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Br J Haematol. 2018 Apr;181(2):183-195. doi: 10.1111/bjh.15090. Epub 2018 Feb 26.

A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP.

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Haematology Project Foundation, Affiliated to the Department of Cell Therapy and Haematology, S. Bortolo Hospital, Vicenza, Italy.


In primary chronic immune thrombocytopenia, long-term response to splenectomy, with 60% of patients enjoying a treatment-free life, is higher when compared with rituximab and similar to that with continuous thrombopoietin-receptor agonists (TPO-RA) administration. Splenectomy should continue to be offered to patients failing initial treatments in the absence of increased surgery-related risks. The higher lifelong safety concerns with splenectomy (increased risk of infection, shared in part with rituximab, and of thrombosis, in common with TPO-RA) and a mortality <1-2%, justify postponing surgery to the chronic phase, when spontaneous remissions are rarer. Patients failing initial treatment with corticosteroids/intravenous immunoglobulin may use TPO-RA (or rituximab in selected cases) as a bridge to surgery if they prefer to reconsider splenectomy later on, in case of no response, adverse effects or if sustained response after stopping TPO-RA is not attained. Special considerations apply in children aged ≤5 years, with splenectomy playing a marginal role. The recent approval of TPO-RA in children may represent a major advancement.


immune thrombocytopenia; rituximab; splenectomy; thrombopoietin-receptor agonists


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