Platelet Function Decreases with Increasing Severity of Liver Cirrhosis and Portal Hypertension—A Prospective Study

Abstract

Background Cirrhotic patients display an increased risk for both bleeding and thrombosis. We investigated platelet activation across Child–Pugh stages (CPSs) and portal hypertension (PH) severity.

Material and Methods A total of 110 cirrhotic patients were prospectively included. CPS and hepatic venous pressure gradient (HVPG) were determined. Platelet surface expression of P-selectin and activated glycoprotein (GP) IIb/IIIa were measured by flow cytometry before/after stimulation with protease-activated receptor (PAR)-1 (thrombin receptor activating peptide, TRAP) and PAR-4 (AYPGKF) agonists, epinephrine, and lipopolysaccharide (LPS).

Results Platelet count was similar across CPS but lower with increasing PH severity. Expression of P-selectin and activated GPIIb/IIIa in response to TRAP and AYPGKF was significantly reduced in platelets of CPS-B/C versus CPS-A patients (all p < 0.05). Platelet P-selectin expression upon epinephrine and LPS stimulation was reduced in CPS-C patients, while activated GPIIb/IIIa in response to these agonists was lower in CPS-B/C (all p < 0.05). Regarding PH severity, P-selectin and activated GPIIb/IIIa in response to AYPGKF were lower in HVPG ≥20 mmHg patients (both p < 0.001 vs. HVPG < 10 mmHg). Similarly, activated GPIIb/IIIa was lower in HVPG ≥20 mmHg patients after TRAP stimulation (p < 0.01 vs. HVPG < 10 mmHg). The lower platelet surface expression of P-selectin and activated GPIIb/IIIa upon stimulation of thrombin receptors (PAR-1/PAR-4) in CPS-B/C and HVPG ≥20 mmHg patients was paralleled by reduced antithrombin-III levels in those patients (all p < 0.05). Overall, PAR-1- and PAR-4-mediated platelet activation correlated with antithrombin-III levels (p < 0.001).

Conclusion Platelet responsiveness decreases with increasing severity of liver cirrhosis and PH but is potentially counterbalanced by lower antithrombin-III levels.

Keywords

advanced chronic liver disease - portal hypertension - flow cytometry - platelet function - platelet activation

Authors' Contribution

Guarantor of the article: T.G. Data collection: K.B., B.S.H., B.S., B.E., D.J.M.B., P.S., M.M., T.R., T.G. Statistical analysis: K.B., B.S.H., T.R., T.G. Drafting of the manuscript: K.B., T.R., T.G. Study supervision: T.R., T.G. Revision for important intellectual content and approval of the final version of the manuscript: all authors.

Publication History

Received: 23 December 2022

Accepted: 14 June 2023

Article published online:
30 July 2023

• References

• 1 Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365 (02) 147-156
• 2 Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol 2022; 76 (06) 1291-1305
• 3 Zermatten MG, Fraga M, Moradpour D. et al. Hemostatic alterations in patients with cirrhosis: from primary hemostasis to fibrinolysis. Hepatology 2020; 71 (06) 2135-2148
• 4 Laffi G, Cominelli F, Ruggiero M, Fedi S, Chiarugi V, Gentilini P. Molecular mechanism underlying impaired platelet responsiveness in liver cirrhosis. FEBS Lett 1987; 220 (01) 217-219
• 5 Laffi G, Cominelli F, Ruggiero M. et al. Altered platelet function in cirrhosis of the liver: impairment of inositol lipid and arachidonic acid metabolism in response to agonists. Hepatology 1988; 8 (06) 1620-1626
• 6 Laffi G, Marra F, Gresele P. et al. Evidence for a storage pool defect in platelets from cirrhotic patients with defective aggregation. Gastroenterology 1992; 103 (02) 641-646
• 7 Laffi G, Marra F, Failli P. et al. Defective signal transduction in platelets from cirrhotics is associated with increased cyclic nucleotides. Gastroenterology 1993; 105 (01) 148-156
• 8 Laffi G, Cinotti S, Filimberti E. et al. Defective aggregation in cirrhosis is independent of in vivo platelet activation. J Hepatol 1996; 24 (04) 436-443
• 9 Ordinas A, Escolar G, Cirera I. et al. Existence of a platelet-adhesion defect in patients with cirrhosis independent of hematocrit: studies under flow conditions. Hepatology 1996; 24 (05) 1137-1142
• 10 Panasiuk A, Prokopowicz D, Zak J, Matowicka-Karna J, Osada J, Wysocka J. Activation of blood platelets in chronic hepatitis and liver cirrhosis P-selectin expression on blood platelets and secretory activity of beta-thromboglobulin and platelet factor-4. Hepatogastroenterology 2001; 48 (39) 818-822
• 11 Ogasawara F, Fusegawa H, Haruki Y, Shiraishi K, Watanabe N, Matsuzaki S. Platelet activation in patients with alcoholic liver disease. Tokai J Exp Clin Med 2005; 30 (01) 41-48
• 12 Panasiuk A, Zak J, Kasprzycka E, Janicka K, Prokopowicz D. Blood platelet and monocyte activations and relation to stages of liver cirrhosis. World J Gastroenterol 2005; 11 (18) 2754-2758
• 13 Vinholt PJ, Hvas AM, Nielsen C. et al. Reduced platelet activation and platelet aggregation in patients with alcoholic liver cirrhosis. Platelets 2018; 29 (05) 520-527
• 14 Zanetto A, Campello E, Bulato C. et al. Increased platelet aggregation in patients with decompensated cirrhosis indicates higher risk of further decompensation and death. J Hepatol 2022; 77 (03) 660-669
• 15 Witters P, Freson K, Verslype C. et al. Review article: blood platelet number and function in chronic liver disease and cirrhosis. Aliment Pharmacol Ther 2008; 27 (11) 1017-1029
• 16 Cardenas A, Reiberger T. Complications of cirrhosis. Clin Liver Dis 2021; 25 (02) xiii-xiv
• 17 Ramadori P, Klag T, Malek NP, Heikenwalder M. Platelets in chronic liver disease, from bench to bedside. JHEP Rep Innov Hepatol 2019; 1 (06) 448-459
• 18 Reiberger T, Schwabl P, Trauner M, Peck-Radosavljevic M, Mandorfer M. Measurement of the hepatic venous pressure gradient and transjugular liver biopsy. J Vis Exp 2020; 160: e58819
• 19 Brusilovskaya K, Simbrunner B, Lee S. et al. Peripheral versus central venous blood sampling does not influence the assessment of platelet activation in cirrhosis. Platelets 2022; 33 (06) 879-886
• 20 Gremmel T, Bhatt DL, Michelson AD. . 36 - Laboratory monitoring of antiplatelet therapy. In: Michelson AD, ed. Platelets. 4th ed. Cambridge, MA: Academic Press; 2019:653–682
• 21 Michelson AD. Flow cytometry: a clinical test of platelet function. Blood 1996; 87 (12) 4925-4936
• 22 Blair TA, Frelinger AL, Michelson AD. . 35 - Flow cytometry. In: Michelson AD, ed. Platelets. 4th ed. Cambridge, MA: Academic Press; 2019:627–651
• 23 Clemetson KJ, Clemetson JM. . 9 - Platelet receptors. In: Michelson AD, ed. Platelets. 4th ed. Cambridge, MA: Academic Press; 2019:169–192
• 24 Gremmel T, Frelinger III AL, Michelson AD. Platelet physiology. Semin Thromb Hemost 2016; 42 (03) 191-204
• 25 Michelson AD. How platelets work: platelet function and dysfunction. J Thromb Thrombolysis 2003; 16 (1–2): 7-12
• 26 Gremmel T, Michelson AD, Frelinger III AL, Bhatt DL. Novel aspects of antiplatelet therapy in cardiovascular disease. Res Pract Thromb Haemost 2018; 2 (03) 439-449
• 27 Wadowski PP, Weikert C, Pultar J. et al. Ticagrelor inhibits Toll-like and protease-activated receptor mediated platelet activation in acute coronary syndromes. Cardiovasc Drugs Ther 2020; 34 (01) 53-63
• 28 Andersen H, Greenberg DL, Fujikawa K, Xu W, Chung DW, Davie EW. Protease-activated receptor 1 is the primary mediator of thrombin-stimulated platelet procoagulant activity. Proc Natl Acad Sci U S A 1999; 96 (20) 11189-11193
• 29 Smolensky Koganov E, Carmichael SL, Forde EE. et al. Platelet function in thrombocytopenic patients with chronic liver disease. Blood 2017; 130: 2314-2314
• 30 Rao AK, Willis J, Kowalska MA, Wachtfogel YT, Colman RW. Differential requirements for platelet aggregation and inhibition of adenylate cyclase by epinephrine. Studies of a familial platelet alpha 2-adrenergic receptor defect. Blood 1988; 71 (02) 494-501
• 31 Martin AC, Zlotnik D, Bonete GP. et al. Epinephrine restores platelet functions inhibited by ticagrelor: a mechanistic approach. Eur J Pharmacol 2020; 866: 172798
• 32 Escolar G, Cases A, Viñas M. et al. Evaluation of acquired platelet dysfunctions in uremic and cirrhotic patients using the platelet function analyzer (PFA-100 ): influence of hematocrit elevation. Haematologica 1999; 84 (07) 614-619
• 33 Albillos A, de Gottardi A, Rescigno M. The gut-liver axis in liver disease: pathophysiological basis for therapy. J Hepatol 2020; 72 (03) 558-577
• 34 Raparelli V, Basili S, Carnevale R. et al. Low-grade endotoxemia and platelet activation in cirrhosis. Hepatology 2017; 65 (02) 571-581
• 35 Queck A, Carnevale R, Uschner FE. et al. Role of portal venous platelet activation in patients with decompensated cirrhosis and TIPS. Gut 2020; 69 (08) 1535-1536
• 36 Vinholt PJ, Hvas A-M, Nybo M. An overview of platelet indices and methods for evaluating platelet function in thrombocytopenic patients. Eur J Haematol 2014; 92 (05) 367-376
• 37 Peck-Radosavljevic M. Thrombocytopenia in chronic liver disease. Liver Int 2017; 37 (06) 778-793
• 38 Lisman T, Bongers TN, Adelmeijer J. et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006; 44 (01) 53-61
• 39 Loncar R, Kalina U, Stoldt V, Thomas V, Scharf RE, Vodovnik A. Antithrombin significantly influences platelet adhesion onto immobilized fibrinogen in an in-vitro system simulating low flow. Thromb J 2006; 4: 19-19