Procedural Risk of Bleeding: Does the Management of Thrombocytopenia in Chronic Liver Disease Patients Make a Difference? A Debate

Abstract

Prof Nezam Afdhal provided a background to thrombocytopenia (TCP) in chronic liver disease (CLD). He explored the causes of TCP and discussed what are considered acceptable platelet levels. He described the delicate balance between thrombosis risk and bleeding risk that puts CLD patients with TCP at risk of complications, particularly when they require invasive procedures. Through a series of case studies, the faculty highlighted current management dilemmas and novel approaches to TCP management. Prof Edoardo Giannini presented the case of a patient with hepatocellular carcinoma (HCC) (platelet count of <50×109/L) who was given a platelet transfusion prior to radiofrequency thermal ablation (RFTA). The patient’s increase in platelet count was not clinically significant; therefore, the procedure was cancelled. Prof Giannini noted that radiology guidelines state that for procedures with a moderate risk of bleeding (such as RFTA), platelet transfusion is recommended for counts <50×109/L. Prof Mark Thursz presented a case of a nonalcoholic steatohepatitis and refractory ascites, in which the patient had a number of large-volume paracentesis procedures. He then presented paracentesis studies highlighting that bleeding events are often unrelated to patients’ platelet levels. Prof Giannini described a study in patients with acute-on-chronic liver failure (AoCLF) who underwent paracentesis and in whom the bleeding rate was 3%. Following these case presentations, Prof Markus Peck-Radosavljevic discussed the role of thrombopoietin (TPO) in TCP in CLD. He then examined the pivotal trials of various TPO-receptor (TPO-R) agonists which have been studied in CLD patients with TCP undergoing invasive procedures. Clinical studies of the TPO-R agonist lusutrombopag included a large proportion of high-risk bleeding patients and therapy with this agent has been shown to elevate platelet count levels for up to 2 weeks, allowing a window in which to schedule invasive procedures.