S2607 A Unique Case of Thrombopoietin Receptor Agonists-Induced Portal Vein Thrombosis

Abstract

INTRODUCTION: It is well known that patients with cirrhosis develop thrombocytopenia secondary to their portal hypertension. Many patients with chronic liver disease induced thrombocytopenia (CLD-T) experience significant acute blood loss due to esophageal variceal bleeding, epistaxis, gingival bleeding, and other adverse bleeding events. Recently, thrombopoietin receptor agonists (TPORA), such as avatrombopag, have come into favor to use periprocedurally for patients with CLD-T. Here, we present a unique case of TPORA induced portal vein thrombosis (PVT). CASE DESCRIPTION/METHODS: A 64-year-old female with a history of decompensated alcohol liver cirrhosis, whose last drink was in December of 2016, presented to the hepatology clinic for routine follow up. One month prior, she was given avatrombopag prior to dental extractions with partial dentures for her thrombocytopenia since during her last dental procedures she had major bleeding requiring hospitalization with blood transfusions. Prior to her procedure her platelets were 81, INR 1.2 and comprehensive metabolic panel normal besides a bilirubin of 1.5. The patient was given avatrombopag 40 mg daily for five days prior to her dental procedure. There was no major bleeding or adverse events. As part of her routine follow up she had an abdominal ultrasound for hepatocellular carcinoma surveillance where she was found to have a new main PVT, compared to her prior abdominal ultrasound done nine months prior. An MRI performed to confirm this showed occlusion of the left portal vein and diminutive main and right portal veins without thrombus. She was started on direct oral anticoagulation with resolution of her left portal vein thrombus on repeat imaging six months later. DISCUSSION: Consideration of thrombosis after use of TPORA such as avatrombopag, especially with platelet counts above 50, is important as this can cause new onset ascites and preclude individuals from liver transplantation. Several peer reviewed articles suggest that there is no increase rate in PVT in patients with CLD-T who use these agents periprocedurally.1,2,3,4,5 Yet, there is a prescribing warning for these medications that PVT can occur in 2% of patients with CLD-T receiving these drugs.6 A high suspicion after utilization of these medications with symptoms such as abdominal pain, new ascites, or other clinical manifestations should warrant clinicians to rule out PVT after use of these medications and start appropriate anticoagulation as able.