Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 27, 2022; 14(7): 1421-1437
Published online Jul 27, 2022. doi: 10.4254/wjh.v14.i7.1421
Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease
Sagnik Biswas, Manas Vaishnav, Piyush Pathak, Deepak Gunjan, Soumya Jagannath Mahapatra, Saurabh Kedia, Gyanranjan Rout, Bhaskar Thakur, Baibaswata Nayak, Ramesh Kumar, Shalimar
Sagnik Biswas, Manas Vaishnav, Piyush Pathak, Deepak Gunjan, Soumya Jagannath Mahapatra, Saurabh Kedia, Gyanranjan Rout, Baibaswata Nayak, Shalimar, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Bhaskar Thakur, Division of Biostatistics, UT Southwestern Medical Center, Dallas, Texas 75390, United States
Ramesh Kumar, Department of Gastroenterology, All India Institute of Medical Sciences, Patna 800014, Bihar, India
Author contributions: The study was designed by Shalimar; Biswas S, Vaishnav M, Pathak P, Gunjan D, Mahapatra SJ, Kedia S, Rout G, Nayak B, Kumar R, Shalimar were all involved in the clinical management of the enrolled patients as well as the collection of data; The analysis of the collected data was done by Shalimar, Thakur B, Vaishnav M, and Biswas S; The manuscript was drafted by Biswas S and Vaishnav M under the guidance of Shalimar and was reviewed and approved by all of the authors.
Institutional review board statement: This study was reviewed and approved by the Institutional Ethics Committee for Post Graduate research (IECPG) of the All India Institute of Medical Sciences, New Delhi, India.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
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: Shalimar, MBBS, MD, Additional Professor, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, Delhi, India. drshalimar@gmail.com
Received: March 23, 2022
Peer-review started: March 23, 2022
First decision: April 28, 2022
Revised: May 13, 2022
Accepted: July 6, 2022
Article in press: July 6, 2022
Published online: July 27, 2022
Processing time: 126 Days and 0 Hours
ARTICLE HIGHLIGHTS
Research background

The most important question answered by this study is that platelet transfusions are not beneficial but harmful to chronic liver disease patients presenting with variceal bleeding. We clearly have shown that thrombocytopenia at baseline did not impact the rebleed rates or mortality. Higher rebleed rates were seen only in those receiving platelets and FFP while those receiving FFP also demonstrated higher mortality rates. Moving further a prospective study to compare the impact of transfusions may be contemplated, but considering the potential of harm to patients, it may not be ethically feasible.

Research motivation

Platelet transfusions increase the rebleed rate at days 5 and 42 but do not contribute to higher mortality rates at day 42. FFP transfusions lead to more severe rebleeds on days 5 and 42 with higher mortality among recipients on day 42.

Research objectives

The study included 913 patients. Rebleeding rates were similar between the three platelet groups (< 20 × 109/L, 20-50 × 109/L, and > 50 × 109/L) on days 5 and 42. On day 42, the mortality rates for the three platelet groups were also similar. On PSM analysis, patients receiving platelets transfusions (n = 89) had significantly higher rebleeding rates on day 5 and day 42 than those who didn't. The mortality rates were also higher among patients receiving platelets, although the difference was insignificant. However, patients who received FFP had higher rebleed rates on days 5 and 42, along with higher mortality rates on day 42, with higher packed red blood cell requirements, indicating a more severe bleed with greater blood loss. 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.

Research methods

All patients with chronic liver disease presenting with acute variceal bleed over 4 years period from 2017 to 2021 and giving consent were enrolled for the study. Demographic and clinical data were collected at baseline and the patients followed up till death or 42 days whichever was later. Patients were divided into 3 groups based on platelet counts- < 20 × 109/L, 20-50 × 109/L, and > 50 × 109/L for analysis. A subgroup analysis was done for those receiving fresh frozen plasma (FFP) and platelets and FFP.

Research results

Our objectives were to identify the impact of platelet count and platelet transfusions in patients with chronic liver disease presenting with an acute variceal bleed in terms of rebleed rates on days 5 and 42 and mortality rates on day 42.

Research conclusions

The lack of data on platelet transfusion often leads to unnecessary transfusions of high volumes of platelets or fresh frozen plasma to chronic liver disease patients with acute variceal bleeding. Transfusions lead to a rise in portal pressure and may precipitate a rebleed, leading to further transfusions and a vicious cycle. Thus patient outcomes may be potentially worsened by unnecessary and empiric transfusions.

Research perspectives

There is a paucity of data on the impact of platelet transfusion on outcomes of patients of chronic liver disease presenting with acute variceal bleed. None of the major clinical guidelines provides definitive recommendations on transfusion of platelets during a variceal bleed to correct thrombocytopenia. Thus clinical management of such patients is guided by local policies rather than evidence-based.