Splenectomy and the incidence of venous thromboembolism and sepsis in patients with immune thrombocytopenia.

Patients with immune thrombocytopenia (ITP) who relapse after an initial trial of corticosteroid treatment present a therapeutic challenge. Current guidelines recommend consideration of splenectomy, despite the known risks associated with surgery and the postsplenectomy state. To better define these risks, we identified a cohort of 9976 patients with ITP, 1762 of whom underwent splenectomy. The cumulative incidence of abdominal venous thromboembolism (AbVTE) was 1.6% compared with 1% in patients who did not undergo splenectomy; venous thromboembolism (VTE) (deep venous thrombosis and pulmonary embolus) after splenectomy was 4.3% compared with 1.7% in patients who did not undergo splenectomy. There was increased risk of AbVTE early (<90 days; hazard ratio [HR] 5.4 [confidence interval (CI), 2.3-12.5]), but not late (≥90 days; HR 1.5 [CI, 0.9-2.6]) after splenectomy. There was increased risk of VTE both early (HR 5.2 [CI, 3.2-8.5]) and late (HR 2.7 [CI, 1.9-3.8]) after splenectomy. The cumulative incidence of sepsis was 11.1% among the ITP patients who underwent splenectomy and 10.1% among the patients who did not. Splenectomy was associated with a higher adjusted risk of sepsis, both early (HR 3.3 [CI, 2.4-4.6]) and late (HR 1.6 or 3.1, depending on comorbidities). We conclude that ITP patients post splenectomy are at increased risk for AbVTE, VTE, and sepsis.

[1]  John A. Heit,et al.  The epidemiology of venous thromboembolism , 2003, Journal of Thrombosis and Thrombolysis.

[2]  M. Baccarani,et al.  Splenectomy as a curative treatment for immune thrombocytopenia: a retrospective analysis of 233 patients with a minimum follow up of 10 years , 2013, Haematologica.

[3]  E. Leandros,et al.  Incidence, risk factors, and outcome of portal vein thrombosis after laparoscopic-assisted splenectomy in β-thalassemia patients: a prospective exploratory study. , 2013, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[4]  F. Rodeghiero,et al.  Short‐ and long‐term risks of splenectomy for benign haematological disorders: should we revisit the indications? , 2012, British journal of haematology.

[5]  M. Crowther,et al.  The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. , 2011, Blood.

[6]  H. Sørensen,et al.  Long-term clinical outcomes of patients with primary chronic immune thrombocytopenia: a Danish population-based cohort study. , 2011, Blood.

[7]  H. Sørensen,et al.  Risk of venous thromboembolism in patients with primary chronic immune thrombocytopenia: a Danish population‐based cohort study , 2011, British journal of haematology.

[8]  A. Aleem.  Durability and factors associated with long term response after splenectomy for primary immune thrombocytopenia (ITP) and outcome of relapsed or refractory patients , 2011, Platelets.

[9]  A. Cohen.  Asia-Pacific Thrombosis Advisory Board consensus paper on prevention of venous thromboembolism after major orthopaedic surgery , 2010, Thrombosis and Haemostasis.

[10]  C. Enger,et al.  Comorbidities in patients with persistent or chronic immune thrombocytopenia , 2010, International journal of hematology.

[11]  Banafsheh Sadeghi,et al.  Evaluation of the predictive value of ICD-9-CM coded administrative data for venous thromboembolism in the United States. , 2010, Thrombosis research.

[12]  D. Farkas,et al.  Risk of venous thromboembolism in splenectomized patients compared with the general population and appendectomized patients: a 10‐year nationwide cohort study , 2010, Journal of thrombosis and haemostasis : JTH.

[13]  H. Sørensen,et al.  Mortality risk in splenectomised patients: a Danish population-based cohort study. , 2010, European journal of internal medicine.

[14]  A. Riis,et al.  Risk for Hospital Contact With Infection in Patients With Splenectomy , 2009, Annals of Internal Medicine.

[15]  G. Buchanan,et al.  Vascular complications after splenectomy for hematologic disorders. , 2009, Blood.

[16]  P. Libby,et al.  Identification of Splenic Reservoir Monocytes and Their Deployment to Inflammatory Sites , 2009, Science.

[17]  J. George,et al.  Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. , 2009, Blood.

[18]  J. Bussel,et al.  Safety and efficacy of long-term treatment with romiplostim in thrombocytopenic patients with chronic ITP. , 2009, Blood.

[19]  D. Chang,et al.  Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Operations , 2008, Journal of Gastrointestinal Surgery.

[20]  F. Mandelli,et al.  Therapy with high-dose dexamethasone (HD-DXM) in previously untreated patients affected by idiopathic thrombocytopenic purpura: a GIMEMA experience. , 2007, Blood.

[21]  J. Bussel,et al.  The pathogenesis of immune thrombocytopaenic purpura , 2006, British journal of haematology.

[22]  H. Chew,et al.  Incidence of venous thromboembolism and its effect on survival among patients with common cancers. , 2006, Archives of internal medicine.

[23]  I. Gich,et al.  Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura , 2006, Surgical Endoscopy And Other Interventional Techniques.

[24]  T. Barbui,et al.  Efficacy and safety of splenectomy in immune thrombocytopenic purpura: long-term results of 402 cases. , 2005, Haematologica.

[25]  S. Vesely,et al.  Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. , 2004, Blood.

[26]  R. Mcmillan,et al.  Long-term outcomes in adults with chronic ITP after splenectomy failure. , 2004, Blood.

[27]  F. Borst,et al.  High-dose dexamethasone as a first- and second-line treatment of idiopathic thrombocytopenic purpura in adults , 2004, Annals of Hematology.

[28]  J. Bussel,et al.  Prospective screening of 205 patients with ITP, including diagnosis, serological markers, and the relationship between platelet counts, endogenous thrombopoietin, and circulating antithrombopoietin antibodies , 2004, American journal of hematology.

[29]  E. Targarona,et al.  Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis , 2004, Surgical Endoscopy And Other Interventional Techniques.

[30]  F. Fujita,et al.  Portal Vein Thrombosis following Splenectomy: Identification of Risk Factors , 2003, The American surgeon.

[31]  S. Proctor,et al.  Clinically significant newly presenting autoimmune thrombocytopenic purpura in adults: a prospective study of a population‐based cohort of 245 patients , 2003, British journal of haematology.

[32]  R. Wong,et al.  Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. , 2003, New England Journal of Medicine.

[33]  A. Goldfine,et al.  Cardiovascular Disease in the Diabetic Patient , 2003 .

[34]  A. Tefferi,et al.  Splenectomy for immune thrombocytopenic purpura: long-term results and treatment of postsplenectomy relapses , 2002, Annals of Hematology.

[35]  I. Lavi,et al.  Risk of infection and death among post-splenectomy patients. , 2001, The Journal of infection.

[36]  R. Westendorp,et al.  Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. , 2001, Blood.

[37]  S. Tura,et al.  Long-term follow-up of idiopathic thrombocytopenic purpura in 310 patients. , 2001, Haematologica.

[38]  G. Kazemier,et al.  Diagnosis and treatment of portal vein thrombosis following splenectomy , 2000, The British journal of surgery.

[39]  H. Sørensen,et al.  Risk and patterns of bacteraemia after splenectomy: a population-based study. , 2000, Scandinavian journal of infectious diseases.

[40]  M. Mazzucconi,et al.  Long‐term follow‐up of autoimmune thrombocytopenic purpura (ATP) patients submitted to splenectomy , 1999, European journal of haematology.

[41]  M. Wichmann,et al.  Laparoscopic splenectomy for idiopathic thrombocytopenic purpura , 1998, Surgical Endoscopy.

[42]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[43]  G. Papa,et al.  Long-term observation of 208 adults with chronic idiopathic thrombocytopenic purpura. , 1995, The American journal of medicine.

[44]  M. Baccarani,et al.  Laparoscopic Splenectomy in Idiopathic Thrombocytopenic Purpura , 1995, Vox sanguinis.

[45]  Schwartz Mz,et al.  Elective splenectomy in children: indications and operative approach. , 1982 .

[46]  L. P. Gustavson,et al.  Elective splenectomy in children: indications and operative approach. , 1982, Texas medicine.

[47]  A. Gottlieb,et al.  Adult idiopathic thrombocytopenic purpura. Clinical findings and response to therapy. , 1980, The American journal of medicine.