Original Article

Digestive Diseases and Sciences

, Volume 58, Issue 2, pp 562-573

Thrombocytopenia and Bleeding in Veterans with Non-hepatitis C-related Chronic Liver Disease

  • John A. HermosAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)Boston University School of Medicine Email author 
  • , Arman AltincatalAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)
  • , H. Christian WeberAffiliated withBoston University School of MedicineGastroenterology Section, Department of Medicine, VA Boston Healthcare System
  • , Kelly GrotzingerAffiliated withGlaxoSmithKline
  • , Kyle J. SmootAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)
  • , Kelly ChoAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)Department of Medicine, Harvard Medical School
  • , David R. GagnonAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)Department of Biostatistics, Boston University School of Public Health
  • , Elizabeth V. LawlerAffiliated withVA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV)Department of Medicine, Harvard Medical School

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Abstract

Background

Thrombocytopenia in chronic liver disease (CLD) typically reflects disease severity and may indicate an increased risk for bleeding.

Aims

To describe the longitudinal course of thrombocytopenia and risks for bleeding in veteran patients with non-hepatitis C-related CLD.

Methods

We identified 2,349 patients with non-hepatitis C-related CLD from databases of the New England Veterans Healthcare System between 1999 and 2008. The cohort was stratified by baseline platelet counts of <50,000, 50–100,000, > 100,000–150,000, and >150,000/μl. Primary outcomes were the incidence and hazard rates for bleeding episodes requiring hospitalization and incident severe thrombocytopenia (<50,000/μl).

Results

Over a median follow-up of 3.3 years (IQR 1.2, 6.3), incident major bleeds, predominantly gastrointestinal, occurred in 254 patients (10.8 % of the cohort) and in 19.9 % of those with baseline platelets <50,000/μl. Incident severe thrombocytopenia occurred in 315 patients (13.4 % of cohort) and in 40.7 % of those with baseline platelet counts between 50,000 and 100,000/μl. Baseline platelet counts between 50,000 and 100,000/μl independently predicted bleeding [adjusted HR 2.89 (1.76, 4.73) p < 0.001] as did esophageal varices, hemoglobin ≤9.9 g %, and INR 1.4–2.0. Incident severe thrombocytopenia and minimum platelet counts <25,000/μl each associated with bleeding episodes, but the average of minimum platelet counts recorded for those who bled was 76,000/μl.

Conclusions

Among veteran patients with non-hepatitis C-related CLD, baseline platelet counts of 50,000 to 100,000/μl increased subsequent risks for both incident severe thrombocytopenia and major bleeding events. Whereas associations between severe thrombocytopenia and bleeding most likely reflect CLD severity, liver-related coagulopathies, and co-morbid bleeding risks, interventions to enhance platelet production may be beneficial for such patients.

Keywords

Chronic liver disease Thrombocytopenia Hemorrhage Veterans