Platelets and Cirrhosis

[hcvJames]

Two questions:
Since May last year platelets have been basing in the mid-40's. Just found out the last CBC on March 2nd showed them at 35. That was 6 shots ago. I had another CBC yesterday but don't know the results, which didn't stop me from taking a shot last night .. :) Ya, I know, danger territory, but I have one more shot next Wednesday and the following week of pills then it's done till 3 month PCR. After pushing for a 2 month continuation in Feb., I'm hardly going to stop now ... but ... I guess I'm asking for reassurances via others experiences with lower levels.

Cirrhosis: Are there different levels of cirrhosis? Or is it simply, compensated or uncompensated? Is damage inferred indirectly via things like AST and ALT? Is there a way to say NN% of your liver is damaged. How is cirrhosis determined, is it in the biopsy? What if that one plunge missed the cirrhotic spot? Does it show up on a say, a CT scan? Tx is almost over and now I ask about it. Go figure.

Thanks all.

[willing]

not much to contribute to the discussion but wanted to congratulate you on getting to the end of the road and wish you the best . Platelets hopefully will recover quickly - the ifn seems to do a number on them Though all my other indicators have been bouncing, platelets have been moving in one direction only. Still no worries but I'm thinking of making sure my Dr. doesn't see any cbcs for a bit.

[paen53]

Just a couple of the links with info of a positive nature for those of us with cirrhosis/advanced liver disease. I re-read these whenever I start to feel shaky. The one thing I've been told I can't let up on is the imaging every 6 months for HCC. For me, it alternates between an MRI and ultrasound. And of course, I would think that any reversal also hinges on maintaining a healthy lifestyle and keeping things like steatosis and metabolic issues in check. Hang in there, Pam


http://www.natap.org/2010/HCV/070710_02.htm

http://natap.org/2010/HCV/082910_01.htm

http://onlinelibrary.wiley.com/doi/10.1111/j.1478-3231.2010.02378.x/full

http://www.medhelp.org/posts/Hepatitis-C/New-study-presented-at-DDW-re-fibrosis-reversal-after-SVR/show/966068

[hcvJames]

foofighter : platelets before tx were never higher than mid 90's

Bill : "... bilirubin, albumin, INR and others." Never had those done, ALT/AST, TSH, AFP, CBC and VL test are about it. Reading the link to Child-Pugh just irritates the sin out of me. The test for ascites was tapping one side of the stomach and seeing if it shook on the other. Well yaaa .. it was a Santa Clause belly shaking like a bowl full of jelly ( lost 50 lbs since.) Never tested for ammonia or creatinine. Sigh ... Are you saying Class A can subdivided into 3 levels? Also is Class B uncompensated OR severe liver damage just short of being uncompensated. Otherwise it's just saying you're either comp or uncomp. Are the mortality rates, for Class A (maybe B) frozen in place if SVR is achieved?

paen53 : ha, the NP wasn't going to request a CBC Wednesday until I asked her to ask the Doc ... Next CBC is 05/04 a week after tx is done. I can't decide whether it's to see if I survived the final two weeks or if the platelets are going up. Must be the first cuz what can be done about platelets? Maybe a prescription for blueberries?  :)

HectorSF : Had a CT and ultrasound. They mentioned some small suspect area (don't remember the wording anymore). Nothing was said about any level of inflammation.

I should have been aggressive in pursuing this from the beginning but honestly I didn't want to know. Was already overwhelmed by what I did know.

Thanks everyone for the answers.

[Archer_]

PS Im no expert in this, just learning like you - the info in my post is just what I have been told  - there are likely others here whose expertise is far greater, Best wishes Archer

[Archer_]

At work - so quick comment.
James Im cirrhotic - after biopsy in 2002 I was told by the major hep Guru Professor X in the main city hospital - that there was so little damage after nearly 30 yrs of HCV - that I was one of the lucky ones - something else would get me in the end (black humour!) - To go away and unless my routine EFTs ever become dramatically worse - not to bother with any further follow ups (not even another later biopsy). EFTs bumbled along like they always had - but by End 2009 my gp (who knew I had HCV) - sent me to a haemotologist to ascertan why my platelets had been below normal and steadily dropping for the last two years ! It was then I discovered I was cirrhotic and likely had been for nearly two years (ie platelets don't start dropping till you are verging on cirrhosis) - which effectively means I was at or approaching Stage 4 within 4 years of being told - I was one of the lucky ones. Ultrasound has identified portal hypertension, splenamegoly and begginings of varices (fortunately not yet osoephageal, which are the more risk). Liver scan put me at 13.8K. My blood levels (in my signature) are a concern for propsed tx as is my IL28B result. Cautionary tale - dont wait for symptoms or rely on one source of measurement to monitor HCV progress and effects.
Platelets - approaching 20/25 (or 20/25,000) is dangerous and can result in spontaneos internal bleeding; which if cerebral or intesinal - has high mortality risk. - dont push the envelope for any reason. If your platelets are too low on last path test to continue - & if Your tx measures have been strong re RVR,or UND - you may not be unduly affected by missing the very last shot. Others can better advise you on this. regards Archer
      

[eureka254]

Since you have just one more shot to go, your platelets should hopefully bounce back soon afterward. Lots of good info above, not much to add except personal experience: my husband also hovered in the 40s and 50s range for much of treatment, but when he had two successive weeks in the 30s (38 and then 35), he was told to dose reduce INF to 135 mcg, and almost immediately his platelets jumped back up to the high 50s.  

In regards to the predictability of cirrhosis, imho there isn't much consistency.  As example, my husband (compensated cirrhosis) has had ALT and AST in normal range for months... in cirrhotics, the more important markers to watch would be the MELD determinants, albumin, and platelets (if not on treatment).  Best of luck! ~eureka

[HectorSF]

As someone else said, you should have had your platelet count monitored more closely since you had very low platelets to begin with. It can be very dangerous to have a platelet count under 20,000. You can start to bleed internally.
Once you stop treatment your platelets will return to there previous levels because it is a side effect of interferon that is causing your platelet count to drop. (thrombocytopenia)

Cirrhosis: Are there different levels of cirrhosis? Yes. This is measured by the MELD score. A formula for calculating 3 blood levels, Bilirubin, INR and creatinine. As was mentioned patients can feel differently even if they have the same MELD score.

Or is it simply, compensated or uncompensated?
Compensated or uncompensated are different states of cirrhosis. Compensated cirrhotics can have no symptoms. When the liver can no longer perform all of functions properly and a patient has symptoms of ascites, edema, bleeding varices and other symptoms they are considered decompensated.

Is damage inferred indirectly via things like AST and ALT?
No. AST and ALT are not true liver function tests and can remain normal in some patients even with compensated cirrhosis.

Is there a way to say NN% of your liver is damaged.
It is more a question about how scared the liver is and the liver failing. As cirrhosis progress the process is sped up right before liver failure. Were as it took 30-40 years to get to that point.

How is cirrhosis determined, is it in the biopsy?
Biopsy is used to confirm cirrhosis. As others said there are many other things that happen internally to because of cirrhosis.

What if that one plunge missed the cirrhotic spot?
Usually more then one sample is taken during biopsy.

Does it show up on a say, a CT scan?
Yes it shows up on abdomen ultrasounds, CT scans and MRIs. It appears are a nodular surface due to scaring.

Good luck on SVR!
Hectorsf

[Fnzol]

My plts never went below 130, and I still had spontaneous nose bleeds for the second half of treatment.  PITA.  Ruined lots of shirts.  

[GoofyDad]

From my personal experience, just when platelets would get real low - they would head north again. But be forwarned: in addition to trauma, you have spontaneous bleeds to worry about. I got CBCs every week.

Gotta run...

[paen53]

oops, see now that you just had another CBC drawn yesterday. Tomorrow you'll have a good feel of where you stand.........

[paen53]

I'm also cirrhotic and remember being told early in tx that they would let my platelets drop to 24,000 before tx would be discontinued but I would be closely monitored and that any activities, even driving, at that point would be curtailed.

Platelets do bounce around quite a bit, but I guess I'm a bit concerned that they aren't checking them more than every 6 weeks (if I'm reading your post right). If it were me, I would push for another CBC just to be on the safe side. You're so close to the end, but you want to make across that finish line intact, ya know?

[Bill1954]

There are others in here that are better versed than I am on cirrhosis; I’ll try to address a couple of your thoughts, and hopefully HectorSF, Eureka or some of the others that have personal experience will stop by as well.

I do think you’re starting to push the envelope with platelets, but I’ve heard anecdotally from others that even 35 is okay, as long as they don’t drop much further. I’d try to avoid any situation that might expose you to trauma; no jumping the grand canyon on your Harley, don’t run through the house with scissors, etc. If you got in a wreck, I think they’d manage; but I doubt you’d win any favors from the ER doc :o).

Cirrhosis can be quantified by liver biopsy as well as biochemical markers like platelets, bilirubin, albumin, INR and others. Also to some extent through imaging; U/S scan, for instance can determine organ dimensions, portal vein diameter, proper flow through the portal tract, etc.

As far as expressing the damage, of course they use the terms ‘compensated’ and ‘decompensated’. This can also be expressed by the Child-Turcotte-Pugh scale:

http://en.wikipedia.org/wiki/Child-Pugh_score

This is often also called simply, ‘Child-score’; For instance, Child-class A. It classifies cirrhosis into three stages again, after F4 is reached. Child class A refers to compensated liver disease; Child-class B and C signify decompensation.

And they also use the MELD score; this is preferred by UNOS and most transplant facilities.

Yeah, while liver biopsy is still an imperfect procedure, it’s still the standard by which other methods are compared. I think if you’re with a competent medical team, they’ll use pathology results as only one part of the equation. They should have a pretty accurate picture of you using multiple means, though.

Do you know what your current MELD score is?

The most critical management tools right now are probably both endoscopy to monitor esophageal varices, as well as periodic surveillance for liver cancer (HCC) by way of AFP blood tests, and U/S or CT scans.

Good luck with your treatment outcome; be sure to let us know what you find as you go forward-

-Bill

[foofighter]

Three plunges have missed the spot twice on me actually. So yes it can happen and does. I would imagine the other direction as well, with people getting told they are stage 4 but have nothing else indicating cirrhosis.

Still, they have a bit of liver that is stage 4 or in my situation, that sliver of liver was stage 2. Hey, good band name, Sliver of Liver.

The other stuff, like labs (your low platelets), a cirrhotic appearing liver in imaging (CT or ultrasound), varices, ascites, all that good stuff, confirm. And those things are what helps stage your level of cirrhosis. I believe there are a couple of grading systems. Child-Pugh comes to mind. All culminating in a MELD score.

I posted this link a few years back and it is still hard to look at. Be forewarned, the images of the cirrhotic livers are shocking:

http://tinyurl.com/3cjyxo

Also, similar to the differences in fibrosis progression caused by HCV, it seems the same is true for cirrhotics:

Often a poor correlation exists between histologic findings and the clinical picture. Some patients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and have a limited chance for survival. Common signs and symptoms may stem from decreased hepatic synthetic function (eg, coagulopathy), decreased detoxification capabilities of the liver (eg, hepatic encephalopathy), or portal hypertension (eg, variceal bleeding).

What were your platelets before you started?