA treatment. Results: Despite the overall improvement, 8.7% patients developed hepatocellular carcinoma and 6.5% patients ascites/upper GI bleeding. We found that FIB-4, MELD and AFP changes at 1 year were the most significant predictors for these outcomes. Additionally, a drop in leukocyte count after 1 year seemed to indicate a risk for hepatocellular carcinoma, but this was not consistent. Conclusions: It might be beneficial to intensify the surveillance for post-treatment adverse liver effects for the patients with these marker changes at 1 year.
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Affiliation(s)
- Secil Omer
- Department of Medical Semiology, Saint Joan Hospital Bucharest, Carol Davila University of Medicine, 042122 Bucharest, Romania
| | - Adrian Iftime
- Department of Biophysics, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence:
| | - Ileana Constantinescu
- Department of Immunology and Transplant Immunology, Fundeni Clinical Institute Bucharest, Carol Davila University of Medicine, 022328 Bucharest, Romania
| | - Ion Dina
- Department of Medical Semiology, Saint Joan Hospital Bucharest, Carol Davila University of Medicine, 042122 Bucharest, Romania
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Chen YC, Chang TS, Chen CH, Cheng PN, Lo CC, Mo LR, Chen CT, Huang CF, Kuo HT, Huang YH, Tai CM, Peng CY, Bair MJ, Yeh ML, Lin CL, Lin CY, Lee PL, Chong LW, Hung CH, Huang JF, Yang CC, Hu JT, Lin CW, Wang CC, Su WW, Hsieh TY, Lin CL, Tsai WL, Lee TH, Chen GY, Wang SJ, Chang CC, Yang SS, Wu WC, Huang CS, Hsiung CK, Kao CN, Tsai PC, Liu CH, Lee MH, Dai CY, Kao JH, Chuang WL, Lin HC, Chen CY, Tseng KC, Yu ML. Factors Associated with Significant Platelet Count Improvement in Thrombocytopenic Chronic Hepatitis C Patients Receiving Direct-Acting Antivirals. Viruses 2022; 14:333. [PMID: 35215926 PMCID: PMC8879038 DOI: 10.3390/v14020333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022] Open
Abstract
To clarify the predictive factors of significant platelet count improvement in thrombocytopenic chronic hepatitis C (CHC) patients. CHC patients with baseline platelet counts of <150 × 103/μL receiving direct-acting antiviral (DAA) therapy with at least 12-weeks post-treatment follow-up (PTW12) were enrolled. Significant platelet count improvement was defined as a ≥10% increase in platelet counts at PTW12 from baseline. Platelet count evolution at treatment week 4, end-of-treatment, PTW12, and PTW48 was evaluated. This study included 4922 patients. Sustained virologic response after 12 weeks post-treatment was achieved in 98.7% of patients. Platelet counts from baseline, treatment week 4, and end-of-treatment to PTW12 were 108.8 ± 30.2, 121.9 ± 41.1, 123.1 ± 43.0, and 121.1 ± 40.8 × 103/μL, respectively. Overall, 2230 patients (45.3%) showed significant platelet count improvement. Multivariable analysis revealed that age (odds ratio (OR) = 0.99, 95% confidence interval (CI): 0.99-1.00, p = 0.01), diabetes mellitus (DM) (OR = 1.20, 95% CI: 1.06-1.38, p = 0.007), cirrhosis (OR = 0.66, 95% CI: 0.58-0.75, p < 0.0001), baseline platelet counts (OR = 0.99, 95% CI: 0.98-0.99, p < 0.0001), and baseline total bilirubin level (OR = 0.80, 95% CI: 0.71-0.91, p = 0.0003) were independent predictive factors of significant platelet count improvement. Subgroup analyses showed that patients with significant platelet count improvement and sustained virologic responses, regardless of advanced fibrosis, had a significant increase in platelet counts from baseline to treatment week 4, end-of-treatment, PTW12, and PTW48. Young age, presence of DM, absence of cirrhosis, reduced baseline platelet counts, and reduced baseline total bilirubin levels were associated with significant platelet count improvement after DAA therapy in thrombocytopenic CHC patients.
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Affiliation(s)
- Yen-Chun Chen
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi School of Medicine, Tzuchi University, Hualien 970, Taiwan;
| | - Te-Sheng Chang
- Division of Hepatogastroenterology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (T.-S.C.); (C.-H.H.)
| | - Chien-Hung Chen
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 333, Taiwan;
| | - Pin-Nan Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Ching-Chu Lo
- Division of Gastroenterology, Department of Internal Medicine, St. Martin De Porres Hospital, Chiayi 600, Taiwan;
| | - Lein-Ray Mo
- Division of Gastroenterology, Tainan Municipal Hospital, Tainan 701, Taiwan;
| | - Chun-Ting Chen
- Division of Gastroenterology, Department of Internal Medicine Tri-Service General Hospital Penghu Branch, National Defense Medical Center, Taipei 114, Taiwan;
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-F.H.); (P.-C.T.); (C.-Y.D.); (W.-L.C.)
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
| | - Hsing-Tao Kuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi Mei Medical Center, Yongkang District, Tainan 710, Taiwan;
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (Y.-H.H.); (H.-C.L.)
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chi-Ming Tai
- Department of Internal Medicine, E-Da Hospital, Kaohsiung 824, Taiwan;
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 824, Taiwan
| | - Cheng-Yuan Peng
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung 406, Taiwan;
| | - Ming-Jong Bair
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taitung 950, Taiwan;
- Mackay Medical College, New Taipei City 252, Taiwan
| | - Ming-Lun Yeh
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Chih-Lang Lin
- Department of Gastroenterology and Hepatology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan;
| | - Chun-Yen Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Linkou 333, Taiwan;
- Graduate Institute of Biomedical Science, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Pei-Lun Lee
- Chi Mei Medical Center, Liouying Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tainan 736, Taiwan;
| | - Lee-Won Chong
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan;
- School of Medicine, Fu-Jen Catholic University, New Taipei City 242, Taiwan
| | - Chao-Hung Hung
- Division of Hepatogastroenterology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (T.-S.C.); (C.-H.H.)
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 333, Taiwan;
| | - Jee-Fu Huang
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Chi-Chieh Yang
- Department of Gastroenterology, Division of Internal Medicine, Show Chwan Memorial Hospital, Changhua 500, Taiwan;
| | - Jui-Ting Hu
- Liver Center, Cathay General Hospital, Taipei 106, Taiwan;
| | - Chih-Wen Lin
- Division of Gastroenterology and Hepatology, E-Da Dachang Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung 824, Taiwan;
| | - Chia-Chi Wang
- Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, New Taipei City 231, Taiwan;
| | - Wei-Wen Su
- Department of Gastroenterology and Hepatology, Changhua Christian Hospital, Changhua 500, Taiwan;
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Chih-Lin Lin
- Department of Gastroenterology, Renai Branch, Taipei City Hospital, Taipei 106, Taiwan;
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan;
| | - Tzong-Hsi Lee
- Division of Gastroenterology and Hepatology, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan;
| | - Guei-Ying Chen
- Penghu Hospital, Ministry of Health and Welfare, Penghu 880, Taiwan;
| | - Szu-Jen Wang
- Division of Gastroenterology, Department of Internal Medicine, Yuan’s General Hospital, Kaohsiung 802, Taiwan;
| | - Chun-Chao Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan;
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Sheng-Shun Yang
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan;
| | | | | | | | - Chien-Neng Kao
- National Taiwan University Hospital Hsin-Chu Branch, Hsinchu 300, Taiwan;
| | - Pei-Chien Tsai
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-F.H.); (P.-C.T.); (C.-Y.D.); (W.-L.C.)
| | - Chen-Hua Liu
- Hepatitis Research Center, Department of Internal Medicine, National Taiwan University Hospital, Taipei 106, Taiwan; (C.-H.L.); (J.-H.K.)
| | - Mei-Hsuan Lee
- Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei 112, Taiwan;
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-F.H.); (P.-C.T.); (C.-Y.D.); (W.-L.C.)
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
| | - Jia-Horng Kao
- Hepatitis Research Center, Department of Internal Medicine, National Taiwan University Hospital, Taipei 106, Taiwan; (C.-H.L.); (J.-H.K.)
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-F.H.); (P.-C.T.); (C.-Y.D.); (W.-L.C.)
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (Y.-H.H.); (H.-C.L.)
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chi-Yi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 600, Taiwan;
| | - Kuo-Chih Tseng
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi School of Medicine, Tzuchi University, Hualien 970, Taiwan;
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-F.H.); (P.-C.T.); (C.-Y.D.); (W.-L.C.)
- School of Medicine and Hepatitis Research Center, College of Medicine, Center for Cancer Research, Center for Liquid Biopsy, Cohort Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (M.-L.Y.); (J.-F.H.)
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung 804, Taiwan
- National Pingtung University of Science and Technology, Pingtung 912, Taiwan
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Huang CE, Chang JJ, Wu YY, Huang SH, Chen WM, Hsu CC, Lu CH, Hung CH, Shi CS, Lee KD, Chen CC, Chen MC. Different impacts of common risk factors associated with thrombocytopenia in patients with hepatitis B virus and hepatitis C virus infection. Biomed J 2021; 45:788-797. [PMID: 34508913 DOI: 10.1016/j.bj.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/21/2021] [Accepted: 09/01/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Thrombocytopenia is a common extrahepatic manifestation in chronic liver disease. However, there have been rare studies of impacts of risk for hepatitis C virus-associated thrombocytopenia (HCV-TP) and hepatitis B virus-associated thrombocytopenia (HBV-TP). The aim of this study is to evaluate different impacts of risk factors for HCV-TP and HBV-TP. MATERIAL AND METHODS We retrospectively collected 1803 HCV patients and 1652 HBV patients to examine the risk factors for time to moderate and severe thrombocytopenia (platelet counts <100 × 109/L and <50 × 109/L, respectively) by Cox proportional hazards models. Moreover, we prospectively enrolled 63 HCV-TP patients, 11 HBV-TP patients, and 27 HCV controls to detect specific antiplatelet antibodies by enzyme-linked immunosorbent assay and analyze their effects. RESULTS Prevalence of platelet <100 × 109/L was 11.86% and 6.35% in HCV and HBV patients without cancer history, respectively. HCV-to-HBV incidence rate ratio for thrombocytopenia was 6.95. Initial thrombocytopenia was the most significant risk factor for HCV-TP and HBV-TP regardless of thrombocytopenia severity. Splenomegaly and cirrhosis were significant risk factors for moderate, but not severe HCV-TP. Hyperbilirubinemia was an important moderate and severe HBV-TP risk factor. Antiplatelet antibodies were correlated with HCV-TP severity, of which anti-glycoprotein IIb/IIIa antibody being associated with smaller spleen size. This antiplatelet autoantibody might contribute thrombocytopenia either independently or with splenomegaly as the important risk in HCV-TP patients without advanced cirrhosis. CONCLUSION HCV was associated with higher thrombocytopenia incidence than HBV. Thrombocytopenia risk factors varied with virus type and severity. Different management for HCV-TP and HBV-TP was suggested.
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Affiliation(s)
- Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Jung-Jung Chang
- Division of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Ying Wu
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shih-Hao Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Public Health and Biostatistics Consulting Center, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Ming Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Chen Hsu
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chang-Hsien Lu
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chao-Hung Hung
- Division of Gastroenterology and Hepatology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Sheng Shi
- Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Der Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Cheng Chen
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Min-Chi Chen
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Public Health and Biostatistics Consulting Center, Chang Gung University, Taoyuan, Taiwan.
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8
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Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, Violi F. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest 2021; 51:e13508. [PMID: 33539542 PMCID: PMC8244048 DOI: 10.1111/eci.13508] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease. METHODS In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome. RESULTS The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy. CONCLUSIONS Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Caporaso
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Angelo Iacobellis
- Division of Gastroenterology, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | | | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Azienda Sanitaria Universitaria Integrata, Academic Hospital, Udine, Italy
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Effect of Direct-Acting Antiviral Therapy on Thrombocytopenic Patients with Hepatitis C Virus-Related Chronic Liver Disease. Gastroenterol Res Pract 2021; 2021:8811203. [PMID: 34122539 PMCID: PMC8169259 DOI: 10.1155/2021/8811203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/25/2021] [Accepted: 04/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Aims Thrombocytopenia is a common complication in patients with chronic hepatitis C virus (HCV) that increases the risk of bleeding. We aimed to analyze the hematologic effects of the new direct-acting antiviral (DAA) therapy, particularly on the platelet count in chronic HCV-infected patients with thrombocytopenia. Patients and Methods. One hundred thrombocytopenic patients chronically infected with HCV were included in a prospective study. All patients were eligible for receiving anti-HCV treatment with sofosbuvir-based regimens for 12 weeks, according to the protocol of the National Program for treatment of HCV in Egypt sponsored by the Ministry of Health. Results At the end of treatment (EOT), there was a highly significant increase in platelet count (p < 0.001), a significant increase in white blood cells (WBCs) count (p ≤ 0.032), and a highly significant decrease in hemoglobin level (p < 0.001) as compared to pretreatment levels. Patients with mild to moderate hepatic fibrosis had significantly higher median and interquartile range (IQR) platelet count at baseline and EOT than those with advanced fibrosis and cirrhosis (p ≤ 0.023 and p < 0.001, respectively). There was more elevation in platelet count at EOT in patients with mild to moderate fibrosis than those with advanced fibrosis and cirrhosis. Out of the hundred patients, 73% showed improvement of platelet count, while 27% showed no improvement or even decrease in the platelet count. Conclusion Sofosbuvir-based DAA therapy is a highly effective and safe treatment regimen that results in the improvement of platelet count in thrombocytopenic patients, particularly in mild to moderate stages of hepatic fibrosis.
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10
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Ramzy I, Fouad R, Salama R, Abdellatif Z, Elsharkawy A, Zayed N, Elsharkawy M, El Akel W, Bakheet N. Evaluation of red cell distribution width to platelet ratio as a novel non-invasive index for predicting hepatic fibrosis in patients with chronic hepatitis C. Arab J Gastroenterol 2021; 22:6-11. [PMID: 33664008 DOI: 10.1016/j.ajg.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/03/2020] [Accepted: 12/28/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIMS Assessing the extent of fibrosis is an essential part of therapeutic decisions in patients with chronic hepatitis C (CHC). Liver biopsies are the "gold standard" for evaluating liver fibrosis but have many limitations. Thus, noninvasive predictors of fibrosis have been developed. This study aimed to determine the effectiveness of red cell distribution width (RDW) to platelet ratio as a simple noninvasive method for predicting the hepatic fibrosis stage in patients with CHC. PATIENTS AND METHODS This cross-sectional study included 197 Egyptian patients with CHC. A routine pretreatment reference needle liver biopsy was performed. Fib-4, transient elastography (TE) by Fibroscan, AST to Platelet Ratio Index (APRI), and RDW to platelet ratio (RPR) were measured. Predictors of significant fibrosis (Metavir score ≥ F2) and advanced fibrosis (Metavir score ≥ F3) were identified. RESULTS Fib-4, TE, APRI, and RPR values differed significantly when comparing different stages of fibrosis (p < 0.01). Fib-4, TE, APRI, and RPR were reliable diagnostic tools at cutoff values of 1.17, 7.75, 0.18, and 0.07, respectively, for predicting significant fibrosis and cutoff values of 1.99, 8, 1.77, and 0.08, respectively, for predicting advanced fibrosis. Using logistic regression analysis, TE was identified as an independent predictor associated with significant and advanced fibrosis. Fib-4 was significantly associated with advanced fibrosis only. CONCLUSION The use of Fib-4, TE, APRI, and RPR measurements may decrease the need for liver biopsies for predicting significant and advanced fibrosis. RPR showed fair sensitivity, specificity, positive and negative predictive values, and overall accuracy for predicting significant fibrosis in patients with CHC.
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Affiliation(s)
- Iman Ramzy
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rabab Fouad
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rabab Salama
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Zeinab Abdellatif
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Aisha Elsharkawy
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Naglaa Zayed
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Marwa Elsharkawy
- Clinical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wafaa El Akel
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nader Bakheet
- Endemic Medicine and Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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11
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Eltrombopag inhibits Type I interferon-mediated antiviral signaling by decreasing cellular iron. Biochem Pharmacol 2021; 186:114436. [PMID: 33539815 DOI: 10.1016/j.bcp.2021.114436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
Thrombocytopenia is common among patients with viral hepatitis, limiting the use of antiviral therapy. Eltrombopag (EP) is a thrombopoietin receptor (TPO-R) agonist that has been approved for treatment of immune thrombocytopenia patients with hepatitis virus infection. Interferon-α (IFN-α) plays a crucial role in the antiviral response, and is recommended as the first-line agent for chronic hepatitis B patients. Here, we investigated whether EP inhibits the production of IFN-stimulated genes (ISGs) induced by IFN-α through the TPO-R-independent pathway by mediating reactive oxygen species production by iron chelation. Our results assessed the inhibitory effect of EP on IFN-α signaling, which contributes to the downregulation of ISGs produced by monocytes and sheds light on the underlying mechanisms using iron chelation to treat patients with hepatitis-related immunological thrombocytopenia.
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12
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Baseline thrombopoietin level is associated with platelet count improvement in thrombocytopenic chronic hepatitis C patients after successful direct-acting antiviral agent therapy. BMC Gastroenterol 2021; 21:30. [PMID: 33478399 PMCID: PMC7818549 DOI: 10.1186/s12876-021-01606-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Thrombocytopenia can rapidly improve in chronic hepatitis C (CHC) patients receiving direct-acting antiviral agents (DAA). The role of baseline (BL) thrombopoietin (TPO) in this phenomenon is unclear. METHODS From June 2016 to February 2019, a total of 104 CHC patients receiving DAA, with a sustained virologic response and BL thrombocytopenia, at Dalin Tzu Chi Hospital, were enrolled in this retrospective study. Significant platelet count improvement and platelet count improvement ratio were analyzed for correlation with BL TPO. RESULTS This cohort included 40 men (38.5%). Seventy-two (69.2%) patients had advanced fibrosis. The platelet count [median (range)] increased from 110.5 (32-149) × 103/µL at BL to 116.5 (40-196) and 118.0 (35-275) × 103/µL at end of treatment (EOT) and 12 weeks after EOT (P12), respectively, (EOT vs. BL, P < 0.001; P12 vs. BL, P < 0.001). BL TPO was positively correlated with significant platelet count improvement (P < 0.001), platelet count improvement ratio at EOT (P = 0.004), and P12 (P < 0.001). The area under the receiver operating characteristic curve and optimal cutoffs (pg/ml) were 0.77 (95% confidence interval, 0.67-0.86) and 120, respectively, for significant platelet count improvement prediction. The sensitivity, specificity, and accuracy were 88.6%, 71.7%, and 78.8%, respectively. CONCLUSIONS BL TPO level might be a useful marker for predicting significant platelet count improvement in thrombocytopenic patients after successful DAA therapy.
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13
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Jali AGP, Nkambule BB. Prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary and quaternary centre in KwaZulu-Natal. Afr J Lab Med 2020; 9:799. [PMID: 32934907 PMCID: PMC7479432 DOI: 10.4102/ajlm.v9i1.799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/02/2020] [Indexed: 11/12/2022] Open
Abstract
Background Thrombocytopenia is a common haematological disorder, characterised by platelet counts below 150 × 109/L. The aetiology of thrombocytopenia is multifactorial; notably, in a misdiagnosis this condition may be due to pre-analytical laboratory artefacts. Knowledge about the common aetiology of thrombocytopenia will assist clinicians in decision-making and interpretation of laboratory tests and this may lead to prompt, adequate patient management and cost-saving measures. Objective This study determined the prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary or quaternary laboratory in Durban, KwaZulu-Natal, South Africa. Methods We conducted a retrospective study at the Inkosi Albert Luthuli Central Hospital haematology laboratory between October 2015 and April 2016. A total of 2076 full blood count results with a platelet count of less than 100 × 109/L were retrieved from the Inkosi Albert Luthuli Academic Hospital database. Laboratory data were extracted and matched with clinical data and used to identify the potential aetiology of thrombocytopenia. Results The prevalence of thrombocytopenia was 14.9% within the selected study period. The haematology or oncology wards and clinic accounted for 55.2% of thrombocytopenia cases, whereas the adult and paediatric intensive care units accounted for 29.3%. Notably, 15.5% of thrombocytopenia cases were reported in non-haematology wards and clinics. The most common cause of thrombocytopenia was chemotherapy which accounted for 38.5% of all causes. Conclusion In our tertiary and quaternary setting, thrombocytopenia in adults was most common in patients admitted to haematology and oncology wards. Moreover, chemotherapy-induced thrombocytopenia accounted for more than a third of all these cases.
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Affiliation(s)
- Ayanda G P Jali
- Department of Haematology, Health King Edward VIII Hospital, University of Kwa-Zulu Natal, Durban, South Africa.,Department of Haematology, National Health Laboratory service, Inkosi Albert Luthuli Academic Hospital, Durban, South Africa
| | - Bongani B Nkambule
- Department of Human Physiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
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14
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Rawi S, Wu GY. Pathogenesis of Thrombocytopenia in Chronic HCV Infection: A Review. J Clin Transl Hepatol 2020; 8:184-191. [PMID: 32832399 PMCID: PMC7438357 DOI: 10.14218/jcth.2020.00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 12/12/2022] Open
Abstract
A large proportion of patients with chronic hepatitis C have associated thrombocytopenia (TCP). Due to bleeding risks, TCP, when severe, can limit diagnostic and therapeutic procedures, treatments, and increases risk of complications, especially excessive bleeding. It is important to understand the mechanisms that cause TCP in order to manage it. In general, TCP can be due to increased destruction or decreased production. Proposed mechanisms of increased destruction include autoantibodies to platelets and hypersplenism with sequestration. Proposed mechanisms of decreased production include virus-induced bone marrow suppression and decreased TPO production. Autoantibodies directed against platelet surface antigens have demonstrated an inverse correlation with platelet counts. Hypersplenism with sequestration involves the interaction of portal hypertension, splenomegaly, and platelet destruction. Decreased production mechanisms involve appropriate and inappropriate levels of TPO secretion. There is limited evidence to support viral-induced bone marrow suppression. In contrast, there is strong evidence to support low levels of TPO in liver failure as a major cause of TCP. TPO-agonists, specifically eltrombopag, have been shown in hepatitis C patients to increase platelet counts without reducing portal hypertension or splenomegaly. We conclude that TCP in hepatitis C virus-induced liver disease is often multifactorial, but an understanding of the mechanisms can lead to judicious use of new drugs for treatment.
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Affiliation(s)
- Sarah Rawi
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Sarah Rawi, Department of Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06032, USA. Tel: +1-858-692-2372, E-mail:
| | - George Y Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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15
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Chen YC, Tseng CW, Tseng KC. Rapid platelet count improvement in chronic hepatitis C patients with thrombocytopenia receiving direct-acting antiviral agents. Medicine (Baltimore) 2020; 99:e20156. [PMID: 32384505 PMCID: PMC7220127 DOI: 10.1097/md.0000000000020156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The effect of direct-acting antiviral agents (DAAs) on short-term platelet improvement in chronic hepatitis C (CHC) patients with thrombocytopenia is unclear.From December 2015 to March 2018, a total of 249 CHC patients receiving DAA treatment with baseline thrombocytopenia (platelet count <150 × 10 /μL) at Dalin Tzu Chi Hospital were enrolled in this retrospective study. Blood examinations were conducted at baseline (BL), week 4 (W4) after DAA initiation, end of treatment (EOT), and 12 weeks after EOT (P12).Hepatitis C virus (HCV) genotyping revealed that 184 patients (73.9%) carried HCV genotype 1. Of the patients in the cohort, 87 (34.9%) were interferon (IFN)-experienced, and 213 (85.5%) had advanced fibrosis. All but 1 patient achieved SVR12 (sustained virologic response (SVR) rate, 99.6%; 248/249). The platelet count recovered significantly in 104 patients (41.7%; 104/249). The mean baseline platelet count was 102 × 10/μL before DAA, increasing to 116 × 10/μL, 114 × 10/μL, and 113 × 10/μL at W4, EOT, and P12, respectively. Comparison of the mean platelet count at baseline with that at W4, EOT, and P 12 showed statistically significant increases at all time points (W4 vs BL, P < .001; EOT vs BL, P < .001; P12 vs BL, P < .001). Multivariate analyses revealed moderate or severe fatty liver (P = .024) and lower baseline platelet count (P = .005) was significantly associated with platelet count improvement.In conclusion, thrombocytopenia associated with CHC rapidly improves with the administration of DAA. Moderate or severe fatty liver and lower baseline platelet count predict significant improvement of platelet count.
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Affiliation(s)
- Yen-Chun Chen
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
| | - Chih-Wei Tseng
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
- School of Medicine, Tzuchi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
- School of Medicine, Tzuchi University, Hualien, Taiwan
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Hsu W, Peng C, Su W, Lai H, Lin C, Chuang P, Chen S, Chen H, Wang H, Huang G. Treatment with direct‐acting antiviral agents is associated with increased platelet count in patients with chronic hepatitis C. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Wei‐Fan Hsu
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Cheng‐Yuan Peng
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
- School of MedicineChina Medical University Taichung Taiwan
| | - Wen‐Pang Su
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Hsueh‐Chou Lai
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
- School of Chinese MedicineChina Medical University Taichung Taiwan
| | - Chia‐Hsin Lin
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Po‐Heng Chuang
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Sheng‐Hung Chen
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
- School of MedicineChina Medical University Taichung Taiwan
| | - Hung‐Yao Chen
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Hung‐Wei Wang
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
| | - Guan‐Tarn Huang
- Division of Hepatogastroenterology, Department of Internal MedicineChina Medical University Hospital Taichung Taiwan
- School of MedicineChina Medical University Taichung Taiwan
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Rattotti S, Ferretti VV, Rusconi C, Rossi A, Fogazzi S, Baldini L, Pioltelli P, Balzarotti M, Farina L, Ferreri AJM, Laszlo D, Speziale V, Varettoni M, Sciarra R, Morello L, Tedeschi A, Frigeni M, Defrancesco I, Zerbi C, Flospergher E, Nizzoli ME, Morra E, Arcaini L. Lymphomas associated with chronic hepatitis C virus infection: A prospective multicenter cohort study from the Rete Ematologica Lombarda (REL) clinical network. Hematol Oncol 2019; 37:160-167. [PMID: 30726562 DOI: 10.1002/hon.2575] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 01/16/2023]
Abstract
Chronic hepatitis C virus (HCV) infection is related with an increased risk of non-Hodgkin lymphomas (NHL). In indolent subtypes, regression of NHL was reported after HCV eradication with antiviral therapy (AT). In 2008 in Lombardy, a region of Northern Italy, the "Rete Ematologica Lombarda" (REL, Hematology Network of Lombardy-Lymphoma Workgroup) started a prospective multicenter observational cohort study on NHL associated with HCV infection, named "Registro Lombardo dei Linfomi HCV-positivi" ("Lombardy Registry of HCV-associated non-Hodgkin lymphomas"). Two hundred fifty patients with a first diagnosis of NHL associated with HCV infection were enrolled; also in our cohort, diffuse large B cell lymphoma (DLBCL) and marginal zone lymphoma (MZL) are the two most frequent HCV-associated lymphomas. Two thirds of patients had HCV-positivity detection before NHL; overall, NHL was diagnosed after a median time of 11 years since HCV survey. Our data on eradication of HCV infection were collected prior the recent introduction of the direct-acting antivirals (DAAs) therapy. Sixteen patients with indolent NHL treated with interferon-based AT as first line anti-lymphoma therapy, because of the absence of criteria for an immediate conventional treatment for lymphoma, had an overall response rate of 90%. After a median follow-up of 7 years, the overall survival (OS) was significantly longer in indolent NHL treated with AT as first line (P = 0.048); this confirms a favorable outcome in this subset. Liver toxicity was an important adverse event after a conventional treatment in 20% of all patients, in particular among DLBCL, in which it is more frequent the coexistence of a more advanced liver disease. Overall, HCV infection should be consider as an important co-pathology in the treatment of lymphomas and an interdisciplinary approach should be always considered, in particular to evaluate the presence of fibrosis or necroinflammatory liver disease.
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Affiliation(s)
- Sara Rattotti
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Chiara Rusconi
- Division of Hematology, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Andrea Rossi
- Division of Hematology, Ospedali Riuniti, Bergamo, Italy
| | | | - Luca Baldini
- Division of Hematology, Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | | | - Lucia Farina
- Division of Hematology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Andrés J M Ferreri
- Unit of Lymphoid Malignancies, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Laszlo
- Division of Hematology, Istituto Europeo di Oncologia, Milan, Italy
| | - Valentina Speziale
- Division of Internal Medicine, Ospedale Civile di Legnano, Legnano, Italy
| | - Marzia Varettoni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Sciarra
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lucia Morello
- Division of Hematology, Humanitas Cancer Center, Milan, Italy
| | | | - Marco Frigeni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Caterina Zerbi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | | | - Enrica Morra
- Division of Hematology, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Luca Arcaini
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Elbedewy TA, Elsebaey MA, Elshweikh SA, Elashry H, Abd-Elsalam S. Predictors for eltrombopag response in patients with hepatitis C virus-associated thrombocytopenia. Ther Clin Risk Manag 2019; 15:269-274. [PMID: 30804674 PMCID: PMC6375108 DOI: 10.2147/tcrm.s186106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and aims Thrombocytopenia is a common hematological abnormality observed in patients infected with hepatitis C virus (HCV). The use of eltrombopag has been approved for HCV-associated thrombocytopenia. This is the first study aiming to determine the predictive factors of response to eltrombopag therapy in patients with HCV-associated thrombocytopenia. Patients and methods This prospective study was carried out on 130 patients with chronic HCV-associated thrombocytopenia (<50,000×109/L) that precludes the initiation of HCV therapy. Eltrombopag was initiated at a dose of 25 mg once daily; the dose was adjusted with 25 mg increments every 2 weeks to achieve the target platelet count. The primary end point was to achieve stable target platelet count (50,000-100,000×109/L) required to initiate antiviral therapy. Results Treatment response was achieved in 111 (85.38%) patients. This prospective study showed that megakaryocyte hypoplasia or aplasia and splenectomy were independent risk factors for eltrombopag nonresponse in chronic HCV-associated thrombocytopenic patients. Conclusion Eltrombopag is safe and effective for patients with HCV-associated thrombocytopenia. Bone marrow examination should be considered before initiating treatment with eltrombopag in chronic HCV-associated thrombocytopenic patients, especially in patients with splenectomy.
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Affiliation(s)
- Tamer A Elbedewy
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed A Elsebaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Samah A Elshweikh
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba Elashry
- Tropical Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt,
| | - Sherief Abd-Elsalam
- Tropical Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt,
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Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures. J Orthop Trauma 2018; 32:565-572. [PMID: 30339646 DOI: 10.1097/bot.0000000000001286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures. METHODS A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis. RESULTS Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV-). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV- cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge. CONCLUSIONS In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Phosphatidylserine-exposing blood cells and microparticles induce procoagulant activity in non-valvular atrial fibrillation. Int J Cardiol 2018; 258:138-143. [PMID: 29544920 DOI: 10.1016/j.ijcard.2018.01.116] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/21/2018] [Accepted: 01/26/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The definitive role of phosphatidylserine (PS) in the prothrombotic state of non-valvular atrial fibrillation (NVAF) remains unclear. Our objectives were to study the PS exposure on blood cells and microparticles (MPs) in NVAF, and evaluate their procoagulant activity (PCA). METHODS NVAF patients without (n = 60) and with left atrial thrombi (n = 18) and controls (n = 36) were included in our study. Exposed PS was analyzed with flow cytometry and confocal microscopy. PCA was evaluated using clotting time, factor Xa (FXa), thrombin and fibrin formation. RESULTS PS+ blood cells and MPs were significantly higher in NVAF patients without and with left atrial thrombi (both P < 0.01) than in controls. Patients with left atrial thrombi showed increased PS+ platelets, neutrophils, erythrocytes and MPs compared with patients without thrombi (all P < 0.05). Moreover, in patients with left atrial thrombi, MPs primarily originated from platelets (56.1%) followed by leukocytes (21.9%, including MPs from neutrophils, monocytes and lymphocytes), erythrocytes (12.2%) and endothelial cells (8.9%). Additionally, PS+ blood cells and MPs contributed to markedly shortened coagulation time and dramatically increased FXa/thrombin/fibrin (all P < 0.001) generation in both NVAF groups. Furthermore, blockade of exposed PS on blood cells and MPs with lactadherin inhibited PCA by approximately 80%. Lastly, we found that the amount of PS+ platelets and MPs was positively correlated with thrombus diameter (all p < 0.005). CONCLUSIONS Our results suggest that exposed PS on blood cells and MPs play a procoagulant role in NVAF patients. Blockade of PS prior to thrombus formation might be a novel therapeutic approach in these patients.
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Peck-Radosavljevic M. Thrombocytopenia in chronic liver disease. Liver Int 2017; 37:778-793. [PMID: 27860293 DOI: 10.1111/liv.13317] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022]
Abstract
Thrombocytopenia is a common haematological disorder in patients with chronic liver disease. It is multifactorial and severity of liver disease is the most influential factor. As a result of the increased risk of bleeding, thrombocytopenia may impact upon medical procedures, such as surgery or liver biopsy. The pathophysiology of thrombocytopenia in chronic liver disease has long been associated with the hypothesis of hypersplenism, where portal hypertension causes pooling and sequestration of all corpuscular elements of the blood, predominantly thrombocytes, in the enlarged and congested spleen. Other mechanisms of importance include bone marrow suppression by toxic substances, such as alcohol or viral infection, and immunological removal of platelets from the circulation. However, insufficient platelet recovery after relief of portal hypertension by shunt procedures or minor and transient recovery after splenic artery embolization have caused many to question the importance and relative contribution of this mechanism to thrombocytopenia. The discovery of the cytokine thrombopoietin has led to the elucidation of a central mechanism. Thrombopoietin is predominantly produced by the liver and is reduced when liver cell mass is severely damaged. This leads to reduced thrombopoiesis in the bone marrow and consequently to thrombocytopenia in the peripheral blood of patients with advanced-stage liver disease. Restoration of adequate thrombopoietin production post-liver transplantation leads to prompt restoration of platelet production. A number of new treatments that substitute thrombopoietin activity are available or in development.
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Affiliation(s)
- Markus Peck-Radosavljevic
- Department of Gastroenterology, Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
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Thrombocytopenia in Patients with Chronic Hepatitis C Virus Infection. Mediterr J Hematol Infect Dis 2017; 9:e2017019. [PMID: 28293407 PMCID: PMC5333732 DOI: 10.4084/mjhid.2017.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 12/11/2022] Open
Abstract
Thrombocytopenia in patients with chronic hepatitis C virus (HCV) infection is a major problem. The pathophysiology is multifactorial, with auto-immunogenicity, direct bone marrow suppression, hypersplenism, decreased production of thrombopoietin and therapeutic adverse effect all contributing to thrombocytopenia in different measures. The greatest challenge in the care of chronic HCV patients with thrombocytopenia is the difficulty in initiating or maintaining IFN containing anti-viral therapy. Although at present, it is possible to avoid this challenge with the use of the sole Direct Antiviral Agents (DAAs) as the primary treatment modality, thrombocytopenia remains of particular interest, especially in cases of advanced liver disease. The increased risk of bleeding with thrombocytopenia may also impede the initiation and maintenance of different invasive diagnostic and therapeutic procedures. While eradication of HCV infection itself is the most practical strategy for the remission of thrombocytopenia, various pharmacological and non-pharmacological therapeutic options, which vary in their effectiveness and adverse effect profiles, are available. Sustained increase in platelet count is seen with splenectomy and splenic artery embolization, in contrast to only transient rise with platelet transfusion. However, their routine use is limited by complications. Different thrombopoietin analogues have been tried. The use of synthetic thrombopoietins, such as recombinant human TPO and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMDGF), has been hampered by the development of neutralizing antibodies. Thrombopoietin-mimetic agents, in particular, eltrombopag and romiplostim, have been shown to be safe and effective for HCV-related thrombocytopenia in various studies, and they increase platelet count without eliciting any immunogenicity Other treatment modalities including newer TPO analogues-AMG-51, PEG-TPOmp and AKR-501, recombinant human IL-11 (rhIL-11, Oprelvekin), recombinant human erythropoietin (rhEPO), danazol and L-carnitine have shown promising early result with improving thrombocytopenia. Thrombocytopenia in chronic HCV infection remain a major problem, however the recent change in DAAs without IFN, as the frontline therapy for HCV, permit to avoid the dilemmas associated with initiating or maintaining IFN based anti-viral therapy.
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The Relationship between Inflammatory Marker Levels and Hepatitis C Virus Severity. Gastroenterol Res Pract 2016; 2016:2978479. [PMID: 28090206 PMCID: PMC5206414 DOI: 10.1155/2016/2978479] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/08/2016] [Indexed: 12/31/2022] Open
Abstract
Background. Red cell distribution width (RDW) and platelet-lymphocyte ratio (PLR) have been studied in a variety of etiological diseases. We aim to investigate the relationship between RDW and PLR and the severity of hepatitis C virus- (HCV-) related liver disease. Methods. We included fifty-two chronic HCV and 42 HCV-related cirrhosis patients and 84 healthy controls. Hematological and virological parameters and liver function biomarkers of HCV-related patients at admission were recorded. Results. RDW, RDW-to-platelet (RPR), and 1/PLR values in HCV-related cirrhosis patients were significantly higher than in chronic HCV patients and healthy controls (all P < 0.001). The aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AAR), AST-to-platelet ratio index (APRI), and fibrosis index based on the four factors (FIB-4) scores in HCV-related cirrhosis patients were significantly higher than in chronic HCV patients (all P < 0.001). The areas under the curve of the RDW, RPR, and 1/PLR for predicting cirrhosis were 0.791, 0.960, and 0.713, respectively. Bivariate logistic regression analysis showed that RDW could independently predict the presence of cirrhosis in chronic HCV patients. Conclusions. RDW, RPR, and PLR may be potential markers for estimating HCV severity.
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Maan R, Zaim R, van der Meer AJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Manns MP, Zeuzem S, Hansen BE, Janssen HLA, Veldt BJ, de Knegt RJ, Uyl-de Groot CA. Real-world medical costs of antiviral therapy among patients with chronic HCV infection and advanced hepatic fibrosis. J Gastroenterol Hepatol 2016; 31:1851-1859. [PMID: 26990109 DOI: 10.1111/jgh.13373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Very potent direct acting antivirals for the treatment of chronic hepatitis C virus infection were recently introduced into daily clinical practice. Currently, treatment uptake is hampered by their high costs, eliciting prioritization of treatment. We aimed to evaluate the direct medical costs during interferon (IFN)-based antiviral treatment and the costs per sustained virological response (SVR) among patients with advanced hepatic fibrosis. METHODS This retrospective cohort study included all consecutive patients with chronic hepatitis C virus infection and biopsy-proven bridging fibrosis or cirrhosis (Ishak 4-6) treated with IFN-based regimens in five hepatology units of tertiary care centers in Europe and Canada. Direct medical costs, expressed in 2013 Euros, during therapy were assessed. The components of care were quantified by three distinct categories: treatment, safety/ monitoring, and complications. Cost per SVR was calculated by dividing the mean cost by the SVR rate. RESULTS In total, 672 interferon-based treatments administered to 455 patients were included. Total medical costs per patient were averaged to €14 559 (95% confidence interval [CI], €13 323-€15 836). The mean cost per SVR was €38 514 (95% CI, €35 244-€41 892). The costs per SVR were €26 105 (95% CI, €23 068-€29 296) for patients with a normal platelet count and €50 907 (95% CI, €44 151-€59 612) for patients with thrombocytopenia, with the costs per SVR of €74 961 (95% CI, €55 463-€103 541) among those patients with a platelet count below 100 * 109 /L. CONCLUSIONS Because of the lower SVR rates, the cost per SVR of IFN-based treatment increased when patients with more advanced liver disease were treated. Additional costs of IFN-free therapy could be limited among these patients.
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Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remziye Zaim
- Institute for Medical Technology Assessment, Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jordan J Feld
- Liver Centre, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry LA Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Liver Centre, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carin A Uyl-de Groot
- Institute for Medical Technology Assessment, Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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The prevalence and co-occurrence of hematological complications at the time of diagnosis of chronic hepatitis C in Poland: a cross-sectional study. Eur J Gastroenterol Hepatol 2016; 28:1008-13. [PMID: 27271160 DOI: 10.1097/meg.0000000000000667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To evaluate the frequency, co-occurrence, and risk factors for hematological complications at the time of diagnosis of chronic hepatitis C (CHC). METHODS This study included 1237 patients with CHC aged 18-88 years diagnosed in the years 1998-2010 in the Pomeranian region of Poland. Clinical data, cell blood count, liver biopsy, and biochemistry results were obtained retrospectively. RESULTS Hematological complications were found in 31% of patients. The most frequent complication was thrombocytopenia (23.8%). The multivariate analysis showed a 5.1-fold increased risk (P<0.05) of at least one additional hematological complication in patients with thrombocytopenia. The greatest increase in risk (7.3) was related to leukopenia and cryoglobulinemia (2.3). The risk of leukopenia was correlated with the severity of thrombocytopenia. The risk of leukopenia and thrombocytopenia increased significantly from, respectively, stages 3 and 2 of liver fibrosis compared with patients without fibrosis. CONCLUSION In patients with CHC, decreases in cell blood count occur quite frequently. The most often is mild and solitary thrombocytopenia, but if severe, it may be accompanied by leukopenia, especially in women. The presence of thrombocytopenia and leukopenia in patients with CHC may indicate advanced liver fibrosis or its final stage: cirrhosis.
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Liver Governs Tendon: A Theory from Traditional Chinese Medicine-Evidence from a Population-Based Matched Cohort Study in Taiwan for the Association of Chronic Liver Disease and Common Diseases in the Chiropractic Office. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:7210705. [PMID: 27437024 PMCID: PMC4942639 DOI: 10.1155/2016/7210705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/26/2016] [Accepted: 06/02/2016] [Indexed: 12/20/2022]
Abstract
In traditional Chinese medicine (TCM) theory, the liver governs the tendons. This retrospective cohort study investigated the relationship between chronic liver disease and common orthopedic conditions by utilizing the National Health Insurance Research Database of Taiwan. The populations included within this study were chronic liver disease patients (International Classification of Diseases/ICD-9 code: 571) and a comparison group composed of patients with nonchronic liver disease. The medical event that was evaluated was internal derangement of joints (ICD-9 codes: 717-718). In comparison with the control group, patients with chronic liver disease were 1.29 times more likely to develop internal derangement of joints when major trauma had also occurred. We did not find the association of viral hepatitis with internal derangement of joints. Patients with chronic liver disease as well as anemia were 3.01 times more likely to develop joint derangements. Our study shows that patients with anemia in addition to chronic liver disease are more prone to develop joint derangements. This is the first documented research study that endorses “the liver governs the tendons which gives the body the ability to move” theory of TCM. The incidence rate of internal derangement of knee joints was higher in patients with chronic liver disease.
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Huang CE, Chen YY, Chang JJ, Kuan FC, Lee KD, Lu CH, Lung J, Shen CH, Chen CC. Thrombopoietic cytokines in patients with hepatitis C virus-associated immune thrombocytopenia. ACTA ACUST UNITED AC 2016; 22:54-60. [PMID: 27396368 DOI: 10.1080/10245332.2016.1204493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Complex and multiple mechanisms are involved in the etiology of Hepatitis C virus-associated immune thrombocytopenia (HCV-ITP). Many hematopoietic growth factors affect the thrombopoiesis. The aim of this study was to clarify the interaction of the thrombopoietic factors in patients with HCV-ITP. METHODS We selected 33 patients with HCV-ITP and 17 normal individuals. We compare serum interleukin (IL)-3, IL-6, IL-11, thrombopoietin (Tpo), stem cell factor (SCF), granulocyte-macrophage colony-stimulating factor (GM-CSF), tumour necrosis factor-α (TNFα), and spleen size between these two groups. RESULTS Our study shows that Tpo, IL-6, and TNFα significantly increased in patients with HCV-ITP compared to the normal population (Tpo:122.577 vs. 40.602; IL-6: 2.175 vs. 0.943; TNFα: 2.460 vs. 1.322). IL-11 was significantly lower in the HCV-ITP group (10.829 vs. 15.042). HCV-ITP patients had a higher spleen index (21.121 vs 13.498, P = 0.003). According to regression analysis and multiple linear regression analysis, only IL-11 had a significantly positive correlation with platelet count, while TNFα showed a negative correlation. DISCUSSIONS Tpo and IL-6 increased in patients with HCV-ITP, suggesting a positive feedback of low platelet count. TNFα-associated immune response is suspected to have an impact on low platelet count. IL-11 is assumed to directly affect thrombopoiesis. CONCLUSIONS This study is the most comprehensive study to evaluate the interaction between platelet count and the important thrombopoetic factors in patients with HCV-ITP. The thrombopoietic factors clearly play an important role in HCV-ITP.
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Affiliation(s)
- Cih-En Huang
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Yi-Yang Chen
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Jung-Jung Chang
- b Division of Cardiology , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Feng-Che Kuan
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Kuan-Der Lee
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan.,c College of Medicine , Chang Gung University , Tao-Yuan , Taiwan
| | - Chang-Hsien Lu
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan.,d Graduate Institute of Clinical Medical Sciences, Chang Gung University , Tao-Yuan , Taiwan
| | - Jrhau Lung
- e Division of Pulmonary and Critical Care Medicine , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Chien-Heng Shen
- f Division of Gastroenterology, Department of Medicine , Chang Gung Memorial Hospital , Chia-yi , Taiwan
| | - Chih-Cheng Chen
- a Division of Hematology and Oncology , Chang Gung Memorial Hospital , Chia-yi , Taiwan.,c College of Medicine , Chang Gung University , Tao-Yuan , Taiwan
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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Lu L, Zhan Y, Yu J, Sui L. Prevalence of Thrombocytopenia and Its Association with Serum Magnesium. Biol Trace Elem Res 2016; 169:46-51. [PMID: 26085060 DOI: 10.1007/s12011-015-0406-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/10/2015] [Indexed: 01/08/2023]
Abstract
The present study aimed to investigate the prevalence of thrombocytopenia and its association with serum magnesium in a nationally representative cohort. A total of 8478 participants aged 18 years and over were recruited in a cross-sectional survey. Thrombocytopenia was defined as platelet count less than 150 × 10(9)/L. Multivariable logistic regression models were applied to examine the association between serum magnesium and thrombocytopenia. The prevalence of thrombocytopenia in total was 16.5% with 18.8% for men and 14.4% for women (P < 0.0001), respectively. Compared with men in the first quartile of serum magnesium, the odds ratios (ORs) and 95% confidence intervals (CIs) for those in the second, third, and fourth quartiles of serum magnesium were 0.96 (0.75, 1.21), 0.78 (0.62, 0.98), and 0.82 (0.65, 1.04), respectively, after adjusting for multiple confounders. Likewise, the corresponding ORs (95% CIs) were 0.80 (0.63, 1.01), 0.79 (0.62, 0.99), and 0.65 (0.51, 0.84) in women. When serum magnesium was treated as a continuous variable, each one standard deviation increase of magnesium was associated with 12 and 8% lower risk of thrombocytopenia in men and women, respectively. Serum magnesium was inversely associated with thrombocytopenia, and the association was slightly different in men compared with that in women.
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Affiliation(s)
- Leihong Lu
- Department of Dermatology, Linyi People's Hospital, Linyi, People's Republic of China
| | - Yiqiang Zhan
- Institute of Clinical Epidemiology, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Jinming Yu
- Institute of Clinical Epidemiology, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Lihong Sui
- Department of Oncology, Wendeng Central Hospital of Weihai, Wendeng, People's Republic of China.
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Patel S, Perry MM, Spolarich AE. Oral surgery in a patient with cirrhosis and thrombocytopenia: a case report. SPECIAL CARE IN DENTISTRY 2015; 36:93-8. [PMID: 26625941 DOI: 10.1111/scd.12150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE While most oral surgical procedures can be safely performed in an outpatient setting, certain medical conditions may present a higher chance of postoperative complications. In particular, those predisposing the patient to bleeding abnormalities pose a potential risk when performing such treatments. The authors report a case involving full-mouth extractions in a patient with cirrhosis and thrombocytopenia after obtaining a platelet transfusion. METHODS/CASE A 62-year-old Caucasian female presented to a university special care dental clinic requiring extractions. Her pertinent medical history was remarkable for cirrhosis and thrombocytopenia, with a platelet count of 32,000/uL. Upon medical consultation, the patient was appointed for a prophylactic platelet transfusion. The surgery was rendered uneventfully, and the patient achieved adequate hemostasis without hospitalization. CONCLUSION/CLINICAL RELEVANCE Patients with cirrhosis pose a potential bleeding risk with dental surgical procedures. Pre-operative medical consultation, review of pertinent laboratory values, and prophylactic platelet transfusion allow these patients to be managed safely in an outpatient setting.
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Affiliation(s)
- Seena Patel
- Associate Director of Oral Medicine, Arizona School of Dentistry and Oral Health, A.T. Still University, Mesa, Arizona
| | - Maureen Munnelly Perry
- Associate Dean for Post-Doctoral Education, Director, The Center for Advanced Oral Health, Associate Professor & Director, Special Care Dentistry, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona.,Associate Director, Central Arizona Region, NYU Lutheran Medical Center, Advanced Education in General Dentistry Program, Mesa, Arizona
| | - Ann Eshenaur Spolarich
- Professor and Director of Research, Arizona School of Dentistry and Oral Health, A.T. Still University, Mesa, Arizona
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Lens S, Rincón D, García-Retortillo M, Albillos A, Calleja JL, Bañares R, Abraldes JG, Bosch J, Sanchez-Tapias JM, Forns X, García-Pagán JC. Association Between Severe Portal Hypertension and Risk of Liver Decompensation in Patients With Hepatitis C, Regardless of Response to Antiviral Therapy. Clin Gastroenterol Hepatol 2015; 13:1846-1853.e1. [PMID: 25912838 DOI: 10.1016/j.cgh.2015.04.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/17/2015] [Accepted: 04/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hepatic venous pressure gradient (HVPG) is associated with a risk of liver events in patients with chronic hepatitis C. Antiviral therapies that lead to a sustained virologic response (SVR) reduce portal pressure and prevent liver disease progression. However, it is not clear to what extent the progression of hepatitis C is modified once patients develop cirrhosis with severe portal hypertension (CSPH) (HVPG ≥ 10 mm Hg). We assessed the effects of HVPG and SVR on the risk of liver decompensation, hepatocellular carcinoma, and/or death in patients with hepatitis C-related cirrhosis. METHODS We collected data from 100 patients with hepatitis C and compensated cirrhosis who underwent HVPG measurement 3 months or less before (baseline) and 24 weeks after therapy with pegylated interferon alfa-2a and ribavirin at 4 hospitals in Spain, from 2001 through 2009. SVR was defined as undetectable serum HCV RNA level 24 weeks after treatment ended. Clinical data were collected until death, liver transplantation, or December 2012 (median, 5 y; interquartile range, 1.4-7 y). RESULTS Seventy-four patients had CSPH at baseline and 35% of patients achieved an SVR. During the follow-up period, 19 patients developed liver decompensation (ascites, variceal bleeding, or encephalopathy). The actuarial probability values for liver decompensation at 1, 5, and 7 years were 3%, 19% and 22%, respectively. The baseline level of HVPG, but not SVR, was associated independently with the risk of liver decompensation. CONCLUSIONS Patients with CSPH, regardless of an SVR to therapy for hepatitis C, remain at risk for liver decompensation within the first 5 years after treatment; they should be monitored closely.
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Affiliation(s)
- Sabela Lens
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Diego Rincón
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | | | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Juan González Abraldes
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jaume Bosch
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jose Maria Sanchez-Tapias
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Juan Carlos García-Pagán
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain.
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32
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Giannini EG, Afdhal NH, Sigal SH, Muir AJ, Reddy KR, Vijayaraghavan S, Elkashab M, Romero-Gómez M, Dusheiko GM, Iyengar M, Vasey SY, Campbell FM, Theodore D. Non-cirrhotic thrombocytopenic patients with hepatitis C virus: Characteristics and outcome of antiviral therapy. J Gastroenterol Hepatol 2015; 30:1301-8. [PMID: 25777337 DOI: 10.1111/jgh.12942] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Thrombocytopenia is frequently observed in patients with chronic hepatitis C virus (HCV) infection and cirrhosis, although it can also be observed in patients without cirrhosis by a virus-mediated phenomenon. This study assessed the prevalence, characteristics, and outcomes of antiviral therapy in patients with chronic HCV infection and thrombocytopenia not associated with cirrhosis. METHODS The study included 1268 patients with HCV infection and thrombocytopenia enrolled in the phase 3 ENABLE studies that assessed the impact of eltrombopag on achieving a sustained virologic response to pegylated interferon and ribavirin. The study population was subdivided according to baseline FibroSURE test results into patients with non-cirrhosis (FibroSURE < 0.4) and cirrhosis-related (FibroSURE ≥ 0.75) thrombocytopenia. RESULTS Compared with patients with cirrhosis-related thrombocytopenia (n = 995; 78.5%), non-cirrhotic patients with thrombocytopenia (n = 59; 4.6%) were younger (mean age [95% confidence interval (CI)]: 43.9 [40.7-47.2] vs 52.7 [52.2-53.3] years; P < 0.0001), predominantly female (64% [51-76] vs 30% [27-33]; P < 0.0001), and less frequently had a Model for End-Stage Liver Disease score ≥ 10 (24% [14-37] vs 45% [42-49]; P = 0.0012), low albumin levels (≤ 35 g/L; 2% [0-9] vs 32% [29-35]; P < 0.0001), and prevalence of diabetes mellitus (3% [0-12] vs 21% [19-24]; P = 0.0005). The sustained virologic response rate was higher in non-cirrhotic patients with thrombocytopenia (46% [95% CI, 33-59] vs 16% [14-18]; P < 0.0001). CONCLUSIONS Patients with thrombocytopenia associated with HCV who have lower FibroSURE test results may have better preserved liver function and higher sustained virologic response rates than patients with cirrhosis.
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Affiliation(s)
| | - Nezam H Afdhal
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel H Sigal
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Andrew J Muir
- Duke Clinical Research Institute, Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, USA
| | - K Rajender Reddy
- University of Pennsylvania School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Magdy Elkashab
- Department of Hepatology, Toronto Liver Center, Toronto, Canada
| | - Manuel Romero-Gómez
- Unit for Medical and Surgical Management of Digestive Diseases and CIBERehd, Valme University Hospital, University of Seville, Sevilla, Spain
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Irving WL, Grotzinger K, Theodore D, Demuth D, Rizzetto M, Roughley A, Forssen U. Antiviral treatment discontinuation among hepatitis C-infected individuals with thrombocytopenia. J Viral Hepat 2015; 22:511. [PMID: 25847467 DOI: 10.1111/jvh.12357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- W L Irving
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University Hospital Nottingham, Nottingham, UK.
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Tana MM, Zhao X, Bradshaw A, Moon MS, Page S, Turner T, Rivera E, Kleiner DE, Heller T. Factors associated with the platelet count in patients with chronic hepatitis C. Thromb Res 2015; 135:823-8. [PMID: 25728497 DOI: 10.1016/j.thromres.2015.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/05/2015] [Accepted: 02/10/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are many potential causes of thrombocytopenia in patients with chronic hepatitis C (CHC). AIMS We sought to determine the association between thrombopoietin (TPO) level, immature platelet fraction (IPF), immunoglobulin G (IgG) level, spleen size, and the platelet count in CHC. METHODS We studied a consecutive sample of patients enrolled in an observational study at a referral-based research center, excluding subjects based on eligibility criteria. TPO, glycocalicin, and von Willebrand Factor (vWF) levels were determined using stored sera. Hepatic fibrosis was assessed via transient elastography (TE) when available, and clinical laboratory values and radiologic data were obtained from the medical record. We performed analyses of the relationships between independent variables and the platelet count. RESULTS On univariate analysis, the following variables were significantly associated with the platelet count: age, alanine aminotransferase (ALT), direct bilirubin, total bilirubin, IPF, international normalized ratio (INR), spleen size, vWF, glycocalicin, fibrosis stage on liver biopsy, and TE (P-values all <0.05). A multivariable model determined that imputed TE score, TPO, IPF, and spleen size were independently associated with the platelet count (P-values all<0.05). CONCLUSIONS The platelet count in CHC is significantly associated with fibrosis, TPO level, IPF, and spleen size. Our findings challenge the proposed mechanism of decreased TPO levels or decreased bone marrow production of platelets as a cause of thrombocytopenia in CHC. Future studies focusing on the effects of fibrosis and splenomegaly on platelets may shed more light on the pathophysiology of thrombocytopenia in patients with CHC.
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Affiliation(s)
- Michele M Tana
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA; Division of Gastroenterology, UCSF Liver Center, University of California, San Francisco, USA.
| | - Xiongce Zhao
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Alyson Bradshaw
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Mi Sun Moon
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Sandy Page
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Tiffany Turner
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Elenita Rivera
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - David E Kleiner
- National Cancer Institute, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
| | - Theo Heller
- Liver Diseases Branch, Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 9000 Rockville Pike, Bldg. 10 Rm. 9B16, Bethesda, MD 20892, USA
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Sharma V. Use of eltrombopag in thrombocytopenia of liver disease. World J Pharmacol 2014; 3:186-192. [DOI: 10.5497/wjp.v3.i4.186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/04/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Second generation thrombopoietin agonists including eltrombopag and romiplostim act on the thrombopoietin receptor to increase the megakaryocyte production. These agents were needed as use of first generation recombinant products was associated with formation of autoantibodies. Eltrombopag is an oral thrombopoietin agonist found effective in raising platelet counts in patients with immune thrombocytopenia. The drug has now been found to be useful in raising platelet counts in thrombocytopenia related to liver disease including cirrhosis and chronic viral hepatitis. Although the drug may help enable adequate interferon therapy in patients with HCV infection and help carry out invasive procedures in patients with cirrhosis, concerns have been raised of possible thrombotic complications including portal vein thrombosis. Randomized trials have shown that use of eltrombopag concomitant with pegylated interferon and ribavirin increased the chances of sustained virologic response while decreasing the dose reductions of interferon. The data on use of romiplostim in these clinical indications is also emerging. However, in the future, availability of interferon free regimens is likely to decrease the use of eltrombopag for enabling antiviral therapy. The review discusses the role of eltrombopag in management of liver disease related thrombocytopenia in wake of recent data as also the dosage, precautions and adverse effects associated with its use.
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Galli L, Gerdes VE, Guasti L, Squizzato A. Thrombosis Associated with Viral Hepatitis. J Clin Transl Hepatol 2014; 2:234-9. [PMID: 26357629 PMCID: PMC4521234 DOI: 10.14218/jcth.2014.00031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 12/19/2022] Open
Abstract
Viral hepatitis may promote the development of venous thromboembolism (VTE) and, more specifically, portal vein thrombosis (PVT). In this narrative review, we summarize the clinical data and discuss the possible pathogenetic roles of cytomegalovirus (CMV), Epstein-Barr virus (EBV), and hepatitis A, B, and C viruses (HAV, HBV, HCV) in the occurrence of VTE. CMV is the first qualified candidate to enter the list of VTE minor risk factors, and in the rare case of fulminant infection, both EBV and CMV, like any severe infection or inflammatory disease, increase risk for thrombosis. In chronic hepatitis B and C, it remains controversial whether antiphospholipid antibodies are important for thrombotic complications or merely an epiphenomenon. Retinal vein occlusion described in chronic hepatitis C is usually attributed to the treatment with interferon. Eltrombopag, used for HCV-related thrombocytopenia, has been associated with increased thrombotic risk. The imbalance between procoagulant and anticoagulant factors associated with chronic liver disease may have clinical implications. This may help to explain why these patients are not protected from clinical events such as VTE, PVT, and the progression of liver fibrosis.
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Affiliation(s)
- Luca Galli
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Department of Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Victor E.A. Gerdes
- Department of Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Luigina Guasti
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Correspondence to: Alessandro Squizzato, U.O. Medicina I, Ospedale di Circolo, Viale Borri 57, Varese 21100, Italy. Tel: +39-0332-278831, Fax: +39-0332-278118. E-mail: ;
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Abstract
The development of thrombocytopenia is common in hospitalized patients and is associated with increased mortality. Frequent and important causes of thrombocytopenia in hospitalized patients include etiologies related to the underlying illness for which the patient is admitted, such as infection and disseminated intravascular coagulation, and iatrogenic etiologies such as drug-induced immune thrombocytopenia, heparin-induced thrombocytopenia, posttransfusion purpura, hemodilution, major surgery, and extracorporeal circuitry. This review presents a brief discussion of the pathophysiology, distinguishing clinical features, and management of these etiologies, and provides a diagnostic approach to hospital-acquired thrombocytopenia that considers the timing and severity of the platelet count fall, the presence of hemorrhage or thrombosis, the clinical context, and the peripheral blood smear. This approach may offer guidance to clinicians in distinguishing among the various causes of hospital-acquired thrombocytopenia and providing management appropriate to the etiology.
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Affiliation(s)
- Christine M McMahon
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Rizzetto M, Grotzinger K, Theodore D, Demuth D, Irving WL, Manns M, Roughley A, Forssen UM. Reasons for nonuse of antiviral treatment in patients with chronic hepatitis C infection and thrombocytopaenia: a retrospective chart review from five European countries. J Viral Hepat 2014; 21:e129-34. [PMID: 24698004 DOI: 10.1111/jvh.12256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 02/18/2014] [Indexed: 01/21/2023]
Abstract
Antiviral therapy has been shown to reduce the risk of disease progression, liver damage and death in patients with chronic hepatitis C virus (HCV) infection. While interferon labels recommend that patients with platelet counts below 50 × 10(3) /μL not receive interferon-based therapy, it is unknown to what extent thrombocytopaenia influences treatment decisions in practice. This study profiles the reasons for withholding antiviral treatment in HCV patients with thrombocytopaenia in five European countries. Medical records of 466 patients who had HCV infection and thrombocytopaenia (platelet count <100 × 10(3) /μL) in 2006 were retrospectively reviewed for clinical characteristics. Collected data included use of antiviral therapy and reasons for withholding therapy. In total 184 of 466 patients (39.5%) did not receive interferon-based therapy during the study period, with treatment withheld most frequently due to multiple clinical characteristics including hepatic cirrhosis (16.3%), thrombocytopaenia (16.3%) and age >60 years (10.9%). The reasons for lack of treatment varied among countries, with thrombocytopaenia as a reason being more common in Italy (10.9%) and Spain (20.0%), and less common in France, Germany and the UK (3.2-7.1%). Overall, thrombocytopaenia was reported as the only reason for withholding treatment in 4.9% of untreated patients. This study demonstrates that thrombocytopaenia is one of many factors, indicative of the poor clinical state of the patient, that contributes to withholding antiviral treatment. In 4.9% of untreated patients, thrombocytopaenia can be considered as a modifiable factor to enable more HCV patients to receive guideline-recommended therapy and thus improved clinical outcomes.
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Affiliation(s)
- M Rizzetto
- Department of Gastroenterology, University of Torino, Torino, Italy
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Hermos JA, Quach L, Gagnon DR, Weber HC, Altincatal A, Cho K, Lawler EV, Grotzinger KM. Incident severe thrombocytopenia in veterans treated with pegylated interferon plus ribavirin for chronic hepatitis C infection. Pharmacoepidemiol Drug Saf 2014; 23:480-8. [PMID: 24677630 DOI: 10.1002/pds.3585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 12/30/2013] [Accepted: 01/14/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE We sought to determine the incidence and risks for severe thrombocytopenia (platelets < 50,000/μL) in United States Veteran patients treated with pegylated interferon (PEG-IFN) plus ribavirin for hepatitis C virus-positive (HCV) chronic liver disease (CLD). METHODS Using a retrospective, observational cohort study design to analyze databases from the New England Veterans Healthcare System, we identified 979 patients diagnosed with HCV-positive CLD treated solely with PEG-IFN plus ribavirin. The cohort was stratified by pre-treatment platelet counts of 50,000-100,000/μL (N = 90), >100,000-150,000/μL (N = 162), and >150,000μL (N = 727). The cumulative incidence of severe thrombocytopenia and major bleeding events were determined for each baseline platelet group for 48 weeks following treatment initiation. Multivariable Cox regression was used to identify risk factors for incident severe thrombocytopenia. RESULTS Overall, severe thrombocytopenia occurred in 6.1% (N = 60), but in 41.1% of patients with pre-treatment platelet counts 50, 000-100,000/μL compared with 11.7% (p < 0.001) and 0.55% (p < 0.001) in the two higher pre-treatment platelet groups. Most episodes occurred within the first 12 weeks of treatment. Median nadir count for these 60 patients was 35,000/μL (inter-quartile range 28,000, 44,000). Baseline platelet counts of 50,000-100,000/μL [adjusted hazard ratio (HR) = 3.81; 95%CI = 2.07-7.00] and hemoglobin <10 g/dL (adjusted HR = 3.39; 95%CI = 1.45-7.960) associated with severe thrombocytopenia. Major bleeding events during the 48-week observation period were rare (N = 5, 0.51%). CONCLUSIONS The incidence of severe thrombocytopenia in a large, observational cohort of veteran patients with HCV CLD treated with PEG-IFN plus ribavirin was 6.1%. Low pre-treatment platelet counts and hemoglobin levels associated with early, incident severe thrombocytopenia.
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Affiliation(s)
- John A Hermos
- VA Cooperative Studies Program, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA; Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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40
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Afdhal NH, Dusheiko GM, Giannini EG, Chen PJ, Han KH, Mohsin A, Rodriguez-Torres M, Rugina S, Bakulin I, Lawitz E, Shiffman ML, Tayyab GUN, Poordad F, Kamel YM, Brainsky A, Geib J, Vasey SY, Patwardhan R, Campbell FM, Theodore D. Eltrombopag increases platelet numbers in thrombocytopenic patients with HCV infection and cirrhosis, allowing for effective antiviral therapy. Gastroenterology 2014; 146:442-52.e1. [PMID: 24126097 DOI: 10.1053/j.gastro.2013.10.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 10/02/2013] [Accepted: 10/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Thrombocytopenia is common among patients with hepatitis C virus (HCV) infection and advanced fibrosis or cirrhosis, limiting initiation and dose of peginterferon-alfa (PEG) and ribavirin (RBV) therapy. The phase 3 randomized, controlled studies, Eltrombopag to Initiate and Maintain Interferon Antiviral Treatment to Benefit Subjects with Hepatitis C-Related Liver Disease (ENABLE)-1 and ENABLE-2, investigated the ability of eltrombopag to increase the number of platelets in patients, thereby allowing them to receive initiation or maintenance therapy with PEG and RBV. METHODS Patients with HCV infection and thrombocytopenia (platelet count <75,000/μL) who participated in ENABLE-1 (n = 715) or ENABLE-2 (n = 805), from approximately 150 centers in 23 countries, received open-label eltrombopag (25-100 mg/day) for 9 weeks or fewer. Patients whose platelet counts reached the predefined minimal threshold for the initiation of PEG and RBV therapy (95% from ENABLE-1 and 94% from ENABLE-2) entered the antiviral treatment phase, and were assigned randomly (2:1) to groups that received eltrombopag or placebo along with antiviral therapy (24 or 48 weeks, depending on HCV genotype). The primary end point was sustained virologic response (SVR) 24 weeks after completion of antiviral therapy. RESULTS More patients who received eltrombopag than placebo achieved SVRs (ENABLE-1: eltrombopag, 23%; placebo, 14%; P = .0064; ENABLE-2: eltrombopag, 19%; placebo, 13%; P = .0202). PEG was administered at higher doses, with fewer dose reductions, in the eltrombopag groups of each study compared with the placebo groups. More patients who received eltrombopag than placebo maintained platelet counts of 50,000/μL or higher throughout antiviral treatment (ENABLE-1, 69% vs 15%; ENABLE-2, 81% vs 23%). Adverse events were similar between groups, with the exception of hepatic decompensation (both studies: eltrombopag, 10%; placebo, 5%) and thromboembolic events, which were more common in the eltrombopag group of ENABLE-2. CONCLUSIONS Eltrombopag increases platelet numbers in thrombocytopenic patients with HCV and advanced fibrosis and cirrhosis, allowing otherwise ineligible or marginal patients to begin and maintain antiviral therapy, leading to significantly increased rates of SVR. Clinical trial no: NCT00516321, NCT00529568.
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Affiliation(s)
- Nezam H Afdhal
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
| | | | | | - Pei-Jer Chen
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - Aftab Mohsin
- Services Institute of Medical Sciences, Lahore, Pakistan
| | | | - Sorin Rugina
- Spitalul Clinic de BoliInfectioase, Constanta, Romania
| | - Igor Bakulin
- Central Scientific Research Institution of Gastroenterology of the Moscow Health Department, Moscow, Russia
| | - Eric Lawitz
- The Texas Liver Institute/University of Texas Health Science Center, San Antonio, Texas
| | | | | | - Fred Poordad
- The Texas Liver Institute/University of Texas Health Science Center, San Antonio, Texas
| | | | | | - James Geib
- GlaxoSmithKline, Collegeville, Pennsylvania
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Fibrosis in hepatitis C patients predicts complications after elective total joint arthroplasty. J Arthroplasty 2014; 29:7-10. [PMID: 23648106 DOI: 10.1016/j.arth.2013.03.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/21/2013] [Accepted: 03/21/2013] [Indexed: 02/01/2023] Open
Abstract
Effects of Hepatitis C on total hip (THA) and total knee arthroplasty (TKA) outcomes are poorly understood. Seventy-two hepatitis C patients underwent 77 primary THA or TKA and were retrospectively identified, stratified by fibrosis and thrombocytopenia and compared to matched controls. Overall, Hepatitis C and control patients had similar outcomes. After TKA, fibrotic hepatitis C patients demonstrated a greater average hemoglobin drop than non-fibrotic hepatitis C patients (4.9 versus 3.8, P=0.023), greater deep infection rate (21% versus 0%, P=0.047), and rate of cellulitis (21% versus 0%, P=0.047). Thrombocytopenia showed a trend toward greater infections. Prior to fibrosis, Hepatitis C patients appear to be at no increased risk of complication after joint arthroplasty. Evaluation of fibrosis may predict poor outcome in Hepatitis C patients.
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Giannini EG. Eltrombopag in patients with chronic hepatitis C and thrombocytopenia. Future Virol 2014. [DOI: 10.2217/fvl.13.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Eltrombopag is a thrombopoietic drug that acts by interacting with the TPO receptor and stimulates megakaryocytopoiesis and platelet production. Thrombocytopenia is a fairly frequent hematological abnormality in patients with chronic liver disease, and may represent an obstacle to interferon-based antiviral therapy in patients with chronic HCV infection who are otherwise good candidates for treatment. In large, multicenter, randomized, placebo-controlled studies, eltrombopag consistently enabled thrombocytopenic chronic hepatitis C patients to be treated with interferon-based therapy and, as an adjunct to antiviral therapy, has shown to be able to increase the sustained virologic response rate to treatment. The safety profile of the drug, with particular attention to the risk of thromboembolic events and the potential for hepatic decompensation, should be taken into account when planning treatment. The aim of this article is to review the information currently available regarding the pharmacokinetics, clinical efficacy and side-effect profile of eltrombopag, and to assess the role of this drug into the current and future hepatitis C treatment paradigm.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, no.6, 16132, Genoa, Italy
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Brunetta DM, De Santis GC, Vilar FC, Brandão RA, Muniz RZDA, Lima GMND, Amorelli-Chacel ME, Covas DT, Machado AA. Hematological particularities and co-infections in injected drug users with AIDS. Braz J Infect Dis 2013; 17:654-6. [PMID: 24001391 PMCID: PMC9427417 DOI: 10.1016/j.bjid.2013.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 02/07/2013] [Accepted: 03/23/2013] [Indexed: 11/22/2022] Open
Abstract
HIV patients infected through injected drug use have poorer prognosis than other groups. We evaluated the hematological alterations and rates of co-infections in injected drug use patients with AIDS. Injected drug use patients were younger, predominantly of male gender, and presented lower CD4, total lymphocyte, and platelet counts, but not neutrophil count, than control group. Injected drug use patients had a higher rate of hepatitis C and mycobacteria infection. Furthermore, all injected drug use patients with hemoglobin <10.0 g dL−1 and lymphocyte <1000 μL−1 had CD4 count lower than 100 μL−1. In conclusion, HIV-infected injected drug use patients constitute a special group of patients, and hemoglobin concentration and lymphocyte count can be used as surrogate markers for disease severity.
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Affiliation(s)
- Denise Menezes Brunetta
- Center for Cell Based Therapy, Medical School of Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil.
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45
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Only severe thrombocytopenia results in bleeding and defective thrombus formation in mice. Blood 2013; 121:4938-47. [DOI: 10.1182/blood-2012-10-461459] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Key Points
Hemostasis, thrombosis, and ischemic brain infarction efficiently occur at unexpectedly low platelet counts in mice. The threshold platelet count required for occlusive thrombus formation differs between thrombosis models.
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Joy SM, Blauvelt BM, Tuncer MA, Beaugrand M, Sangro B, Colombo M, Bridges JFP. Stakeholder perspectives on European priorities for comprehensive liver cancer control: a conjoint analysis. Eur J Public Health 2013; 23:951-7. [PMID: 23531524 DOI: 10.1093/eurpub/cks173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND As liver cancer incidence and mortality remain high in many parts of Europe, a more comprehensive response is required to reduce the burden. Expert stakeholders should be involved in the design of responses because they have important insights about potentially effective responses and will be affected by policy changes. We aimed to prioritize liver cancer control strategies based on European liver cancer stakeholders' views of which strategies would have the greatest impact in a comprehensive liver cancer control plan. METHODS One hundred liver cancer clinical, policy and advocacy stakeholders from France, Germany, Italy, Spain and Turkey were surveyed. Respondents completed 12 conjoint choice tasks in which they chose which of two subsets of 11 strategies would have the greatest impact in their country. RESULTS All strategies were considered likely to have a positive impact (P < 0.01). The highest priority strategy was monitoring of at-risk populations, followed by centres of excellence, clinical education, multidisciplinary management, national guidelines, measuring social burden, public awareness, risk assessment and referral, research infrastructure and access to treatments. CONCLUSIONS Canvassing stakeholder views through a conjoint analysis survey provided a robust quantitative prioritization that can complement traditional qualitative consultation processes. The prioritized strategies provide a logical starting point for decision makers considering developing national plans or collaborative efforts to achieve comprehensive liver cancer control in Europe.
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Affiliation(s)
- Susan M Joy
- 1 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Abstract
INTRODUCTION Thrombocytopenia may represent a barrier to optimal management of chronic liver disease patients undergoing invasive procedures, or who need to be treated with interferon-based antiviral therapy. Eltrombopag is a thrombopoietic drug that acts upon binding thrombopoietin receptor and stimulates megakaryocytopoiesis and platelet production. AREAS COVERED A summary of the preclinical studies and of studies carried out in patients with chronic liver disease with eltrombopag are presented in this paper. Data are based on abstracts from journal articles and international conferences found in a PubMed search of literature published up to November 2012. EXPERT OPINION Eltrombopag has shown to be capable of reducing the need for platelet transfusion in thrombocytopenic patients with advanced liver disease undergoing invasive procedures and help increase the sustained virological response rate to interferon-based antiviral therapy in patients with chronic hepatitis C who were poor candidates to treatment because of thrombocytopenia. In chronic liver disease patients, the possible benefits of eltrombopag administration should be accurately weighed against the adverse events profile of the drug due to possible concerns regarding the occurrence of thromboembolic events and the potential for decompensation of chronic liver disease.
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Affiliation(s)
- Edoardo G Giannini
- University of Genoa, Department of Internal Medicine, Gastroenterology Unit, Viale Benedetto XV, No. 6,16132, Genoa, Italy.
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Kee KM, Wang JH, Hung CH, Chen CH, Lee CM, Lu SN. Improvement of thrombocytopenia in hepatitis C-related advanced fibrosis patients after sustained virological response. Dig Dis Sci 2013; 58:556-61. [PMID: 23001404 DOI: 10.1007/s10620-012-2380-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 08/20/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The long-term trend of platelet count in chronic hepatitis C virus patients with sustained virological response (SVR) has rarely been investigated. AIMS To elucidate changes of thrombocytopenia after SVR, trajectory patterns of platelet count over time and their associated factors. METHODS From May 1999 to July 2005, a total of 135 patients (mean age 50.2 ± 11.1 years) that received interferon-α based regimen plus ribavirin were enrolled. Platelet counts were followed every 6 months prospectively. The patterns of platelet counts over time were identified by trajectory analysis. RESULTS Mean follow-up duration was 4.4 ± 1.7 years (median 4.5; range 1.0-8.5 years). Baseline platelet count in all and thrombocytopenic patients increase significantly at the end of follow-up, from 172 ± 56 × 10(9)/l and 115 ± 21 × 10(9)/l to 196 ± 57 × 10(9)/l and 148 ± 37 × 10(9)/l, respectively (all p < 0.001). In patients with advanced fibrosis (n = 50), pretreatment platelet count also increased significantly (146 ± 45 × 10(9)/l vs. 173 ± 51 × 10(9)/l, p < 0.001). Twenty-six of 37 (69.2 %) patients with pretreatment mild thrombocytopenia (100-150 × 10(9)/l) had normalization of platelet count, while seven of 13 (53.8 %) patients with pretreatment moderate to severe thrombocytopenia (<100 × 10(9)/l) had elevation of platelet count up to 100-150 × 10(9)/l. Three trajectory groups were identified, i.e., elevation (n = 43, 31.9 %), stationary (n = 79, 58.5 %), and decrease (n = 13, 9.6 %) groups. Multiple logistic regression showed pretreatment thrombocytopenia was the factor in elevation of platelet count (OR = 2.28, 95 % confidence interval = 1.01-5.11, p = 0.046). CONCLUSIONS Platelet count increased significantly in patients with SVR after long-term follow-up. Patients with low baseline platelet count benefit more from SVR with respect to increased platelet count, compared to those with higher platelet count at baseline.
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Affiliation(s)
- Kwong-Ming Kee
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, 833, Taiwan
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Aref S, Ibrahem L, El Menshawy N, Bassam A. Effect of splenectomy on platelets associated antibodies in hepatitis C patients with thrombocytopenia. ACTA ACUST UNITED AC 2012; 17:118-21. [PMID: 22664051 DOI: 10.1179/102453312x13221316477705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND This study aimed to assess the role of splenomegaly as a source of platelet-associated immunoglobulins (PAIgs) in thrombocytopenic patients with chronic hepatitis C virus (HCV) infection. SUBJECTS AND METHODS The present study was conducted on 63 subjects categorized as follows. Group 1: Included 63 cases diagnosed as patients with HCV liver cirrhosis combined with thrombocytopenia before splenectomy. Group 2: Included the same 63 cases one week after splenectomy. For all subjects included in this study platelets counts were evaluated as well as PAIgs (total Igs, IgG, IgM, and IgA). RESULTS All patients were thrombocytopenic before undergoing splenectomy (platelet counts [median 68.5; range 44-95]). After splenectomy all patients achieved normal platelet counts (median 180; range 108-235). The mean ± SD of PAIgs was 64.2 ± 9.6 for total IgG, 53.6 ± 8.1 for IgG, 3.8 ± 2.1 for IgM, 6.7 ± 4.7 for IgA presplenectomy versus postsplenectomy 13.4 ± 19.3 for total Igs, 5.4 ± 1.8 for IgG, 1.9 ± 1.06 for IgM, 2.1 ± 0.9 for IgA, and the differences between pre and postsplenectomy figures were statistically significant (P < 0.001). The correlation studies between platelet count and PAIgs level in patients with chronic HCV infection presplenectomy revealed that there is significant negative correlation between platelet counts and all immunoglobulins (total Igs: r - 0.804, P = 0.000; IgG: r - 0.907, P = 0.000; IgM: r - 0.467, P = 0.002; and IgA: r - 0.519, P = 0.000). CONCLUSION Autoimmune mechanism plays an important role in the HCV-associated thrombocytopenia and spleen is a major source of PAIgs.
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Affiliation(s)
- Salah Aref
- Hematology Unit, Clinical Pathology Department, Faculty of Medicine, Mansoura University, Egypt.
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Successful antiviral therapy for hepatitis C virus-induced cirrhosis after an increase in the platelet count with romiplostim: two case reports. Eur J Gastroenterol Hepatol 2012; 24:1455-8. [PMID: 22890208 DOI: 10.1097/meg.0b013e328357d5f2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Thrombocytopenia is a common finding in patients with chronic liver disease related to hepatitis C virus (HCV) infection. Interferon therapy may aggravate thrombopenia through the inhibition of platelet production, leading to premature discontinuation of therapy, dose reduction, and viral relapse. The use of thrombopoietin agonists (romiplostim and eltrombopag) seem to be a useful way to increase the platelet count and facilitate interferon therapy in patients with a chronic HCV infection. Here, we report on the first two cases of patients with HCV-related cirrhosis successfully treated for HCV infection following an increase in the platelet count with romiplostim. Severe thrombocytopenia developed in both patients at weeks 22 and 12 of antiviral therapy, respectively. Considering the risk of relapse in the case of interferon dose reduction or early treatment discontinuation, we initiated platelet growth factor therapy with romiplostim. This approach allowed us to maintain a reasonable platelet count (>50 × 10⁹/l) and completion of an anti-HCV protocol without dose reduction, achieving a sustained virological response.
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