Decreased platelet activation predicts hepatic decompensation and mortality in patients with cirrhosis

Abstract

Background & Aims: Patients with cirrhosis show alterations in primary haemostasis, yet prognostic implications of changes in platelet activation remain controversial and assay validity is often limited by thrombocytopenia. We aimed to study the prognostic role of platelet activation in cirrhosis, focusing on bleeding/thromboembolic events, decompensation and mortality. Approach & Results: We prospectively included 107 cirrhotic patients undergoing a same-day hepatic venous pressure gradient (HVPG) and platelet activation measurement. Platelet activation was assessed using flow cytometry after protease-activated receptor (PAR)-1, PAR-4, or epinephrine stimulation. Over a follow-up of 25.3 (IQR:15.7-31.2) months, first/further decompensation occurred in 29 patients and 17 died. More pronounced platelet activation was associated with an improved prognosis, even after adjusting for systemic inflammation, HVPG and disease severity. Specifically, higher PAR-4-inducible platelet activation was independently linked to a lower decompensation risk (aHR per 100 MFI [median fluorescence intensity]:0.95 [95%CI:0.90-0.99]; p=0.036) and higher PAR-1-inducible platelet activation was independently linked to longer survival (aHR per 100 MFI:0.93 [95%CI:0.87-0.99]; p=0.040). Thromboembolic events occurred in 8 patients (75% non-tumoral portal vein thrombosis [PVT]). Higher epinephrine-inducible platelet activation was associated with an increased risk of thrombosis (HR per 10 MFI:1.07 [95%CI:1.02-1.12]; p=0.007) and PVT (HR per 10 MFI:1.08 [95%CI:1.02-1.14]; p=0.004). In contrast, of the 11 major bleedings that occurred, 9 were portal hypertension-related, and HVPG thus emerged as the primary risk factor. Conclusions: Preserved PAR-1- and PAR-4-inducible platelet activation was linked to a lower risk of decompensation and death. In contrast, higher epinephrine-inducible platelet activation was a risk factor for thromboembolism and PVT.