Jurnal Sains dan Kesehatan

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Analysis of Platelet Count on Liver Cirrhosis Patients Based on Child-Pugh

Classification

Renanda Maulidya Fadyla1,*, Rahmat Bakhtiar2, RR. Ignatia Sinta Murti3

Medical Study Program, Faculty of Medicine, Mulawarman University, Samarinda, Indonesia

1
2Department of Public Health, Faculty of Medicine, Mulawarman University, Samarinda, Indonesia
3Department of Internal Medicine, Faculty of Medicine, Mulawarman University, Samarinda, Indonesia

*Email korespondensi: nanda.fadyla@gmail.com

Abstrak
Sirosis hepatis menggambarkan proses patologis yang bersifat difus ditandai dengan fibrosis dan
perubahan arsitektur hati normal menjadi struktur nodular yang abnormal. Sirosis hepatis dapat
disebabkan oleh penyakit hati kronik akibat virus maupun non virus. Trombositopenia merupakan
kelainan hematologi yang paling sering ditemui pada pasien sirosis hepatis. Tingkat keparahan dan
prognosis sirosis hepatis dapat ditentukan dengan menggunakan klasifikasi Child-Pugh. Penelitian ini
bertujuan untuk mengetahui perbedaan rata-rata kadar trombosit pada penderita sirosis hepatis
berdasarkan klasifikasi Child-Pugh. Jenis penelitian menggunakan observasional analitik dengan
desain cross sectional. Data diambil dari rekam medik pasien sirosis hepatis yang dirawat di RSUD
Abdul Wahab Sjahranie Samarinda periode 2018-2020. Analisis statistik menggunakan uji Krsukal-
Wallis. Hasil penelitian menunjukkan pasien sirosis hepatis paling banyak berada pada Child-Pugh C.
Rata-rata kadar trombosit pasien sirosis hepatis dengan Child-Pugh A sebesar 73.250/μl, Child-Pugh
B sebesar 126.370/μl, dan Child-Pugh C sebesar 148.375/μl. Berdasarkan uji statistik didapatkan nilai
p = 0,19 (p > 0,05), sehingga tidak terdapat perbedaan rata-rata kadar trombosit di antara ketiga
klasifikasi Child-Pugh.

Kata Kunci: sirosis, trombosit, Child-Pugh

Abstract
Liver cirrhosis is described as a diffused pathological process which marked with fibrosis and
architectural changes of normal liver that becomes an abnormal nodular structure. Liver cirrhosis is
caused by chronic liver disease of virus nor non virus. Thrombocytopenia is a hematology abnormality
which frequently found on liver cirrhosis patients. Severity level and prognosis of liver cirrhosis can
be determined by Child-Pugh classification. This research aims to know the difference of mean platelet
count on liver cirrhosis patients based on Child-Pugh classification. It applied analytic observational
method with cross-sectional design. The data was taken from medical records of patients at Abdul

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p-ISSN: 2303-0267, e-ISSN: 2407-6082
Analysis of Platelet Count on Liver Cirrhosis Patients Based on Child-Pugh Classification

Wahab Sjahranie Hospital in Samarinda of 2018-2020 period. Statistical analysis was using Kruskal-
Wallis test. The results showed liver cirrhosis patients in Child-Pugh C is at most. Mean platelet count
of liver cirrhosis with Child-Pugh A is 73.250/μl, Child-Pugh B is 126.370/μl, and Child-Pugh C is
148.375/ μl. Based on statistical test, the score p = 0,19 (p > 0,05), there are no differences of mean
platelet count among the three Child-Pugh classifications.

Keywords: cirrhosis, platelets, Child-Pugh

Submitted: 22 Oktober 2020 Accepted: 20 Agustus 2021 DOI: https://doi.org/10.25026/jsk.v3i4.340

1 Introduction INR (International Normalized Ratio) that

divide patients to Child-Pugh A, Child-Pugh B,
Liver cirrhosis (LC) is a fibrotic liver and Child-Pugh C [14].
disease with irreversible inflammation and One of research in Padang, found the
develop slowly over a period of years [1]. Liver difference of mean platelet count on LC patients
cirrhosis is described as a diffused pathological based of Child-Pugh classification (p < 0,05). The
process which marked with fibrosis and result showed platelet count of LC patients with
architectural changes of normal liver that bleeding is decreasing according to the severity
becomes an abnormal nodular structure [2]. level of LC disease [15]. Another research by
Liver cirrhosis can be categorized by the size of Nwokediuko et al showed the significant
nodul, etiology, morphology, and clinical [3]. correlation between platelet count and Child-
According to World Health Organization Pugh classification (p = 0,0001 ; y = -0,6183)
(WHO), LC causes the most deaths in the world, [16]. Whereas a research in Turkey categorized
covers 1,3% of it [4]. LC causes 1,2% deaths in all of LC patients by Child-Pugh classification,
United States [5]. Meanwhile in Indonesia itself, each categories being compared by the mean
the number of LC disease since the year 2000- platelet count and no significant difference was
2016 was recorded 26,9 millions of patients and found (p > 0,05) [17]. This research intends to
causing 51,1 deaths of men and 27,1 of women know the difference of mean platelet count on
per 100.000 population in 2016 [6,7]. In 2010, LC patients based on Child-Pugh classification.
LC was in 20 causes of deaths in the worlds and
one of five causes of deaths in Indonesia [4].
2 Research and Methods
Hematological abnormalities that
accompany LC can be identified through This research was implemented at Abdul
laboratory examinations. Abnormalities that Wahab Sjahranie Hospital in Samarinda, started
can be occurred such as anemia, on 17th of June until 3rd of July 2020, by
thrombocytopenia, and neutropenia [8]. analyzing all of medical records of LC patients in
Thrombocytopenia is blood abnormalities that the year 2018-2020 and classified as an analytic
most frequently found on LC [9,10]. observational research using cross-sectional
Thrombocytopenia frequently used as a marker design. Medical records that have been
on advanced liver disease and several research identified as LC are excluded if followed by non-
showed moderate to severe thrombocytopenia liver infection disease, hematologic disorder,
as a predictor of death [11]. HIV-AIDS, and incomplete examination result.
Several research showed that if the level of There are 71 data of medical records that are
liver disease is increasing, the platelet count qualified for the research criteria.
would be decreasing [12,13]. On LC, the level of Child-Pugh classification (independent
severity and prognosis are determined by using variable) is classified into three Child-Pugh
Child-Pugh classification such as bilirubin classifications such as A, B, and C which
serum, albumin serum, ascites, hepatic obtained from the result of score calculations
encephalopathy, and PT (Prothrombin Time) or [14]. Platelet count (dependent variable) can be

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Analysis of Platelet Count on Liver Cirrhosis Patients Based on Child-Pugh Classification

seen from medical records and cross-checked Wahab Sjahranie Hospital in Samarinda.
by laboratory data of Pathology Clinic. Another research with similar results, where as
Normality test resulting the score p = 0,000 (p < many as 78,6% of LC patients at Prof.Dr.R.D
0,05), this result showed the data is distributed Kandou Manado Hospital are male patients [21].
as not normal, so the alternative for statistical In line with the result, a research by Husni et al
analysis is Kruskal-Wallis test. Data of this has also shown that more men (94,28%) have
research is processed by IBM SPSS Statistics 26. LC disease than women (5,71%) [22].
There are some factors that presumed to
3 Results and Discussion be increasing the factor of LC occurrence risk on
men. Based on data, the prevalence of men
having hepatitis and alcohol consumption is
higher than on women [23,24].
Based on age, cirrhosis patients divided
Table 1. Characteristics of Liver Cirrhosis Patients into five categories of ages. Category with most
Characteristics N (71) %
frequent LC occurrence is at the age of 51-60
Child-Pugh A 4 5.6
B 27 38 years old (40,8%), and category with the least
C 40 56.3 LC occurrence is at the age less than 31 years
Sex Male 58 81.7 old, only occurred to one person (1,4%) out of
Female 13 18.3
Age < 31 1 1.4 all sample patients. The result is similar with a
31-40 4 5.6 research by Tambunan et al about
41-50 19 26.8 characteristics of patients at Dr. Soedarso
51-60 29 40.8
> 60 18 25.4
Pontianak Hospital, the majority of LC patients
Platelet Count Low 50 70.4 are at the age of 50-59 years old (31%) [25]. A
Normal 20 28.2 research in Manado by Patasik et al also showed
High 1 1.4
that the age of 50-59 years old are the most
frequent occurrence of LC patients (31,4%)
[26].
Liver cirrhosis is a chronic liver disease
Child-Pugh classification of LC patients at that tends to be latent and changes of pathology
Abdul Wahab Sjahranie Hospital in Samarinda, that occurred slow progress, so it often
with the majority of Child-Pugh C category, encountered with age. A patient with hepatitis
consists of 40 people (56,3%). There are only 4 history, changes from chronic hepatitis to LC
people (5,6%) in Child-Pugh A, and the rest of takes time approximately 10 to 30 years,
the people is in Child-Pugh B (38%). The similar whereas compensate LC becomes
result is shown by Lovena et al, in her research decompensate takes six years. A cirrhosis
about characteristics of LC patients at Dr. M. patient usually would not check themselves if
Djamil Padang Hospital, the majority of LC the symptoms are not seen yet [18].
patients are in Child-Pugh C with the percentage Platelet count on LC patients in this
of 60,3% [18]. The research by Saksana et al, in research is in low (thrombocytopenia), normal,
line with previous research, the highest and high (thrombocytosis). As many as 50 out of
percentage was in Child-Pugh C (49,3%) [19]. 71 people as sample have thrombocytopenia
Liver cirrhosis with Child-Pugh C has the (70,4%). There are 20 people with normal
worst prognosis and indicates advanced liver platelet count (28,2%), and the rest have
dysfunction [3,14]. A patient with Child-Pugh C thrombocytosis (1,4%). The occurrence rate of
has one year of survival rate and two years less high thrombocytopenia is also shown in a
than 50% [20]. This research showed that most research in Tasikmalaya, where 80% of LC
of the LC patients at Abdul Wahab Sjahranie patients have low platelet count and the rest
Hospital came with severe disease condition. have normal platelet count (20%) [27]. In line
According to Nurdjanah, patients who came to with this research, a research in Manado has
clinic are usually already at the stage of shown 34 LC patients as samples, where most of
decompensate with complications [3]. them have thrombocytopenia (85,2%), whereas
There are more of male LC patients there are four patients with normal platelet
(81,7%) than female patients (18,3%) at Abdul

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Analysis of Platelet Count on Liver Cirrhosis Patients Based on Child-Pugh Classification

count (11,7%), and the rest have On Kruskal-Wallis test shows that the
thrombocytosis (3%) [28]. score p is 0,19 (score p > 0,05), this shows that
Thrombocytopenia is a common there are no differences of mean platelet count
occurrence on chronic liver disease, and it among the three Child-Pugh classifications that
occurs on 76% of LC patients. This occurrence is the level of LC disease doesn't affect platelet
caused by increased pooling of platelets in an count in this research.
enlarged spleen, secondary to portal The result of this research is in line with a
hypertension and extensive cirrhosis [29]. research by Erdem on 201 LC patients. LC
patients are categorized by Child-Pugh
classifications regardless of the etiology.
Table 2. Mean Platelet Count on Liver Cirrhosis Patients Research by Erdem showed that there are no
Based on Child-Pugh Classifications significant difference between Child-Pugh
Child- N % Platelet (/µl) classification and mean platelet count (p > 0,05)
Pugh (71) Mean Min Max
[17]. Research results in Bosnia also showed the
A 4 5.6 73,250 42,000 152,000
B 27 38 126,370 43,000 412,000 similar results, there are no correlation between
C 40 56.3 148,375 21,000 507,000 Child-Pugh classification and platelet count (p >
0,05) [30].
However, this result is contradicted with
other research that showed correlations
between level of LC disease and the platelet
Based on Child-Pugh classification, the
count of patients. A research implemented at the
mean platelet count on Child-Pugh A patients is
hospital in Hyderabad University, showed the
73.250/μl, Child-Pugh B patients is 126.370/μl,
differences of mean platelet count among the
and Child-Pugh C patients is 148.375/μl. The
three Child-Pugh classifications (p < 0,05 ; Child-
result shows that the higher Child-Pugh
Pugh A vs Child-Pugh C & Child-Pugh B vs Child-
classification occurs, the higher platelet count of
Pugh C, p < 0,05) and the platelet count in the
patients as well. However, the result of research
research inversely proportional to level of LC
by Al Hijjah et al in Padang showed different
disease [31]. This result showed the further the
results. In the research, the mean platelet count
course of the disease, the chances of the patients
of Child-Pugh A patients is 192.181/μl, Child-
to have thrombocytopenia are increasing. In line
Pugh B patients is 155.687/μl, and Child-Pugh C
with the research, a research by Adinolfi et al to
patients is 96.485/μl. This shows that Child-
see the role of liver fibrosis in causing
Pugh classification inversely proportional to
thrombocytopenia on chronic virus hepatitis,
platelet count [15].
showed higher prevalence of thrombocytopenia
According to the researcher’s analysis, the
on patients with advanced liver fibrosis [32]. A
difference is obtained because of maximum and
research by Shao et al also showed that liver
minimum scores and also the number of spread
fibrosis has a negative correlation with the
of patients in each Child-Pugh classifications by
platelet count of patients [33].
the researcher and Al Hijjah. Aside of that, the
In theory, the main cause of
amount of varying platelet count among the
thrombocytopenia on LC is acceleration platelet
patients being the sample can also affect the
destruction or sequestration in splenomegaly
mean platelet count between the two
and suppressed thrombopoiesis because of
researchers.
reduced thrombopoietin hormone production
[34]. This theory is supported by research by
Osada et al and Shimizu et al [12,35]. However,
Table 3. Kruskal-Wallis Test another research has different results, that
Child-Pugh Mean Rank Df Kruskal-Wallis H p
A 17.75 2 3.326 0.19
splenomegaly and level of thrombopoeitin
Platelet B 36.76 hormone have no correlation with platelet
C 37.31 count of LC patients [30,36]. This conflicting
Sig : p < 0.05
research showed factors other than
splenomegaly and thrombopoeitin hormone
which can affect platelet count of LC patients.
According to Hayashi et al, bone marrow

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Analysis of Platelet Count on Liver Cirrhosis Patients Based on Child-Pugh Classification

suppression by chronic hepatitis C virus platelet count among the three Child-Pugh
infection and anti-cancer agents, and antiviral classifications.
treatment with interferon based therapy, can In this research is also found certain
affect the platelet counts on patients [37]. limitations such as lack of Child-Pugh A
The cause of there are no differences of variation, a lot of unrecorded complications on
mean platelet count in three Child-Pugh medical records, and laboratory examinations
classifications presumed to be related to diverse along with physical examination of variables
etiology of the LC patients. In research by Kuo et used for Child-Pugh classification which were
al, platelet count on chronic liver disease with not taken on the same day, the chances of
virus etiology and non-virus have significant patients having worsening nor better condition
differences (p < 0,05), where the mean platelet caused by medical intervention in the time of
count on chronic virus infection is lower than treatment at the hospital that can affect the
not infected by virus was found [38]. Virus score calculation of Child-Pugh classification.
infection can causes lower platelet count
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