Procedure‐related bleeding risk in patients with cirrhosis and severe thrombocytopenia

Abstract

The PReBRiC (Procedure-Related Bleeding Risk in Cirrhosis) groupThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

“…Anonymized questionnaire responses were collected and analyzed by two independent reviewers, then emailed back to all nine CHEC guideline development group members for second-round review. Due to an absence of regional and international consensus statements and guidelines on TPO-RA use for CLD patients with TCP undergoing elective procedures, the expert CEHC group used the European systematic literature review recently conducted by Alvaro et al (2021) [20], where appropriate, as evidence to support each platelet count threshold recommendation. Good practice recommendations were also formulated based on the clinical experience of the CHEC guideline development group.…”

“…The primary outcomes for L-PLUS 1 and L-PLUS 2 were similar to the phase 3 trials for avatrombopag (Table 1 and Figure 1). Pooled data from L-PLUS 1 and L-PLUS 2 showed that lusutrombopag vs. placebo was associated with a numerically lower rate of postprocedural bleeding (6.7% vs 10.6%, respectively) without increased risk of thrombosis [21][22][23]. In addition, adverse events were somewhat balanced between the treatment and placebo arms [21][22][23].…”

“…Notably, only a few studies, among those that assessed the Lusutrombopag is another oral, small-molecule TPO agonist that stimulates platelet production through its action on TPO surface cells of megakaryocytes [16]. Evidence supporting the efficacy and safety of lusutrombopag is provided from two multicenter, randomized, double-blind, parallel-group, placebo-controlled phase 3 studies, L-PLUS 1 [21] and L-PLUS 2 [22]. The primary outcomes for L-PLUS 1 and L-PLUS 2 were similar to the phase 3 trials for avatrombopag (Table 1 and Figure 1).…”

Treatment algorithm for thrombocytopenia in patients with chronic liver disease undergoing planned invasive procedures

“…55 A recent narrative review concluded that there is still a lack of adequate and reliable data describing the risk of bleeding following invasive procedures in patients with advanced liver disease, and its potential association with decreased platelet count. 56 Treatment options for patients with platelet count <50 £ 10 9 /L For patients with CLD whose pretreatment platelet count is <50 � 10 9 /L, our algorithm recommends TPORAs as first-line therapy (Figure 1). For patients who are ineligible for treatment with TPORAs, such as children and pregnant women, or patients who require urgent procedures, platelet transfusion can be considered.…”

Prophylactic blood transfusion prior to elective invasive procedures

“…The most severe complications of liver biopsies are intraperitoneal hemorrhage, hemobilia, and hematoma formation. The risk of clinically relevant bleeding complications that result in hemodynamic compromise or require some form of intervention ranges from 0.01 to 0.5% 30,31 .…”