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

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 Coxproportional 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 nonsignificant effect on mortality.

Coronavirus Disease-2019(COVID-19)and the Liver

Within a year of its emergence,coronavirus disease-2019(COVID-19)has evolved into a pandemic.What has emerged during the past 1 year is that,apart from its potentially fatal respiratory presentation from which the severe acute respiratory syndrome-coronavirus-2(SARS-CoV-2)derives its name,it presents with a myriad of gastrointestinal(GI)and liver manifestations.Expression of the angiotensinconverting enzyme-2(ACE-2)receptor throughout the GI tract and liver,which is the receptor for the SARS-CoV-2,may be responsible for the GI and liver manifestations.Besides acting directly via the ACE-2 receptor,the virus triggers a potent immune response,which might have a role in pathogenesis.The virus leads to derangement in liver function tests in close to 50%of the patients.The impact of these derangements in patients with a normal underlying liver seems to be innocuous.Severe clinical presentations include acute decompensation and acute-on-chronic liver failure in a patient with chronic liver disease,leading to high mortality.Evolving data suggests that,contrary to intuition,liver transplant recipients and patients with autoimmune liver disease on immunosuppression do not have increased mortality.The exact mechanism underlying why immunosuppressed patients fare well as compared to other patients remains to be deciphered.With newer variants of COVID-19,which can spread faster than the original strain,the data on hepatic manifestations needs to be updated to keep a step ahead of the virus.