Published online Jul 27, 2022. doi: 10.4254/wjh.v14.i7.1421
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
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.
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.
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.
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.
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.
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.
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.