Comment on “The application of avatrombopag in chronic liver disease patients with severe thrombocytopenia undergoing procedures in China: a prospective real-world cohort study”

To the Editor, Xiao et al report a prospective, multicenter real-world cohort from China evaluating avatrombopag for peri-procedural thrombocytopenia in chronic liver disease (CLD) patients with baseline platelets <50 × 109/L[1]. This is a clinically important setting where procedure volume is high, platelet transfusion logistics are imperfect, and the “rebalanced haemostasis” concept has complicated how clinicians interpret fixed platelet thresholds[2]. This commentary was prepared in accordance with the TITAN 2025 guideline to promote transparent and responsible reporting[3]. The key practice-facing signal is consistency: avatrombopag substantially increased the proportion of patients meeting the clinically meaningful endpoint of avoiding platelet transfusion or rescue therapy for bleeding through day 10, and markedly improved achievement of platelet ≥50 × 109/L on the procedure day[1]. These observations align with the pivotal ADAPT-1/ADAPT-2 phase 3 trials, where avatrombopag reduced the need for transfusion or rescue procedures compared with placebo in CLD patients undergoing planned interventions[4]. The current study strengthens external validity by focusing on real-world procedural mixes common in China (notably transhepatic parenchymal/endovascular interventions) and by reflecting routine comparator practices (rhTPO/rhIL-11/other strategies)[1]. An additional contribution is the authors’ exploratory identification of a lower “tipping point” around a procedure-day platelet count of ~37 × 109/L, below which transfusion/rescue needs rose[1]. While hypothesis-generating, this is clinically relevant because contemporary guidance emphasizes individualized correction strategies rather than automatic normalization of coagulation tests for every procedure[2]. Important caveats remain. Allocation was nonrandomized and the control arm was heterogeneous, making confounding by indication likely despite adjustment and weighting[1]. The study was also stopped early after an interim analysis met the primary endpoint, which can inflate the apparent effect size[1]. Finally, a longer follow-up is needed to better quantify thrombotic risk (e.g., portal vein thrombosis) and to understand performance in higher-risk subgroups[1]. Overall, Xiao et al provide pragmatic evidence that avatrombopag can reduce transfusion reliance and support safer, more streamlined peri-procedural care in Chinese CLD patients with severe thrombocytopenia[1]. Prospective comparative studies with standardized control regimens and harmonized bleeding definitions are now warranted to define optimal thresholds and the highest-benefit procedural scenarios.