Real World Data of thrombopoietin receptor for thrombocytopenia with chronic liver disease

Abstract

© Digestive Medicine Research. All rights reserved. Dig Med Res 2021;4:41 | https://dx.doi.org/10.21037/dmr-21-68 Thrombocytopenia is one of major complication in chronic liver disease patients, with approximately 76% of patients having platelet counts <150,000/μL and approximately 13% having platelet counts between 50,000–75,000/μL (1). Periprocedural bleeding risk management is an essential strategy in chronic liver disease. Chronic liver disease patients frequently require invasive diagnostic and therapeutic procedures, such as liver biopsies, variceal band ligation, or percutaneous procedures such as radiofrequency ablation and microwave ablation for hepatocellular carcinoma (HCC) (2). However, these procedures may be delayed or sometimes canceled due to the risk of bleeding in patients who also have thrombocytopenia. Therefore, thrombocytopenia is a major issue in patients with chronic liver disease. Historically, the treatment options for thrombocytopenia in chronic liver disease have been platelet transfusions, either immediately before or during the procedure (3,4). Platelet transfusion has been established is considered the standard of care for managing thrombocytopenia in patients with chronic liver disease (3,4), and is supported by society guidelines, with platelet goals ≥50,000/μL widely recommended for many procedures (3,4). However, platelet transfusion has many disadvantages, such as increased risk of viral and bacterial infections (5), the development of febrile nonhemolytic reactions such as anaphylactic shock, anaphylaxis, hypotension, dyspnea, transfusion associated circulatory overload (TACO), and transfusion-related acute lung injury (TRALI) (6) and non-serious adverse reactions such as urticaria and fever. There are also problems such as the risk of infectious diseases and platelet transfusion refractoriness due to repeated transfusion due to human leukocyte antigen alloimmunization (7). Recently with the advance in the knowledge of thrombopoiesis and the role of its key regulator, thrombopoietin (TPO) led to the production of novel drugs that act as TPO receptor (TPO-R) agonists that activate and enhance megakaryopoiesis which in turn increase platelet synthesis (8). Hence, TPO, also known as Megakaryocyte Growth and Development Factor (MGDF) or c-MpL ligand, is a hormone which is synthesized in the liver and dominantly regulates the process of megakaryocytopoiesis (9). TPO acts on c-MpL receptor on the surface of megakaryocytes and stimulates various steps of platelet production within the bone marrow (10). TPO generation in turn is regulated by the rate of platelet cycling (production and destruction), as well as the synthetic function of liver (11). Several studies have argued about the relative majority influence on this multifactorial etiology of thrombocytopenia in CLD (11). Romiplostim and eltrombopag were developed as successful first generation TPO receptor agonists. Romiplostim is indicated for thrombocytopenia due to hematologic disorders. Hence, some studies and case Editorial