Albumin–bilirubin grade as a predictor of survival in hepatocellular carcinoma patients with thrombocytopenia

BACKGROUND The models for assessing liver function,mainly the Child–Pugh(CP),albuminbilirubin(ALBI),and platelet–ALBI(PALBI)classifications,have been validated for use in estimating the prognosis of hepatocellular carcinoma(HCC)patients.However,thrombocytopenia is a common finding and may influence the prognostic value of the three models in HCC.AIM To investigate and compare the prognostic performance of the above three models in thrombocytopenic HCC patients.METHODS A total of 135 patients with thrombocytopenic HCC who underwent radical surgery were retrospectively analyzed.Preoperative scores on the CP,ALBI and PALBI classifications were estimated accordingly.Kaplan–Meier curves with logrank tests and Cox regression models were used to explore the significant factors associated with overall survival(OS)and recurrence-free survival(RFS).RESULTS The preoperative platelet counts were significantly different among the CP,ALBI and PALBI groups.After a median follow-up of 28 mo,39.3%(53/135)of the patients experienced postoperative recurrence,and 36.3%(49/135)died.Univariate analysis suggested thatα-fetoprotein levels,tumor size,vascular invasion,and ALBI grade were significant predictors of OS and RFS.According to the multivariate Cox regression model,ALBI was identified as an independent prognostic factor.However,CP and PALBI grades were not statistically significant prognostic indicators.CONCLUSION The ALBI grade,rather than CP or PALBI grade,is a significant prognostic indicator for thrombocytopenic HCC patients.

Predictive value of thrombocytopenia for bloodstream infection in patients with sepsis and septic shock

BACKGROUND Thrombocytopenia is common in patients with sepsis and septic shock.AIM To analyse the decrease in the number of platelets for predicting bloodstream infection in patients with sepsis and septic shock in the intensive care unit.METHODS A retrospective analysis of patients admitted with sepsis and septic shock in Xingtai People Hospital was revisited.Patient population characteristics and laboratory data were collected for analysis.RESULTS The study group consisted of 85(39%)inpatients with bloodstream infection,and the control group consisted of 133(61%)with negative results or contamination.The percentage decline in platelet counts(PPCs)in patients positive for pathogens[57.1(41.3-74.6)]was distinctly higher than that in the control group[18.2(5.1–43.1)](P<0.001),whereas the PPCs were not significantly different among those with gram-positive bacteraemia,gram-negative bacteraemia,and fungal infection.Using receiver operating characteristic curves,the area under the curve of the platelet drop rate was 0.839(95%CI:0.783-0.895).CONCLUSION The percentage decline in platelet counts is sensitive in predicting bloodstream infection in patients with sepsis and septic shock.However,it cannot identify gram-positive bacteraemia,gram-negative bacteraemia,and fungal infection.

Pituitary apoplexy secondary to dengue fever-induced-thrombocytopenia:A case report and review of literature

Rationale:Pituitary apoplexy(PA)is a rare endocrine emergency that requires prompt diagnosis and management.Dengue fever-induced-thrombocytopenia may rarely predispose to PA.Patient’s Concern:A 58-year-old male patient having known pituitary macroadenoma presented to the emergency department with fever,a sudden onset severe headache,and altered sensorium.Diagnosis:Pituitary apoplexy caused by dengue fever-induced-thrombocytopenia.Interventions:Conservative management with fluids,mannitol,dexamethasone and symptomatic treatment.Outcomes:The patient responded well to the treatment and was discharged uneventfully.Lessons:Although dengue hemorrhagic fever is a rare cause of pituitary apoplexy,it should be considered if a patient presents with headache and altered sensorium,and prompt initiation of treatment is crucial to prevent fatality and neuro-ophthalmic deficits.

Spontaneous Heparin-Induced Thrombocytopenia Presenting as Concomitant Bilateral Cerebrovascular Infarction and Acute Coronary Syndrome

Background:Spontaneous heparin-induced thrombocytopenia is a pro-thrombotic syndrome in which anti-heparin antibodies develop without heparin exposure.Case presentation:A 78-year-old man who underwent a successful lumbar laminectomy presented to the hospital 5 days after discharge for stroke-like symptoms and was found to have acute infarcts of the bilateral frontal lobes.The patient was found to be severely thrombocytopenic and was incidentally found to have an inferior wall myocardial infarction.Further investigation led to the diagnosis of bilateral lower extremity deep vein thromboses.His overall clinical presentation prompted a detailed hematologic workup that indicated positivity for heparin-induced thrombocy-topenia despite no previous exposure to heparin products.Conclusions:This case illustrates a patient with no prior lifetime heparin exposure who underwent laminectomy with subsequent development of acute infarcts of the bilateral frontal lobes,an inferior wall myocardial infarction,and bilateral lower extremity deep vein thromboses,with concern for sequelae of spontaneous heparin-induced thrombo-cytopenia.

Rivaroxaban for the treatment of heparin-induced thrombocytopenia with thrombosis in a patient undergoing artificial hip arthroplasty:A case report

BACKGROUND Anticoagulation treatment after lower limb surgery is one of the key methods to avoid thrombosis,and low-molecular-weight heparin is the treatment that is most frequently used in clinical practice.But one uncommon side effect of lowmolecular-weight heparin is heparin-induced thrombocytopenia(HIT),which can develop into thrombosis if not caught early or managed incorrectly.CASE SUMMARY We present a case of a patient who underwent hip arthroplasty and experienced thrombocytopenia due to HIT on the 9th d following the application of lowmolecular-weight heparin anticoagulation.We did not diagnose HIT in time and applied 1 unit of platelets to the patient,which led to thrombosis.Luckily,the patient recovered following effective and timely surgery and treatment with rivaroxaban.CONCLUSION Patients using low-molecular-weight heparin after lower limb surgery need to have their platelet counts regularly checked.If HIT develops,platelet treatment should be given with caution.

Chinese expert consensus on managing thrombocytopenia in patients with cancer and liver injury

Thrombocytopenia and liver injury are serious clinical problems in patients with cancer. The etiologyof thrombocytopenia in patients with cancer and liver injury (TCLI) is complicated. Managing cancertherapy-induced thrombocytopenia has gradually become standardized, and managing liver injuryassociatedthrombocytopenia has become more effective with the approval and marketing of relevantdrugs. However, the optimal strategy for managing thrombocytopenia in patients with cancer and liverinjury remains unclear, and the superposition of thrombocytopenia and liver injury further increasesthe difficulty of cancer treatment. Therefore, the Committee of Cancer Support Therapy of the ChineseAnti-Cancer Association has organized experts to analyze and discuss relevant literature to form aChinese expert consensus on managing thrombocytopenia in patients with cancer and liver injury(2022 Edition) to guide clinical practice.

Neonatal Thrombocytopenia at Dakar Principal Hospital

Neonatal thrombocytopenia accounts for 20% of neonates hospitalized in the neonatal intensive care unit (NICU) at DPH. The etiologies are multiple, but bacterial infection is the third leading cause of neonatal mortality worldwide. We therefore set out to assess the frequency of neonatal thrombocytopenia associated or not with bacterial infection in the NICU. We conducted a retrospective and prospective study with the DPH NICU, over 10 months (August 2018 and April 2019). Thrombocytopenia encountered in the NICUs, were the subject of research into bacteriological, inflammatory, and epidemiological parameters using Inlog laboratory data processing software. During this period, 1280 babies were hospitalized, 94 of whom underwent thrombocytopenia, corresponding to 7.34%, with a sex ratio of 0.92. The number of babies presenting with thrombocytopenia during the first week of hospitalization was 72, accounting for 76.6%. The clinical context was usually low birth weight in 30.8% of cases and perinatal asphyxia (25%). Thrombocytopenia ranged from 2000 to 137,000 with an average of 69,520/mm3. Among these thrombocytopenias, 64 cases (68%) were below 100,000 mm3 and 44 cases had a CRP >5 mg/l. A total of 30 bacteria were isolated, including 23 Enterobacteria, 2 Streptococci, and 1 Acinetobacter. Among these enterobacteria, 14 were multidrug-resistant (MDR). Thrombocytopenia associated with a multidrug-resistant bacterial infection is a real challenging management.

Diagnostic Approach of Thrombocytopenia in Pregnancy: A Review

Thrombocytopenia (defined as platelet count 9/L) is present in 7% - 12% of pregnant women at delivery. Although there are mild etiologies of this condition that are often diagnosed incidentally, there are more severe causes that can be life threating. Thrombocytopenia also has a great implication in surgical risk and regional anesthesia. A structured evaluation of thrombocytopenia is necessary to allow an adequate diagnostic approach. Here we summarized the current knowledge of thrombocytopenia in pregnancy.

The Role and Safety of Personalized Care in Improving Thrombocytopenia after Lymphoma Chemotherapy

Objective:To explore and analyze the effect and safety of personalized nursing in improving thrombocytopenia after lymphoma chemotherapy.Methods:80 lymphoma patients with thrombocytopenia after lymphoma chemotherapy in the Department of Hematology of our hospital from May 2021 to May 2023 were selected as the research objects,and they were divided into an experimental group and reference group by random drawing,with 40 cases in each group.The experimental group received individualized nursing,and the reference group received routine nursing.The platelet count,platelet-related indicators,incidence of adverse reactions,and life scores were compared between the two groups.Results:Before the intervention,there was no significant difference in platelet count between the groups(P>0.05);after the intervention,the platelet count in the experimental group was significantly higher compared to the reference group(P<0.05).In the experimental group,the duration for platelet decline and the time for platelets to normalize were notably shorter compared to the reference group(P<0.05).Moreover,the personality group displayed a significantly lower incidence of adverse reactions than the reference group(P<0.05).Prior to the intervention,there were no statistically significant differences(P>0.05)in the life scores between the two groups,such as functional condition,symptom manifestation,and health scores among the groups.However,post-intervention,the personality group exhibited a significant improvement in those scores compared to the reference group(P<0.05).Conclusion:Individualized nursing can optimize the platelet level in thrombocytopenia after lymphoma chemotherapy,improve symptoms,and reduce the occurrence of adverse reactions.

Efficacy of Low-Dose Rituximab in Primary Immune Thrombocytopenia

Objective:To explore the effect of low-dose rituximab in primary immune thrombocytopenia.Methods:From January 2022 to January 2023,60 patients with primary immune thrombocytopenia were randomly divided into two groups.The control group was treated with standard doses of rituximab,and the observation group was treated with low doses of rituximab.Rituximab was used for treatment,and the clinical curative effect of the two groups was observed.Results:Before treatment,there was no statistically significant difference in platelet count(PLT),anti-GPⅡb/Ⅲa antibody,and anti-GPⅠb/Ⅸantibody between the two groups(P>0.05).After treatment,the PLT of the two groups increased significantly.Antibodies were all decreased,and there was no significant difference between the two groups(P>0.05).The incidence of adverse reactions in the observation group was 13.33%,and that in the control group was 40.00%.The adverse reactions in the observation group were significantly lower than the control group(P<0.05).Conclusion:In the clinical treatment of primary immune thrombocytopenia,low-dose rituximab can control the progression of the disease,improve blood routine indicators,and have fewer adverse reactions.

Heparin-induced thrombocytopenia in solid organ transplant recipients: The current scientific knowledge

Exposure to heparin is associated with a high incidence of immunization against platelet factor 4(PF4)/heparin complexes. A subgroup of immunized patients is at risk of developing heparin-induced thrombocytopenia(HIT), an immune mediated prothrombotic adverse drug effect. Transplant recipients are frequently exposed to heparin either due to the underlying end-stage disease, which leads to listing and transplantation or during the transplant procedure and the perioperative period. To review the current scientific knowledge on antiheparin/PF4 antibodies and HIT in transplant recipients a systematic Pub Med literature search on articles in English language was performed. The definition of HIT is inconsistent amongst the publications. Overall, six studies and 15 case reports have been published on HIT before or after heart, liver, kidney, and lung transplantation, respectively. The frequency of seroconversion for anti-PF4/heparin antibodies ranged between 1.9% and 57.9%. However, different methods to detect anti-PF4/heparin antibodies were applied. In none of the studies HIT-associated thromboembolic events or fatalities were observed. More importantly, in patients with a history of HIT, reexposure to heparin during transplantation was not associated with thrombotic complications. Taken together, the overall incidence of HIT after solid organ transplantation seems to be very low. However, according to the current knowledge, cardiac transplant recipients may have the highest risk to develop HIT. Different alternative suggestions for heparin-free anticoagulation have been reported for recipients with suspected HIT albeit no official recommendations on management have been published for this special collective so far.

Transplacental transmission of EDTA dependent pseudothrombocytopenia in a neonate

Verifying platelet counts can prevent unwarranted diagnostic tests and transfusions. In case of thrombocytopenia, if the clinical picture and history do not suggest bleeding tendency, one should always perform peripheral blood smear by directly obtaining blood by finger puncture before doing any further tests. If the peripheral blood smear exhibits platelet clumps, pseudothrombocytopenia should always be remembered. In this case, we present a neonate with a diagnosis of transplacental transmission of EDTA-dependant pseudothrombocytopenia.

Management of thrombocytopenia due to liver cirrhosis:A review

Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment of liver cirrhosis,limiting the ability to administer therapy and delaying planned surgical/diagnostic procedures because of an increased risk of bleeding.Multiple factors,including splenic sequestration,reduced activity of the hematopoietic growth factor thrombopoietin,bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents,and antiviral treatment with interferon-based therapy,can contribute to the development of thrombocytopenia in cirrhotic patients.Of these factors,the major mechanisms for thrombocytopenia in liver cirrhosis are(1)platelet sequestration in the spleen;and(2)decreased production of thrombopoietin in the liver.Several treatment options,including platelet transfusion,interventional partial splenic embolization,and surgical splenectomy,are now available for severe thrombocytopenia in cirrhotic patients.Although thrombopoietin agonists and targeted agents are alternative tools for noninvasively treating thrombocytopenia due to liver cirrhosis,their ability to improve thrombocytopenia in cirrhotic patients is under investigation in clinical trials.In this review,we propose a treatment approach to thrombocytopenia according to our novel concept of splenic volume,and we describe the current management of thrombocytopenia due to liver cirrhosis.

Acquired amegakaryocytic thrombocytopenia previously diagnosed as idiopathic thrombocytopenic purpura in a patient with hepatitis C virus infection

We report the first case of a patient with hepatitis C virus(HCV) infection and idiopathic thrombocytopenic purpura(ITP), who later developed acquired amegakaryocytic thrombocytopenia(AAMT), with autoantibodies to the thrombopoietin(TPO) receptor(c-Mpl). A 64-year-old woman, with chronic hepatitis C, developed severe thrombocytopenia and was diagnosed with ITP. She died of liver failure. Autopsy revealed cirrhosis and liver carcinoma. In the bone marrow, a marked reduction in the number of megakaryocytes was observed, while other cell lineages were preserved. Therefore, she was diagnosed with AAMT. Additionally, autoantibodies to c-Mpl were detected in her serum. Autoantibodies to c-Mpl are one of the causes of AAMT, acting through inhibition of TPO function, megakaryocytic maturation, and platelet formation. HCV infection induces several autoantibodies. HCV infection might also induce autoantibodies to c-Mpl, resulting in the development of AAMT. This mechanism may be one of the causes of thrombocytopenia in patients with HCV infection.

Profound thrombocytopenia induced by clopidogrel with a prior history of long-term safe administration

Clopidogrel has shown an excellent safety,tolerability and efficacy ever since its marketing.However,here we report a rare case with profound thrombocytopenia following clopidogrel administration previously safely exposed to this same drug.This reminds us that thrombocytopenia might be induced by clopidogrel even with a prior,safe history of long-term administration.

Close Correlation between Development of MODS during the Initial 72h of Hospitalization and Hospital Mortality in Severe Fever with Thrombocytopenia Syndrome

An emerging infectious disease was identified as severe fever with thrombocytopenia syn- drome （SFTS） in central China since late March 2009. We found the patients with SFTS had severe clinical symptoms, and progressed rapidly to multiple organ dysfunction syndrome （MODS） with high fatality rate of 25%-30%. The aim of this study was to assess the significance of risk factors predicting the development of MODS and death in SFTS patients. Consecutive SFTS admissions between May 2009 and September 2011 were analyzed for parameters of organ function during hospitalization using Marshall scoring system for MODS, and platelet counts were recorded on admission and at 24, 48, 72 h and one week after admission. We investigated the kinetics of organ failures and analyzed the associa- tion between age, platelet count and development of MODS or death. A total of 92 SFTS patients were enrolled in this study. Among them, 32 patients with dysfunction of over 4 organs were identified, 45% of them died within 72 h, 72% died within 5 days, and 76% died within 7 days after admission. We also found cumulative Marshall score was significantly higher in death patients （11.76＋2.05） than in survival patients （4.22~1.98） （P〈0.001）. In addition, SFTS patients had older age and lower platelet counts in MODS and death groups. Furthermore, we also observed that there was a close correlation between platelet count on admission and Marshall score （P〈0.001）. High Marshall score, advanced age and lower platelet counts were the main risk factors for the development of MODS, and those factors could predict mortality in SFTS patients, suggesting prompt treatment and close monitoring of severe complications, especially MODS, are of great importance in saving patients＇ lives.

High frequency of thrombocytopenia in patients with acute-on-chronic liver failure treated with linezolid

BACKGROUND： Linezolid is an effective antibiotic reagent for Gram-positive bacterial infection; its most common side effect is thrombocytopenia. However, the incidence of throm- bocytopenia in patients with acute-on-chronic liver failure （ACLF） who underwent linezolid therapy was unclear. The present study was to evaluate the incidence of thrombocyto- penia in ACLF and non-ACLF patients treated with linezolid and the risk factors of thrombocytopenia in these patients.

Thrombocytopenia after liver transplantation:should we care?

Transient thrombocytopenia is a common phenomenon after liver transplantation. After liver transplantation(LT), platelet count decreases and reaches a nadir on postoperative days 3-5, with an average reduction in platelet counts of 60%; platelet count recovers to preoperative levels approximately two weeks after LT. The putative mechanisms include haemodilution, decreased platelet production, increased sequestration, medications, infections, thrombosis, or combination of these processes. However, the precise mechanisms remain unclear. The role of platelets in liver transplantation has been highlighted in recent years, and particular attention has been given to their effects beyond hemostasis and thrombosis. Previous studies have demonstrated that perioperative thrombocytopenia causes poor graft regeneration, increases the incidence of postoperative morbidity, and deteriorates the graft and decreases patient survival in both the short and long term after liver transplantation. Platelet therapies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist, platelet transfusion, splenectomy, and intravenous immunoglobulin treatment might have a potential for improving graft survival, however clinical trials are lacking. Further studies are warranted to detect direct evidence on whether thrombocytopenia is the cause or result of poor-graft function and postoperative complications, and to determine who needs platelet therapies in order to prevent postoperative complications and thus improve post-transplant outcomes.

Thrombocytopenia in cirrhosis:Impact of fibrinogen on bleeding risk

AIM To investigate the relationship between baseline platelet count,clauss fibrinogen,maximum amplitude(MA) on thromboelastography,and blood loss in orthotopic liver transplantation(OLT).METHODS A retrospective analysis of our OLT Database(2006-2015) was performed.Baseline haematological indices and intraoperative blood transfusion requirements,as a combination of cell salvage return and estimation of 300 mls/unit of allogenic blood,was noted as a surrogate for intraoperative bleeding.Two groups:Excessive transfusion(>1200 mL returned) and No excessive transfusion(<1200 m L returned) were analysed.All data analyses were conducted using IBM SPSS Statistics version 23.RESULTS Of 322 OLT patients,77 were excluded due to fulminant disease;redo transplant or baseline haemoglobin(Hb) of<80 g/L.One hundred and fourteen(46.3%) were classified into the excessive transfusion group,132(53.7%) in the no excessive transfusion group.Mean age and gender distribution were similar in both groups.Baseline Hb(P≤0.001),platelet count(P=0.005),clauss fibrinogen(P=0.004) and heparinase MA(P=0.001) were all statistically significantly different.Univariate logistic regression with a cut-off of platelets<50×10~9/L as the predictor and Haemorrhage as the outcome showed an odds ratio of 1.393(95%CI:0.758-2.563;P=0.286).Review of receiver operating characteristic curves showed an area under the curve(AUC) for platelet count of 0.604(95%CI:0.534-0.675;P=0.005) as compared with AUC for fibrinogen level,0.678(95%CI:0.612-0.744;P≤0.001).A multivariate logistic regression shows United Kingdom model for End Stage Liver Disease(P=0.006),Hb(P=0.022) and Fibrinogen(P=0.026) to be statistically significant,whereas Platelet count was not statistically significant.CONCLUSION Platelet count alone does not predict excessive transfusion.Additional investigations,e.g.,clauss fibrinogen and viscoelastic tests,provide more robust assessment of bleeding-risk in thrombocytopenia and cirrhosis.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

Thrombocytopenia is a common complication of critical care patients.The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia.Therefore,the Critical Care Medicine Committee of Chinese People’s Liberation Army(PLA)worked with Chinese Society of Laboratory Medicine,Chinese Medical Association to develop this consensus to provide guidance for clinical practice.The consensus includes five sections and 27 items:the definition of thrombocytopenia,etiology and pathophysiology,diagnosis and differential diagnosis,treatment and prevention.