Splenectomy in immune thrombocytopenic purpura: recent controversies and long-term outcomes

Immune thrombocytopenic purpura (ITP) is an uncommon disorder but a relatively frequent cause of isolated thrombocytopenia. The pathogenesis of ITP involves enhanced platelet clearance, primarily in the spleen, caused by antiplatelet glycoprotein antibodies. Most patients with ITP respond transiently to an initial course of corticosteroids, although only 20% of adult patients achieve a durable remission after such therapy. Classically, patients who fail corticosteroid therapy undergo splenectomy, with approximately two thirds of these individuals maintaining partial remissions 5 years later. However, due to evidence suggesting a continuous relapse rate in splenectomized patients with ITP, in addition to the emergence of newer agents associated with durable remissions in ITP patients with intact spleens, the therapeutic approach to ITP is evolving. This article reviews the role of splenectomy in patients with ITP and reviews new approaches to management of ITP in patients who fail an initial trial of corticosteroids.