Immune thrombocytopenic purpura following liver transplantation: A case series and review of the literature

Abstract

Thrombocytopenia is common among liver transplant candidates and recipients. The aim of our study was to determine the incidence and outcome of new-onset immune-mediated thrombocytopenic purpura (ITP) following liver transplantation at a single center. Among the 256 liver transplant recipients with an International Classification of Diseases, Ninth Edition code for thrombocytopenia, 8 cases of new-onset ITP were identified, leading to an overall incidence of 0.7% in 1,105 consecutive liver transplant recipients over a 15-year period. All 8 patients were Caucasian, 5 (63%) were male, and the median age at ITP onset was 54 years (range, 15-63). The median platelet count at presentation was 3,500 cells/mL (range, 1,000-12,000) and liver disease was due to hepatitis C (38%), primary sclerosing cholangitis (38%), and cryptogenic cirrhosis (25%). The median time from transplant to ITP onset was 53.5 months (range, 1.9-173). Three of the 6 patients tested (50%) had cell-bound antiplatelet antibodies, 1 patient had an underlying hematological malignancy, and none of the organ donors had a history of ITP. Corticosteroids and/or immunoglobulin infusions were effective in 4 patients. However, serial rituximab infusions were required in 4 patients with persistent thrombocytopenia, and 3 of them eventually required splenectomy to induce disease remission. At a median follow-up of 19.7 months, 7 long-term survivors remain in remission with a median platelet count of 267,000 cells/mL. In conclusion, new-onset ITP is an infrequent but important cause of severe thrombocytopenia in liver transplant recipients. Corticosteroids and immunoglobulin infusions were effective in 50% while the remainder of patients required rituximab infusions or eventual splenectomy for long-term disease remission. Liver Transpl 12: 781-791, 2006.

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“…6 Similar to our patient, ITP occurrs mostly after 1 year. 6 Miloh and associates reported 2 cases of new-onset ITP after LT with an incidence of 1.3% among 158 pediatric patients. 5 Additionally, they found 2 isolated autoimmune hemolytic anemia and 1 Evans syndrome cases.…”

“…Taylor and associates reported 8 adult cases of new-onset ITP after LT among 256 patients. 6 They found an incidence of ITP after LT was 0.7%, median platelet count at presentation was 3.5 × 10 9 /L, and median time from transplant to ITP onset was 53.5 months (range, 1.9-173 mo). 6 Similar to our patient, ITP occurrs mostly after 1 year.…”

“…6 They found an incidence of ITP after LT was 0.7%, median platelet count at presentation was 3.5 × 10 9 /L, and median time from transplant to ITP onset was 53.5 months (range, 1.9-173 mo). 6 Similar to our patient, ITP occurrs mostly after 1 year. 6 Miloh and associates reported 2 cases of new-onset ITP after LT with an incidence of 1.3% among 158 pediatric patients.…”

“…5 Median time from transplant time to ITP onset was 13 months (range, 1 d-5 y). 5 Associated cytomegalovirus, Epstein-Barr virus, and parvovirus B19 infections are described with ITP after LT. 5,6 Preexisting ITP in liver donors, or those with alloimmune thrombocytopenia because of human platelet antigen-1, may cause thrombocytopenia after LT. 6 Corticosteroids, immunoglobulin infusions, anti-D antibody, rituximab, or splenectomy may be chosen as a treatment. 7 Long-term remission can be achieved in most patients by these therapies.…”

Severe thrombocytopenia in liver transplantation

“…Many factors can contribute, such as reduced hepatic thrombopoietin production, allograft sequestration, hypersplenism (1,3,4), hemorrhage, heparin-induced thrompocytopenia, immunologic reactions, hemolysis, drugs, infections, platelet consumption secondary to DIC and sepsis (3,4). However most of these factors are not usually the cause of severe thrombocytopenia.…”