Splenectomy for immune thrombocytopenia: down but not out
Splenectomy for immune thrombocytopenia: down but not out
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DOI：
10.1182/blood-2017-09-742353
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发表时间：
2018-03-15
期刊：
影响因子：
20.3
通讯作者：
McCrae, Keith R.
中科院分区：
文献类型：
--
作者：
Chaturvedi, Shruti;Arnold, Donald M.;McCrae, Keith R.
脾切除术是治疗激素难治性或依赖性免疫性血小板减少症(ITP)的有效方法。随着医疗替代品的出现，如利妥昔单抗和血小板生成素受体拮抗剂，脾切除术的使用已经减少，通常保留给多次药物治疗失败的患者。脾切除术去除了血小板清除和自身抗体产生的主要部位，与其他ITP疗法相比，提供了最高的持久应答率(50%至70%)。然而，没有可靠的预测脾切除反应的指标，必须考虑感染和心血管并发症的长期风险。由于不同二线药物治疗ITP的长期疗效尚未进行直接比较，因此必须在没有支持性证据的情况下做出治疗决定。对于许多患者来说，脾切除术仍然是一个合理的治疗选择，包括那些生活方式积极的患者，他们希望摆脱药物和监测，以及患有暴发性ITP的患者，他们对药物治疗没有很好的反应。我们尽量避免在ITP诊断后的头12个月内切除脾，以允许自发或治疗诱导的缓解，特别是在手术发病率增加和反应率较低的老年患者和年幼儿童。治疗决定必须根据患者的合并症、生活方式和偏好进行个性化。未来的研究应该侧重于比较接受不同二线治疗的患者的长期结果，并开发个性化的药物方法，以确定最有可能对脾切除术或其他治疗方法有反应的患者亚群。
Splenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists, the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies. Splenectomy removes the primary site of platelet clearance and autoantibody production and offers the highest rate of durable response (50% to 70%) compared with other ITP therapies. However, there are no reliable predictors of splenectomy response, and long-term risks of infection and cardiovascular complications must be considered. Because the long-term efficacy of different second-line medical therapies for ITP have not been directly compared, treatment decisions must be made without supportive evidence. Splenectomy continues to be a reasonable treatment option for many patients, including those with an active lifestyle who desire freedom from medication and monitoring, and patients with fulminant ITP that does not respond well to medical therapy. We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response, and in young children. Treatment decisions must be individualized based on patients' comorbidities, lifestyles, and preferences. Future research should focus on comparing long-term outcomes of patients treated with different second-line therapies and on developing personalized medicine approaches to identify subsets of patients most likely to respond to splenectomy or other therapeutic approaches.