S1324 Empiric Platelet Transfusion in Acute Variceal Bleeding Is Associated With Higher Mortality and Rebleeding: A Systematic Review and Meta-Analysis

Introduction: Acute variceal bleeding (AVB) is one of the leading causes of mortality in cirrhosis patients, having around a 20% mortality rate at 6 weeks. Although platelet transfusions are frequently performed to manage thrombocytopenia, they carry risks such as inflammation and fluid overload. Their efficacy associated with the transfusions is questionable. This systematic review and meta-analysis aim to assess whether providing patients with AVB platelet transfusions has any effect on mortality and rebleeding. Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified cohort studies reporting mortality outcomes at 42 days or 6 weeks after empirical platelet transfusion compared to management without transfusion for Acute Variceal Bleed. Data was analyzed using RevMan 5.4. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I²). Statistical significance was set at P < 0.05. Risk of bias was assessed with the Newcastle-Ottawa Scale (NOS). Results: Three retrospective (2 single-centre, one multicentre) studies met inclusion (n = 1,375; 175 transfused, 1,200 controls). Platelet transfusion was associated with significantly higher 42-day mortality: 32% vs 14% (pooled risk ratio = 4.22, 95% CI 1.34–13.35, P = 0.01). All individual study estimates favoured no transfusion. Heterogeneity was high (I² = 91%), driven mainly by a cohort in which transfusion occurred within massive-transfusion protocols; leave-one-out analysis reduced I² to 48% while the harm signal persisted (RR = 2.38, 95% CI 1.37–4.11). Biswas 2022 documented day 5/ 42 rebleeds of 14.3% → 31.9% vs 4.3% → 13.3% (propensity-matched HR 2.9) while Canakis 2020 reported failure-to-control bleeding at 5 days in 18% vs 4% with platelets. Conclusion: Existing evidence suggests that in AVB, empiric platelet transfusion gives no survival benefit and may increase short-term mortality by more than 2-fold. Results from adequately powered RCTs will need to stratify by platelet count, bleeding severity, and portal hypertensive physiology before routine platelet replacement is performed under rigidly defined criteria. Until then, targeted vasoactive medications, early endoscopic procedures, and conservative packed red blood cell will remain to be the mainstay of treatment for managing AVB.