Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease

Abstract

BACKGROUND Platelet transfusion in acute variceal bleeding (AVB) is recommended by few guidelines and is common in routine clinical practice, even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear. AIM To determine how platelet counts, platelets transfusions, and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality. METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB. The outcomes were assessed as the risk of rebleeding at days 5 and 42, and risk of death at day 42, considering the platelet counts and platelet transfusion. Propensity score matching (PSM) was used to compare the outcomes in those who received platelet transfusion. Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Cox-proportional hazard model for rebleeding and for 42-d mortality. RESULTS The study included 913 patients, with 83.5% men, median age 45 years, and Model for End-stage Liver Disease score 14.7. Platelet count < 20 × 10 9 /L, 20-50 × 10 9 /L, and > 50 × 10 9 /L were found in 23 (2.5%), 168 (18.4%), and 722 (79.1%) patients, respectively. Rebleeding rates were similar between the three platelet groups on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on days 5, P = 0.150; and 21.7%, 17.3%, and 14.4%, respectively, on days 42, P = 0.433). At day 42, the mortality rates for the three platelet groups were also similar (13.0%, 23.2%, and 17.2%, respectively, P = 0.153). On PSM analysis patients receiving platelets transfusions ( n = 89) had significantly higher rebleeding rates on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014), compared to those who didn't. The mortality rates were also higher among patients receiving platelets (25.8% vs 23.6%; P = 0.862), although the difference was not significant. On multivariate analysis, platelet transfusion and not platelet count, was independently associated with 42-d rebleeding. Hepatic encephalopathy was independently associated with 42-d mortality. CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB; however, platelet transfusion increased rebleeding on days 5 and 42, with a higher but non-significant effect on mortality.

Massive Transfusion Protocol and Outcome of Patients with Acute Variceal Bleeding

“…Restrictive transfusion was linked with decreased risk of all-cause mortality (RR 0.65, 95% CI 0.44-0.97, p = 0•03) and overall rebleeding (0.58, 0.40-0.84, p = 0.004) when acute upper gastrointestinal bleeding occurred [30]. In previous clinical studies, fresh frozen plasma, platelet, and pRBC transfusions were associated with poor clinical outcomes in patients with AVB [31][32][33]. Notably, compared to non-variceal bleeders receiving a blood transfusion, variceal bleeders had nearly fourfold higher odds of inpatient mortality [33].…”

Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines

“…Similarly, Biswas et al [ 75 ] investigated how platelet counts, platelet transfusions, and fresh frozen plasma transfusions affect the outcomes of acute variceal bleeding in cirrhosis patients in terms of bleeding control, rebleeding, and mortality. In a cohort of 913 patients stratified into three different groups according to platelet count (< 20000/μL, 20000/μL-50000/μL, > 50000/μL), thrombocytopenia did not affect rebleeding rates on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on day 5; and 21.7%, 17.3%, and 14.4%, respectively, on day 42) and mortality rates (13.0%, 23.2%, and 17.2%, respectively) that were similar between the three platelet groups.…”

“…In a cohort of 913 patients stratified into three different groups according to platelet count (< 20000/μL, 20000/μL-50000/μL, > 50000/μL), thrombocytopenia did not affect rebleeding rates on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on day 5; and 21.7%, 17.3%, and 14.4%, respectively, on day 42) and mortality rates (13.0%, 23.2%, and 17.2%, respectively) that were similar between the three platelet groups. However, platelet transfusion increased rebleeding on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014) compared to patients who did not receive it, with a higher but nonsignificant effect on mortality (25.8% vs 23.6%)[ 75 ].…”