Splenectomy Outcomes in Relapsed or Refractory Immune Thrombocytopenia according to First-Line Intravenous Immunoglobulin Response

Objectives: Although splenectomy has long been second-line option for immune thrombocytopenia (ITP) patients, an indicator that reliably predicts the efficacy of splenectomy is still being explored. We investigated the treatment outcomes of splenectomy as a second-line therapy for relapsed/refractory ITP according to first-line intravenous immunoglobulin (IVIG) responses. Methods: Fifty-two adult patients treated with splenectomy as second-line therapy for ITP between 2009 and 2019 were included, and they were classified according to first-line IVIG responses (no response to IVIG: nonresponders; only transient IVIG response shorter than 4 weeks: poor responders; IVIG response for a longer period; stable responders). The efficacy of splenectomy was analyzed in the three subgroups. Results: Of the 52 patients, 10 were IVIG nonresponders, 34 were poor responders, and the remaining 8 were stable responders. Response to splenectomy was observed in 50.0% of IVIG nonresponders, 94.1% of poor responders, and 100% of stable responders (p = 0.0030). Among the 45 patients who responded to splenectomy, 51.1% relapsed subsequently, and a significantly lower relapse rate was noted in the stable IVIG responders (12.5%, p = 0.0220) than in nonresponders (60.0%) and poor responders (59.4%). Conclusions: First-line IVIG response is indicated as a useful predictive factor for response to splenectomy.

[1]  S. Vesely,et al.  American Society of Hematology 2019 guidelines for immune thrombocytopenia. , 2019, Blood advances.

[2]  W. R. Burack,et al.  Intravenous immunoglobulin treatment of spleen cells from patients with immune thrombocytopenia significantly increases the percentage of myeloid‐derived suppressor cells , 2018, British journal of haematology.

[3]  K. McCrae,et al.  Splenectomy for immune thrombocytopenia: down but not out. , 2018, Blood.

[4]  Ayesha M. Khan,et al.  Clinical Practice Updates in the Management Of Immune Thrombocytopenia. , 2017, P & T : a peer-reviewed journal for formulary management.

[5]  M. Lambert,et al.  Clinical updates in adult immune thrombocytopenia. , 2017, Blood.

[6]  B. Bonnotte,et al.  Fcγ receptor expression on splenic macrophages in adult immune thrombocytopenia , 2017, Clinical and experimental immunology.

[7]  M. Shahjahani,et al.  Bone marrow niche in immune thrombocytopenia: a focus on megakaryopoiesis , 2016, Annals of Hematology.

[8]  Guk Jin Lee,et al.  Clinical Outcome and Predictive Factors in the Response to Splenectomy in Elderly Patients with Primary Immune Thrombocytopenia: A Multicenter Retrospective Study , 2016, Acta Haematologica.

[9]  J. Liu,et al.  Association of autoantibody specificity and response to intravenous immunoglobulin G therapy in immune thrombocytopenia: a multicenter cohort study , 2014, Journal of thrombosis and haemostasis : JTH.

[10]  J. González-Porras,et al.  Safety and efficacy of splenectomy in over 65‐yrs‐old patients with immune thrombocytopenia , 2013, European journal of haematology.

[11]  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.

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

[13]  A. Newland,et al.  Guidelines for immune thrombocytopenia. , 2011, The New England journal of medicine.

[14]  Jae Jin Lee,et al.  Long-term outcomes of a 5-year follow up of patients with immune thrombocytopenic purpura after splenectomy , 2010, The Korean journal of hematology.

[15]  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.

[16]  Y. Ikeda,et al.  Splenic macrophages maintain the anti‐platelet autoimmune response via uptake of opsonized platelets in patients with immune thrombocytopenic purpura , 2009, Journal of thrombosis and haemostasis : JTH.

[17]  Hyo-jin Kim,et al.  Prognostic Factors of Response to Laparoscopic Splenectomy in Patients with Idiopathic Thrombocytopenic Purpura , 2005, Journal of Korean medical science.

[18]  J. Balthasar,et al.  Mechanisms of intravenous immunoglobulin action in immune thrombocytopenic purpura. , 2005, Human immunology.

[19]  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.

[20]  B. Olsson,et al.  T-cell-mediated cytotoxicity toward platelets in chronic idiopathic thrombocytopenic purpura , 2003, Nature Medicine.

[21]  Guidelines for the use of platelet transfusions , 2003, British journal of haematology.

[22]  J. Bussel,et al.  Do the acute platelet responses of patients with immune thrombocytopenic purpura (ITP) to IV anti‐D and to IV gammaglobulin predict response to subsequent splenectomy? , 2001, American journal of hematology.

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

[24]  J. Ahn,et al.  Response to high‐dose intravenous immune globulin as a valuable factor predicting the effect of splenectomy in chronic idiopathic thrombocytopenic purpura patients , 2001, American journal of hematology.

[25]  P. Faccini,et al.  Factors predicting response to splenectomy in adult patients with idiopathic thrombocytopenic purpura. , 2000, Haematologica.

[26]  P. Bierling,et al.  The response to high‐dose intravenous immunoglobulin or steroids is not predictive of outcome after splenectomy in adults with autoimmune thrombocytopenic purpura , 1999, British journal of haematology.

[27]  T. Aoki,et al.  Surgical treatments of chronic idiopathic thrombocytopenic purpura and prognostic factors for splenectomy. , 1996, International surgery.

[28]  T. Barbui,et al.  High risk of severe bleeding in aged patients with chronic idiopathic thrombocytopenic purpura. , 1991, Blood.