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World J Gastroenterol. Aug 14, 2022; 28(30): 4061-4074
Published online Aug 14, 2022. doi: 10.3748/wjg.v28.i30.4061
Thrombocytopenia in chronic liver disease: Physiopathology and new therapeutic strategies before invasive procedures
Paolo Gallo, Francesca Terracciani, Giulia Di Pasquale, Matteo Esposito, Antonio Picardi, Umberto Vespasiani-Gentilucci
Paolo Gallo, Francesca Terracciani, Giulia Di Pasquale, Matteo Esposito, Antonio Picardi, Umberto Vespasiani-Gentilucci, Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
Author contributions: Vespasiani-Gentilucci U and Gallo P conceived the study; Gallo P, Terracciani F, Di Pasquale G, and Esposito M wrote the manuscript; Picardi A and Vespasiani-Gentilucci U helped in drafting and revising the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Paolo Gallo, MD, Associate Research Scientist, Doctor, Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Via Alvaro del Portillo, 200, Roma 00128, Italy. paolo.gallo@policlinicocampus.it
Received: January 24, 2022
Peer-review started: January 24, 2022
First decision: April 10, 2022
Revised: April 21, 2022
Accepted: July 18, 2022
Article in press: July 18, 2022
Published online: August 14, 2022
Abstract

Chronic liver disease is characterized by several hematological derangements resulting in a complex and barely rebalanced haemostatic environment. Thrombocytopenia is the most common abnormality observed in these patients and recent advances have led to researchers focus the attention on the multifactorial origin of thrombocytopenia and on the key role of thrombopoietin (TPO) in its physiopathology. Severe thrombocytopenia (platelet count < 50000/μL) complicates the management of patients with chronic liver disease by increasing the potential risk of bleeding for invasive procedures, which may be therefore delayed or canceled even if lifesaving. In the very last years, the development of new drugs which exceed the limits of the current standard of care (platelet transfusions, either immediately before or during the procedure) paves the way to a new scenario in the management of this population of patients. Novel agents, such as the TPO-receptor agonists avatrombopag and lusutrombopag, have been developed in order to increase platelet production as an alternative to platelet transfusions. These agents have demonstrated a good profile in terms of efficacy and safety and will hopefully allow reducing limitations and risks associated with platelet transfusion, without any delay in scheduled interventions. Altogether, it is expected that patients with chronic liver disease will be able to face invasive procedures with one more string in their bow.

Keywords: Thrombocytopenia, Chronic liver disease, Thrombopoietin agonists, Platelet transfusions, Avatrombopag, Lusutrombopag

Core Tip: Recent advances have shed light on the pathophysiology of thrombocytopenia in chronic liver disease and on the key role of thrombopoietin (TPO). Severe thrombocytopenia complicates the management of patients with liver disease by increasing the potential risk of bleeding for invasive procedures, possibly delaying lifesaving interventions. In the very last years, novel agents such as the TPO-receptor agonists avatrombopag and lusutrombopag have been developed in order to increase platelet production as an alternative to platelet transfusions, with positive efficacy and safety outcomes.