Table 2.
CEHC Initiative Group consensus recommendations for managing TCP in patients with CLD scheduled for an invasive procedure.
| Procedure | Benchmark * | Minimum Platelet Count for Procedure n (%) |
Is TPO-RA Suitable for Platelet Count Elevation? n (%) |
Additional Comments and Considerations | ||
|---|---|---|---|---|---|---|
| >30 × 109/L | >50 × 109/L | >80 × 109/L | ||||
| 1. Endoscopic/endovascular procedures: | ||||||
| a. Endoscopic polypectomy | Bleeding risk ~7.5% for patients with platelet count < 50 × 109/L (retrospective data); Immediate post-procedural bleeding rate was 27.5% with RR = 6 | NR | 9 (100.0%) | Yes: 8 (88.9%) No: 1 (11.1%) |
||
| b. Endoscopic variceal ligation | Bleeding risk ~2.75−7.33%; No association between bleeding risk and platelet count | 7 (77.8%) | 2 (22.2%) | Yes: 8 (88.9%) No/NA: 1 (11.1%) |
TPO-RA can be used for urgent procedures regardless of platelet count; For elective ligation, TPO-RA is recommended when platelet count is <50 × 109/L; In acute variceal bleeding, ligation may be performed at any platelet count, i.e., as secondary prophylaxis when platelet count is >30 × 109/L | |
| c. Endoscopy without intervention (e.g., gastroscopy, colonoscopy) | No data was provided in the article; Advisory Board discussed the low risk of bleeding | 9 (100%) | Yes: 4 (44.4%) No/NA: 5 (55.6%) |
Not performed in patients with spontaneous bleeding; May be performed at any platelet count | ||
| d. Percutaneous ablation | Rarely performed in patients with platelet count < 50 × 109/L and is usually preceded by platelet transfusions and close monitoring of platelet count; Bleeding risk following radio-frequency ablation of HCC is <1 | NR | 9 (100.0%) | Yes: 97 (100.0%) No: 0 (0.0%) |
||
| 2. Surgical procedures: | ||||||
| a. Abdominal surgery and other invasive procedures ** | Available evidence insufficient to assess association between platelet count and post-procedural bleeding risk | NR | 8 (88.9%) | 1 (11.1%) | Yes: 9 (100.0%) No: 0 (0.0%) |
|
| b. Paracentesis | Typically performed in cirrhotic patients with significant portal hypertension and TCP; No bleeding was recorded in patients with platelet count < 50 × 109/L | 9 (100.0%) | Yes: 5 (55.6%) No/NA: 4 (44.4%) |
In patients with severe dyspnoea due to large ascites, evacuatory paracentesis is recommended even at lower platelet counts; Paracentesis may be performed at any platelet count; can be safe even if platelet count is <30 × 109/L but can be associated with bleeding in rare situations | ||
| c. Liver biopsy | Bleeding risk ~0.6%; Usually performed in patients without portal hypertension and platelet count > 50 × 109/L | NR | 8 (88.9%) | 1 (11.1%) | Yes: 9 (100%) No: 0 (0%) |
For percutaneous liver biopsy; Except for patients with portal hypertension when platelet count should be >80 × 109/L; In the last few years, liver biopsy has become less popular and Central European physicians are more cautious |
| d. Liver surgery | Portal hypertension is the main determinant of outcome; Even mild TCP (platelet count < 150 × 109/L) predicted major postoperative complications and mortality after resection of HCC | NR | 1 (11.1%) | 8 (88.9%) | Yes: 9 (100.0%) No: 0 (0.0%) |
|
| e. Liver transplantation | No association between platelet count and intra- or post-transplantation bleeding | 7 (77.8%) | 1 (11.1%) | 1 (11.1%) | Yes: 7 (77.8%) No: 2 (22.2%) |
May be performed at any platelet count; Usually not a planned procedure |
| 3. Dentistry: | ||||||
| a. Dentistry (high-bleeding risk procedures) ** | Bleeding risk seemed to be inherently related to the procedure or the number of teeth extracted rather than to platelet count; Bleeding risk ~2.9% for a patient with platelet count = 50 × 109/L and INR =2.5 (prospective study data) | 1 (11.1%) | 8 (88.9%) | Yes: 9 (100.0%) No: 0 (0.0%) |
Local therapy is generally preferred; Patient and procedure dependent; There is currently no uniformity between dentists; Many Central European dentists request platelet transfusions for platelet count < 80 × 109/L; TPO-RAs should always be considered for patients with Child Pugh score C | |
* Existing Evidence-Based Recommendations from Alvaro et al., 2021 [20] and the Central European Advisory Board on 22 February 2021. ** Abdominal surgery, e.g., vascular catheter insertion, HVPG measurement, cholecystectomy, herniotomy, thoracentesis, urological surgery, other; Dentistry high-risk bleeding procedures, e.g., tooth extraction, root canal procedures, dental implants, comprehensive hygienist procedures. Consensus recommendations reported as a percentage of the total expert responses. Note: Only a few studies that assessed the risk of bleeding in relation to platelet count found that TCP may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumors and endoscopic polypectomy. Procedures are grouped by category of procedure for easy reference rather than in order of the frequency they are performed. Abbreviations: CLD, chronic liver disease; HCC, hepatocellular carcinoma; INR, international normalized ratio; NR, not recommended; RR, relative risk; TCP, thrombocytopenia.