e., the alarming platelet count) nor the target, i.e., the platelet number posttransfusion before invasive procedures, are evidence-based. Laboratory methods that may help determine the trigger/target platelet count needed before invasive procedures are also lacking. Some years ago Lisman et al,[6] provided in vitro evidence that the adhesion of platelets from patients with cirrhosis to

the subendothelial matrix was normal despite the fact that these patients were thrombocytopenic. This is explained by the increased levels of the adhesive protein von Willebrand factor, which is a typical feature of patients with cirrhosis.[6] Recently, we showed in an in vitro study of platelet-rich plasma that the threshold platelet count needed to secure thrombin generation see more correspondent to the lower limit of the normal reference range amounts to 56 × 109/L.[7] However, the methods employed in the Lisman et al.[6] and in our study,[7] although useful to shed light on the mechanisms of adhesiveness and thrombin generation mediated by platelets in cirrhosis, are not yet applicable to manage patients. Furthermore, in another study we showed that the prophylactic transfusion of find more one single adult platelet unit (often used regardless of the pretransfusion platelet counts) is barely sufficient to increase platelet counts above 50 × 109/L and that both

thrombin generation and thromboelastometry (i.e., a global method that assesses Dipeptidyl peptidase the viscoelastic properties of clotting blood) were barely affected by this transfusion schedule.[8] Accordingly, if a greater platelet count is required, this requires multiple transfusions. Thrombopoietin receptor agonists that are able to increase platelet counts in chronic idiopathic thrombocytopenic purpura may present an alternative to multiple transfusions.[9] In a recent issue of the New England Journal of Medicine, Afdhal et al.[10] reported interesting results on a randomized/controlled clinical trial of one such oral agent (eltrombopag) for its ability to spare platelet transfusion in patients with cirrhosis undergoing an elective invasive procedure. The study was timely, as platelet transfusions have some limitations (short duration of efficacy,

risk of transfusion reactions, and development of antiplatelet antibodies). Patients with platelet counts equal or lower than 50 × 109/L were randomized to receive eltrombopag 75 mg once daily or placebo.[10] A platelet transfusion was avoided in 72% of the patients who received eltrombopag and in 19% of those who received placebo. No significant difference between the eltrombopag (17% of patients) and placebo (23% of patients) groups was observed in bleeding episodes of World Health Organization (WHO) grade 2 or higher.[10] However, thrombotic events of the portal venous system were observed in six patients who received eltrombopag, as compared with one who received placebo. Because of this, the investigators opted for an early termination of the study.