Journal of Hepatology 47 (2007) 625629 www.elsevier.

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Editorial

Thrombocytopenia in chronic liver disease: Lessons from transplanted patients q

Giacomo La*, Roberto Tarquini, Fabio Marra
` Di Firenze, Viale Morgagni 85 50134 Firenze, Italy Dipartimento di Medicina Interna, Universita

See Article, pages 651657

Patients with advanced cirrhosis have a complex hemostatic disturbance [13], and thrombocytopenia is a common feature of this derangement [13]. The pathogenesis of this phenomenon is complex, and splenic pooling, increased platelet consumption and/or impaired production have been variably suggested to contribute as etiologic factors [13]. Kinetic studies using radiolabelled platelets indicate an increase in platelet sequestration together with a reduction in mean platelet survival [4]. Nevertheless, the mean platelet count in patients with mild disease has been found to be nearly normal, because platelet production by the bone marrow is increased nearly twice above normal values [4]. Several studies have provided evidence for the hypothesis that when liver function progressively fails, reduced synthesis of thrombopoietin (TPO) results in an inappropriate stimulation of the bone marrow, and thrombocytopenia develops [510]. Besides quantitative changes, abnormalities of platelet function are also present in cirrhotics. An intrinsic platelet defect was suggested to be the most likely cause, related to impaired transmembrane signalling mechanisms, together with alterations in TxB2 production and in cholesterol content of the platelet membrane [11,12]. Evidence for an acquired platelet storage pool defect has also been obtained [13]. Extrinsic causes, such as abnormal high-density lipoproteins, reduced hematocrit, or

Associate Editor: Massimo Colombo q The authors declare that they have nothing to disclose regarding funding or conict of interest with respect to this manuscript. * Corresponding author. Tel.: +39 0554296466; fax: +39 055417123. E-mail address: g.la@dmi.uni.it (G. La).

nitric oxide overproduction due to altered platelet-vessel wall interaction, may also contribute to the platelet defect [1416]. Clinical relevance of defective platelet function remains uncertain and recently Lisman et al. have suggested that reduced platelet number and function may be compensated by the presence of elevated levels of von Willebrand Factor [17]. Moreover, Tripodi et al. [18] suggested that when blood coagulation capacity is globally measured using thrombin generation assay, as a function of coagulant and anticoagulant factors, patients with cirrhosis and abnormal standard coagulation tests form thrombin in amounts similar to healthy subjects. On the basis of these data, even the relevance of hemostatic derangement as a major cause of bleeding in liver disease has been questioned [19]. However, in daily practice, patients with cirrhosis are still considered at risk for surgery, and several guidelines indicate dened limits in platelet number below which invasive manoeuvres, including liver biopsy, are not recommended [2022]. In a recent elegant study, Tripodi et al. [23] provided evidence that thrombocytopenia plays a key role in thrombin generation, suggesting the need for correction of this defect in patients with severe thrombocytopenia and risk of bleeding. The study by Nascimbene et al. [5], published in this issue of the Journal, focuses on some interesting aspects related to thrombocytopenia in the transplanted patient, another relevant problem in this scenario, and adds relevant data on the pathogenesis and treatment of this defect. Thrombocytopenia due to hypersplenism is extremely common in transplant candidates, but even after transplantation (OLT) thrombocytopenia is frequent, and during the rst post-operative week a moderate

0168-8278/$32.00 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2007.08.006

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reduction in platelet count (20,00050,000/ll) occurs in about half of the patients, and counts below 20,000/ll are reported in about 8% of patients [2427]. Spontaneous resolution usually begins during the second week, and by the third week platelet count reaches or exceeds the levels measured before OLT. Persistence of thrombocytopenia increases the risk of bleeding-related complications, and therefore worsens the prognosis of the transplanted patients [2426]. Intra-abdominal bleeding after OLT is a common complication, and an exploratory laparotomy for bleeding is required in up to 14.5% of patients undergoing OLT [24,25]. McCaughan et al. [26] described the occurrence of intracranial hemorrhage in recently transplanted patients with severe thrombocytopenia. Finally, use of liver biopsy in the early post-operative period to diagnose allograft rejection can be precluded. All these aspects highlight the fact that thrombocytopenia may continue to be a relevant problem also after OLT. Several mechanisms may potentially account for thrombocytopenia in the transplanted patient. Post-transplant thrombocytopenia has been attributed to decreased platelet production, increased platelet consumption, or sepsis [2428]. Pre-existing hypersplenism also makes an important contribution, because the spleen gradually shrinks over a period of months, and up to a year after OLT, until a normal portal pressure can be restored [29]. A decrease in platelet count starts after reperfusion and platelet sequestration in the newly grafted liver has been suggested to occur [24]. Nascimbene et al. [5] have performed an accurate and thorough study on platelet turnover before and after OLT, serially measuring thrombopoietin levels and reticulated platelets. They also analyzed specic surface markers which indicate the extent of platelet activation, both in basal conditions and after ADP exposure. Moreover, antibodies directed against human platelet antigens, class I major histocompatibility complex and cardiolipin were also measured. In selected cases, bone marrow aspirate was obtained. An important point is that the authors excluded a pathogenetic role of infection, drug-induced myelosuppression, and autoimmunity, since in all patients antiplatelet antibodies were absent. The data obtained in the present study not only oer novel and compelling information on the pathogenesis of thrombocytopenia in the transplanted patient, but are also valuable to better elucidate the pathogenesis of thrombocytopenia in patients with advanced cirrhosis, awaiting OLT. Nonetheless, a possible limitation of the study is its diculty to explain why in some patients the degree of reduction in platelet count is extremely severe. A combination of chronic peripheral activation in the presence of a central maturation decit are considered the factors responsible for thrombocytopenia in the recently transplanted patient. According to several reports [510], once synthesis of TPO is restored by liver replacement,

platelet count progressively normalizes, despite the persistence of peripheral activation, thus pointing at reduced TPO levels as a cause of thrombocytopenia. On the other hand, although the pathogenesis of platelet activation is complex, the liver graft appears to be the most likely site of platelet activation and sequestration immediately after OLT. This hypothesis is supported by several lines of evidence, including basic science data [30]. Platelets are blood constituents that play a pivotal role not only in hemostais, but also in inammation and wound healing. Upon activation, platelets can release inammatory mediators and growth factors, that can either enhance or limit/repair tissue injury of the liver [31,32]. In this situation, apoptosis has been extensively indicated as an important mechanism of graft failure in the preserved and reperfused liver [33]. Studies on the isolated perfused rat liver model have shown that platelets, sequestered in the ischemic liver after reperfusion, induce sinusoidal endothelial cell apoptosis through a mechanism dependent on platelet adhesion on the sinusoidal lumen [33]. More recent experimental data also indicate that hepatic ischemia and reperfusion are followed by tissue repair and liver regeneration that are mediated by platelets [32]. In an experimental model of orthotopic and heterotopic liver graft in the pig, Porte et al. [34] demonstrated a sharp drop in platelet count in the venous outow of the graft after reperfusion, and histologic examination by electron microscopic of the liver biopsy taken after reperfusion demonstrated, as in a previous study [35], platelet accumulation in the sinusoids, where most platelets showed cell processes and many seemed to have lost their granuli, compatible with their activation. Studies on labelled platelets performed in patients conrm accumulation of platelets in the newly grafted liver [24]. Finally, McCaughan et al. [26], who studied the extent and time-course of thrombocytopenia in a large group of patients undergoing OLT, found that allograft dysfunction (maximum post-operative bilirubin and/or AST/ALT) is the most consistent predictor of the extent and duration of thrombocytopenia. Thus, platelet activation in vivo is conrmed to be a common occurrence in transplanted patients, similar to what has been demonstrated in cirrhotics, although the sites and mechanisms of activation are likely to be dierent. Additional important information is provided by the paper of Nascimbene et al. [5] on the therapeutic approaches for post-transplant thrombocytopenia. For management of thrombocytopenia in transplanted patients, it is rst critical to rule out the occurrence of sepsis, intravascular coagulation, immunological causes and drug-induced thrombocytopenia. Administration of high-dose intravenous immunoglobulins (IVIG) and steroids, although based on anecdotical reports, is the rst line therapy, while plasma exchange has been used to

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treat cyclosporine-associated thrombotic thrombocytopenic purpura [36] and splenectomy is reserved to severe and persistent thrombocytopenia [37]. High-dose IVIG, the treatment of choice in idiopathic thrombocytopenic purpura and other autoimmune diseases, exert their therapeutic eect by modulating Fcgamma-mediated platelet destruction in the spleen [38,39]. In fact, the spleen, the major site of platelet destruction, contains a large number of Fc receptor-bearing phagocytic cells, such as monocytes and macrophages, which can bind and destroy opsonized platelets. The more likely mechanism of action advocated for IVIG is the inhibition of Fcgamma RII and RIII receptors [38,39]. Alternative mechanisms of action, albeit not denitively proven, may be related to the presence of anti-idiotypic antibodies within IVIG, that may mediate the elimination of antiplatelet antibodies [39]. Data obtained by Nascimbene et al. [5] are important in that they provide indication, even though from a retrospective and not controlled study, that IVIG induce a rapid and ecient resolution of non-immune thrombocytopenia in posttransplanted patients. How can these data, obtained in the transplanted patient, provide help for the treatment of thrombocytopenia in cirrhotic patients, a problem that the hepatologist faces every day? At the moment, the available therapeutic armamentarium to correct thrombocytopenia, even in selected conditions such as bleeding, surgery or invasive manoeuvres, is scarce. Platelet transfusion would provide a suitable phospholipid surface to complement the normal thrombin generation provided by plasma, thus securing normal coagulation even in those patients with severe thrombocytopenia [23]. Platelet transfusion is eective when there is a rise of 10,000 plt/ml for each unit transfused [3]. Because of splenic pooling and accelerated consumption, cirrhotic patients seldom respond with this optimal rise in platelet count [3]. Moreover, platelet transfusion may induce alloimmunization and refractoriness to new transfusions, and a low risk of transferring infectious pathogens still exists [2]. Stimulation of megakaryocytes in the bone marrow would appear a promising therapeutic strategy in cirrhotics with defective TPO synthesis. Recombinant human TPO (rhTPO) and pegylated recombinant human megakaryocyte growth and development factor (PEG-rhMGDF) are synthetic peptides available as therapeutic TPOs [40]. PEG-rhMGDF showed good therapeutic ecacy in favouring platelet recovery in patients with ITP, but its administration was followed by development of antibodies against the recombinant drug, cross-reacting with endogenous TPO and causing severe thrombocytopenia [41,42]. The aminoterminal domain of TPO shares a remarkable homology with erythropoietin. This domain is the one that binds to the c-Mpl receptor and is sucient for signalling and to support cellular proliferation [43]. Pirisi

et al. [44] administered a short-term course (720 days) of recombinant human erythropoietin (4000 IU/day s.c.) to 12 patients with chronic liver disease (in 11 of whom diagnosis of cirrhosis was conrmed) and placebo to seven patients with cirrhosis with a platelet count <85 109/L. After treatment, platelets increased in the group treated with rhEPO from 70,000 to 101,250/ll while no dierences were observed in the placebo group. Four of the patients (33%) did not respond to the treatment, and remarkably, these patients had the lower baseline platelet count (58,500/ll vs 75,750/ll). The reduced response could be related to enhanced hemocathartic activity in these patients. Homoncik et al. [45] administered 100 IE/kg erythropoietin or placebo in a randomized, double-blind fashion to 22 patients with alcoholic cirrhosis (platelet count <120 109/L). The treatment increased platelet count by 25% and reactivity, indicated by activator-stimulated expression of Pselectin, was increased by twofold versus baseline. The increase in platelet count was more pronounced in patients with platelet count <80 109/L. Taken together, the data from Nascimbene et al. [5], indicating the relevance of the defect in TPO secretion, highlight the need for a safe and eective agent acting on this pathway. Along these lines, interleukin-11 acts synergistically with IL-3, TPO and stem cell factor to increase the number and maturation of megakaryocytic progenitors. Ghalib et al. [46] administered rhIL-11 to patients with cirrhosis and thrombocytopenia and observed an increase in platelet count. Nonetheless, its wide use is limited by the relevant side eects, such as uid retention, observed in about 60% of treated patients. An additional nal suggestion that may be derived from the study by Nascimbene et al. [5] is the possible use of IVIG in cirrhotic patients. However, more solid data based on controlled trials must be rst obtained in post-transplant thrombocytopenia, before a possible extrapolation to the wide area of patients with end-stage liver disease. In this latter setting, patients with increased hemocathartic activity are the most likely candidates to benet from this approach. The nice study published in this issue of the Journal has the merit of providing non-anecdotical evidence on a severe and difcult complication such as that of thrombocytopenia in liver-transplanted patients, and to focus attention to the needs of the scores of patients with cirrhosis that are at risk of dying of bleeding-related complications.

References
[1] Zwicker JI, Drews RE. Hematologic disorders and the liver. In: Schi ER, Sorrell MF, Maddrey WC, editors. Schis diseases of the liver. Philadelphia: Lippincott Williams& Wilkins; 2007. p. 49363. [2] Hedner U, Erhardtsen E. Hemostatic disorders in liver diseases. In: Schi ER, Sorrell MF, Maddrey WC, editors. Schis diseases

628

G. La et al. / Journal of Hepatology 47 (2007) 625629 of the Liver. Philadelphia: Lippincott Williams& Wilkins; 2003. p. 625636. Fiore LD, Brophy MT, Deykin D. Hemostasis. In: Zakim D, Boyer TD, editors. Hepatology. A textbook of liver disease. Philadelphia: Saunders; 2003. p. 49580. Stein SF, Harker LA. Kinetic and functional studies of platelets, brinogen, and plasminogen in patients with hepatic cirrhosis. J Lab Clin Med 1982;99:217230. Nascimbene A, Iannacone M, Brando B, De Gasperi A. Acute thrombocytopenia after liver transplant: Role of platelet activation, thrombopoietin deciency and response to high dose intravenous IgG treatment. J Hepatol 2007;47:651657. Peck-Radosavljevic M, Zacherl J, Meng YG, Pidlich J, Lipinski E, Langle F, et al. Is inadequate thrombocytopenia in cirrhosis of the liver? J Hepatol 1997;27:127131. Martin TG, Somberg KA, Meng G, Cohen RL, Heid CA, Sauvage FJ, et al. Thrombopoietin levels in patients with cirrhosis before and after orthotopic liver transplantation. Ann Int Med 1997;127:285288. Goulis J, Chau TN, Jordan S, Mehta AB, Watkinson A, Rolles K, et al. Thrombopoietin concentrations are low in patients with cirrhosis and thrombocytopenia and are restored after orthotopic liver transplantation. Gut 1999;44:754758. Faeh M, Hauser SP, Nydegger UE. Transient thrombopoietin peak after liver transplantation for end-stage liver disease. Br J Haematol 2001;112:493498. Peck-Radosavljevic M, Wichlas M, Zacherl J, Stiegler G, Stohlawetz P, Fuchsjager M, et al. Thrombopoietin induces a rapid resolution of thrombocytopenia after orthotopic liver transplantation through increased platelet production. Blood 2000;95:795801. La G, Cominelli F, Ruggiero M, Fedi S, Chiarugi VP, La Villa G, et al. Altered platelet function in cirrhosis of the liver: impairment of inositol lipid and arachidonic acid metabolism in response to agonists. Hepatology 1988;8:16201626. Owen JSA, Hutton RA, Day RC. Platelet lipid composition and platelet aggregation in human liver disease. J Lipid Res 1981;22:423430. La G, Marra F, Gresele P, Romagnoli P, Palermo A, Bartolini O, et al. Evidence for a storage pool defect in platelets from cirrhotic patients with detective aggregation. Gastroenterology 1992;103:641646. Desai K, Mistry P, Bagget C, Burroughs AK, Bellamy MF, Owen JS. Inhibition of platelet aggregation by abnormal high density lipoprotein particles in plasma from patients with hepatic cirrhosis. Lancet 1989;1:693695. Turitto VT, Baumgartner HR. Platelet interaction with subendothelium in a perfusion system: a physical role of red blood cells. Microvasc Res 1975;9:335344. La G, Marra F, Failli P, Ruggiero M, Cecchi E, Carloni V, et al. Defective signal transduction in platelets from cirrhotics is associated with increased cyclic nucleotides. Gastroenterology 1993;105:148156. Lisman T, Bongers TN, Adelmeijer J, Janssen HLA, de Maat MPM, deGroot PG, et al. Elevated levels of von Willebrand Factor in Cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006;44:5361. Tripodi A, Salerno F, Chantarangkul V, Clerici M, Cazzaniga M, Primignani M, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005;4:553558. Mannucci PM. Abnormal hemostasis tests and bleeding in chronic liver disease: are they related? No. J Thromb Haemost 2006;4:721723. La G, Marra F, Tarquini R, Abbate R. Coagulation defects in cirrhosis old dogmas not yet ready for burial. J Thromb Haemost 2006;4:20682069. [21] Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. Gut 1999;45 (Suppl. 4):111. [22] Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001;344:495500. [23] Tripodi A, Primignani M, Chantarangkul V, Clerici M, DellEra A, Fabris F, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology 2006;44:440445. [24] Plevak DJ, Halma GA, Forstrom LA, Dewanjee MK, O Connor MK, Moore SB, et al. Thrombocytopenia after liver transplantation. Transplant Proc 1988;20:630633. [25] Munoz SJ, Carabasi AR, Moritz MJ, Jarrell BE, Maddrey WC. Postoperative thrombocytopenia in liver transplant recipients: prognostic implications and treatment with high dose of gammaglobulin. Transplant Proc 1989;21:35453546. [26] McCaughan GW, Herkes R, Powers B, Rickard K, Gallagher ND, Thompson JF, et al. Thrombocytopenia postliver transplantation. Correlations with pre-operative platelet count,blood transfusion requirements, allograft function and outcome. J Hepatol 1992;16:1622. [27] Richards EM, Alexander GJM, Calne RY, Baglin TP. Thrombocytopenia following liver transplantation is associated with platelet consumption and thrombin generation. Br J Haematol 1997;98:315321. [28] Miyata T, Yokoyama I, Todo S, Tzakis A, Selby R, Starzl TE. Endotoxaemia, pulmonary complications and thrombocytopenia in liver transplantation. Lancet 1989;2:189191. [29] Witte M, Langnas AN, Hirst K, Stratta RJ, Shaw BW. Impact of liver transplantation on the reversal of hypersplenism. Transplant Proc 1993;25:1987. [30] Cywes R, Packham MA, Tietze L, Sanabria JR, Harvey PR, Phillips MJ, et al. Role of platelets in hepatic allograft preservation injury in the rat. Hepatology 1993;18:635647. [31] Mannaioni PF, Di Bello MG, Masini E. Platelets and inammation:role of platelet-derived growth factor, adhesion molecules and istamine. Inamm Res 1997;46:418. [32] Nocito A, Georgiev P, Dahm F, Jochum W, Bader M, Graf R, et al. Platelets and platelet-derived serotonin promote tissue repair after normothermic hepatic ischemia in mice. Gastroenterology 2007;45:369376. [33] Sindram D, Porte RJ, Homan MR, Bentley RC, Clavien PA. Platelets induce sinusoidal endothelial cell apoptosis upon reperfusion of the cold ischemic rat liver. Gastroenterology 2000;118:183191. [34] Porte RJ, Blauw E, Knot EAR, de Maat MPM, de Ruiter C, Bakker CM, et al. Role of the donor liver in the origin of platelet disorders and hyperbrinolysis in liver transplantation. J Hepatol 1994;21:592600. [35] Hutchison DE, Genton E, Porter KA, Daloze PM, Huguet C, Brettschneider L, et al. Platelet changes following clinical and experimental hepatic homotransplantations. Arch Surg 1968;97:2733. [36] Dzik WH, Georgi BA, Khettry U, Jenkins RL. Cyclosporineassociated thrombotic thrombocytopenic purpura following liver transplantation: successful treatment with plasma exchange. Transplantation 1987;44:570572. [37] Altaca G, Scigliano E, Guy S, Scheiner P, Reich D, Schwartz M, et al. Persistent hypersplenism early after liver transplant: The role of splenectomy. Transplantation 1997;64:14811483. [38] Lazarus AH, Crow AR. Mechanism of action of IVIG and anti-D in ITP. Transfus Apher Sci 2003;28:249255. [39] Jin F, Balthasar JP. Mechanisms of intravenous immunoglobulin action in Immune Thrombocytopenic Purpura. Hum Immunol 2005;66:403410. [40] Vadhan-Raj S, Cohen V, Bueso-Ramos C. Thrombopoietin growth factors and cytokines. Curr Hematol Rep 2005;4:137144. [41] Nomura S, Dan K, Hotta T, Fujimura K, Ikeda Y. Eects of pegylated recombinant human megakaryocyte growth and development factor in patients with ITP. Blood 2002;100:728730.

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

G. La et al. / Journal of Hepatology 47 (2007) 625629 [42] Li J, Yang C, Xia Y, Bertino A, Glaspry J, Roberts M, et al. Thrombocytopenia caused by the development of antibodies to thrombopoietin. Blood 2001;98:32413248. [43] Cosman D. The hematopoietin receptor superfamily. Cytokine 1993;5:95106. [44] Pirisi M, Fabris C, Soardo G, Cecchin E, Toniutto P, Bartoli E. Thrombocytopenia of chronic liver disease corrected by erythropoietin treatment. J Hepatol 1994;21:376380.

629

[45] Homoncik M, Jilma-Stohlawetz P, Schmid M, Ferlitsch A, PeckRadosavljevic M. Erythropoietin increases platelet reactivity and platelets counts in patients with alcoholic liver cirrhosis: a randomized, double-blind placebo-controlled study. Aliment Pharmacol Ther 2004;20:437443. [46] Ghalib R, Levine C, Hassan M, McClelland T, Goss J, Stribling R, et al. Recombinant human Interleukin-11 improves thrombocytopenia in patients with cirrhosis. Hepatology 2003;37:11651171.