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Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 10 / Issue 05 / Feb. 15, 2021 Page 435
Study of Platelet Indices and Their Interpretation in
Thrombocytopenia in a Tertiary Care Hospital
Vani Mittal1, Munesh2, Irbinder Kour Bali3, Sunil Arora4, Jyoti Singh5, Mohit Dadu6
1, 2, 3 Department of Pathology (FMHS), SGT Medical College, Hospital and Research
Institute, Gurugram, Haryana, India. 5, 6 Department of Public Health Dentistry,
Uttaranchal Dental and Medical Research Institute, Dehradun, Uttarakhand, India.
ABSTRACT
BACKGROUND
Thrombocytopenia may either be due to increased destruction or impaired
production of platelets. Platelet count alone is not enough to determine the
mechanism of low platelets. Platelet indices like mean platelet volume (MPV),
platelet distribution width (PDW), platelet large cell ratio (P-LCR) and platelet crit
(PCT) can help determine the cause and we aimed at finding their role and function
in cases of thrombocytopenia.
METHODS
An observational cross-sectional study of 155 patients with thrombocytopenia and
71 controls was done for a period of six months in SGT Hospital, Gurugram, to
determine the mechanism behind the low platelet count with the help of these
indices.
RESULTS
The mean values of the platelet indices (PDW, P-LCR and PCT) were found to be
higher in accelerated destruction group (P < 0.05) in comparison to hypoproductive
group, whereas, mean MPV values were higher in the former, but was not
statistically significant. On comparison with the controls, both the groups of
thrombocytopenia showed a statistically significant difference with P < 0.005 in all
the four indices. Mean PCT values showed a highly significant difference between
the two groups as well as with controls (P < 0.001) and also the relationship of PCT
with severity of thrombocytopenia showed a direct relationship which was also
significant (P < 0.001).
CONCLUSIONS
In distinguishing between the cause of thrombocytopenia i.e., hypoproductive or
hyper destruction, platelet parameters play an important role. These platelet
indices are easily available with the help of automated haematology analysers and
can reduce the need for costly and invasive tests for evaluation of
thrombocytopenia.
KEY WORDS
Mean Platelet Volume, Platelet crit, Platelet Distribution Width, Platelet Large Cell
Ratio, Thrombocytopenia
Corresponding Author:
Dr. Sunil Arora,
Professor, Department of Pathology
(FMHS), SGT Medical College,
Hospital and Research
Institute, Gurugram – 122505,
Uttarakhand, India.
E-mail: jugs.arora915@gmail.com
DOI: 10.14260/jemds/2021/96
How to Cite This Article:
Mittal V, Munesh, Bali IK, et al. Study of
platelet indices and their interpretation in
thrombocytopenia in a tertiary care
hospital. J Evolution Med Dent Sci
2021;10(07):435-439, DOI:
10.14260/jemds/2021/96
Submission 13-10-2020,
Peer Review 17-10-2020,
Acceptance 24-12-2020,
Published 15-02-2021.
Copyright © 2021 Vani Mittal et al. This is
an open access article distributed under
Creative Commons Attribution License
[Attribution 4.0 International (CC BY 4.0)]
Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 10 / Issue 07 / Feb. 15, 2021 Page 436
BACKGROUND
Thrombocytopenia is one of the common findings among
patients in a clinical setting. It is defined by platelet count
below the normal values and has a significant role in both
hospitalised and non-hospitalised patients.1 The counts
below 1,50,000 / µL are considered as thrombocytopenia.2
The clinical manifestation varies from mild symptoms such as
easy bruising / mild bleeding to massive bleeding /
haemorrhage that may result in death.3
Platelets play a vital role in homeostasis and also have
non-homeostatic role in angiogenesis, repairing of tissue and
inflammation.1 In order to evaluate the cause of low platelet
count, it is necessary to relate whether it is due to hyper
destruction or impaired production. Hyperdestructive
thrombocytopenia is a result of extramedullary destruction of
platelets with a normal or an increased bone marrow
production; causes comprise of malaria, dengue, idiopathic
thrombocytopenic purpura (ITP), disseminated intravascular
coagulation (DIC), haemolytic uremic syndrome (HUS). The
category of impaired production is a result of primary or
secondary bone marrow diseases with a decreased bone
marrow production. It includes causes such as bone marrow
aplasia, haematological malignancies, post chemotherapy,
post radiation, hypersplenism etc.4,5 After evaluating the
mechanism behind the low platelet count, which can be
helpful to the clinician in providing proper treatment to the
patient.6 Bone marrow aspiration study is the gold standard
for finding the cause for thrombocytopenia, but its use is
restricted since it is an invasive procedure. There is also a
high risk of bleeding complication associated with the
procedure.7
Automated cell counters are used widely these days
which furnish us the valuable information of various blood
cell parameters including red blood cells, white blood cells
and platelets with platelet parameters.8 Recently platelet
parameters like mean platelet volume (MPV), platelet
distribution width (PDW), platelet crit (PCT) and Platelet
large cell ratio (P-LCR) have been investigated as important
platelet activation markers. All these parameters are
provided by automated blood cells analysers and these
indices can be correlated with platelet counts.9 Quantification
of platelet indices in automated analysers has superiority
over the manual estimation because it is quick, effortless and
cost-effective method which also eliminates the observer bias
and artifactual problems of manual method.10
The study of these platelet indices can help establish the
mechanism behind thrombocytopenia. MPV and PDW are
both derived from platelet distribution curve and related to
change in platelet size and shape.11 P-LCR can be used as an
effective tool in distinguishing between hyper destruction
and impaired production.12 P-LCR is directly related to PDW
and MPV, whereas it is inversely related to platelet count.13
PCT is the volume occupied by the platelets in the blood and
is expressed in terms of percentage and plays an important
role in diagnosing platelet quantitative abnormalities.1,14
Platelet indices can have a significant prognostic role as
early evaluation of thrombocytopenia can help reduce
morbidity and mortality of patients with low platelet count.
This study aims to find the usefulness of these platelet indices
in initial evaluation, as their role is still not clear in patients
with thrombocytopenia.
29
METHODS
An observational cross-sectional study was undertaken for a
period of six months from September 2019 to February 2020
in the pathology laboratory at SGT Hospital, Gurugram. All
the blood samples of patients which were received in K3-
EDTA anti-coagulated vacutainers in the laboratory, were
processed within one hour of collection using the 6-part
automated haematology analyser. From the analyser
generated reports, platelet count and platelet parameters i.e.
mean platelet volume (MPV), platelet distribution width
(PDW), platelet large cell ratio (P-LCR) and platelet crit (PCT)
were recorded and platelet count was reassessed by
peripheral blood smear examination on Leishman stained
slides in all the cases. We included 155 patients of age more
than 1 year with thrombocytopenia (platelet count < 150 x
109 / L). Control group included 71 persons who had all the
haemogram parameters within normal limits.
Approval for patient consent and patient information
sheet (PIS) was obtained from institutional ethical committee
since the study involved the data available in the records that
was anonymised and coded so as to delink any data related to
identification of the patient.15
Exclusion Criteria
Patients of age < 1 year (infants) – to avoid age related
changes in platelet indices.
Patients with myelodysplastic syndrome. (MDS)
Patients with autoimmune disorders such as systemic
lupus erythematosus (SLE), Type 1 diabetes mellitus
(DM), vitiligo, juvenile rheumatoid arthritis .
Patients on anti-platelet drugs and drugs causing
thrombocytopenia.
Platelet parameters were then assessed in both the
groups and compared with those of the control group.
Statistical Analysis
The data was tabulated and analysed using the Statistical
Package for the Social Sciences (SPSS) software 23.0 for
Windows 10. Statistical mean and standard deviation were
calculated for the respective parameters in the different
groups. Multiple comparisons and associations were assessed
using an analysis of variance (ANOVA) and Bonferroni’s test
was used as a post hoc test between different categories. A P-
value of less than 0.05 only was considered as statistically
significant.
RESULTS
A total of 155 patients with thrombocytopenia after informed
consent were included in the study. There were 65 % males
and 35 % were females in this study. Table I shows the age-
sex wise distribution of the cases with thrombocytopenia.
Our age group ranged from 1 - 80 years, with more than 54 %
of the cases falling in the age group of 21 - 40 years.
Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 10 / Issue 07 / Feb. 15, 2021 Page 437
Comparison of the platelet indices with the severity of
thrombocytopenia was also assessed. (Table II) They were
categorised into 3 categories: mild thrombocytopenia with
platelet count ≥ 100 to < 150 x 109 / L, moderate
thrombocytopenia with platelet count > 50 x 109 / L and <
100 x 109 / L and severe thrombocytopenia with platelet
count ≤ 50 x 109 / L. Our study showed a significant
difference only in one of the platelet parameters i.e. platelet
crit (P < 0.001), while the rest of the parameters showed no
significant difference.
Sl. No.
Age Group
(In Years)
Male
Female
Total No
%
1
01 - 10
8
6
14
9.03
2
11 - 20
15
13
28
18.06
3
21 - 30
32
14
46
29.68
4
31 - 40
28
11
39
25.16
5
41 - 50
9
4
13
8.39
6
51 - 60
5
2
7
4.52
7
61 - 70
3
3
6
3.87
8
71 - 80
1
1
2
1.29
Total
101 (65.16 %)
54 (34.84 %)
155
100
Table 1. Age and Sex Distribution of Cases of Thrombocytopenia
Platelet
Count
Cases
PDW (fL)
(Mean ± SD)
MPV (fL)
(Mean ± SD)
P-LCR (%)
(Mean ± SD)
PCT (%)
(Mean ± SD)
≤ 50 x 109 / L
25
18.06 ± 3.29
13.21 ± 1.07
49.36 ± 7.03
0.03 ± 0.01
> 50 - < 100 x 109/ L
50
18.71 ± 3.10
13.48 ± 1.18
52.37 ± 9.32
0.06 ± 0.02
≥ 100 - < 150 x 109 / L
80
19.02 ± 3.32
13.55 ± 1.18
52.60 ± 9.18
0.08 ± 0.03
P-value (between groups)
0.428
0.460
0.269
< 0.001*
Table 2. Relationship of Platelet Indices
with Severity of Thrombocytopenia
PDW – Platelet Distribution Width, MPV – Mean Platelet Value,
P - LCR – Platelet Large Cell Ratio, PCT – Platelet crit
* The mean difference is significant at the level 0.05 level.
Group
Cases
Platelet (x
109 / L)
(Mean ±
SD)
PDW (fL)
(Mean ± SD)
MPV (fL)
(Mean ±SD)
P-LCR (%)
(Mean ± SD)
PCT (%)
(Mean ± SD)
A - Accelerated
destruction
102
103.7 ± 23.6
19.37 ±
3.04
13.66 ±
1.15
53.64 ±
8.98
0.08 ±
0.02
B - Impaired production
53
71.5 ± 32.3
17.60 ±
3.34
13.11 ±
1.10
48.85 ±
8.03
0.03 ±
0.01
Control
71
249.7 ± 77.5
16.01 ±
4.40
12.21 ±
1.75
41.85 ±
13.63
0.25 ±
0.09
Table 3. Platelet Count and Platelet Parameters
According to Each Group
PDW – Platelet Distribution Width, MPV – Mean Platelet Value,
P - LCR – Platelet Large Cell Ratio, PCT – Platelet crit.
* The mean difference is significant at the level 0.05 level.
Platelet
Paramete
rs
Group A vs. Control
Group B vs. Control
Group A vs. Group B
Mean
SD
P-
Value
Mean
SD
P-
Value
Mean
SD
P-
Value
PDW
3.3623
0.5550
P <
0.001*
1.5925
0.6519
P =
0.046*
1.7698
0.6081
P =
0.012*
MPV
1.4485
0.2109
P <
0.001*
0.9057
0.2477
P =
0.001*
0.5428
0.2310
P =
0.05 9
P-LCR
11.786
4
1.6206
P <
0.001*
7.0007
1.9033
P =
0.001*
4.7856
1.7754
P =
0.023*
PCT
-
0.1643
9
0.00868
P <
0.001*
- 0.22041
0.0101
9
P <
0.001*
0.05602
0.0095
1
P <
0.001*
Table 4. Statistical Comparison of Platelet Parameters within Groups
PDW – Platelet Distribution Width, MPV – Mean Platelet Value, P-LCR –
Platelet Large Cell Ratio, PCT – Platelet crit
* The mean difference is significant at the level 0.05 level.
Patients with thrombocytopenia were grouped into 2
groups according to the mechanism causing low platelet
count i.e. group A included those with hyper destructive
causes of low platelet count and group B included causes
leading to impaired production of platelets. Group A included
102 patients who were diagnosed as either of the following:
dengue (28), burns (5), pregnancy (13), malaria (16), typhoid
(8), disseminated intravascular coagulation (4), sepsis (6),
viral infections (12), idiopathic thrombocytopenic purpura
(3), or renal diseases (7). Group B included 53 patients who
were diagnosed as either of the following: tuberculosis (9),
chicken pox (3), deep vein thrombosis (2), chikungunya (7),
megaloblastic anaemia (7), iron deficiency anaemia (10),
pancytopenia (6), leukemia (5), or cirrhosis (4). Group A
cases 65.8 % as compared to 34.2 % cases in Group B.
Table III and IV comparison and statistical analyses
between the mean platelet parameters within the two groups
of PCT and also the controls. It shows a significant difference
i.e., P value < 0.05 in PDW, P-LCR and highly significant
difference i.e., P < 0.001 in mean PCT values of the three
categories. Mean MPV shows slight difference when
thrombocytopenia is compared with control but, there is no
difference between the 2 mechanisms of low platelet count (P
= 0.05).
DISCUSSION
Thrombocytopenia is one of the common findings in many
disease conditions. The major pathogenesis behind this is
basically either due to decreased or impaired bone marrow
production, peripheral accelerated destruction or due to
increased splenic sequestration.1 Clinically, it is difficult to
ascertain the reason behind the decrease in platelet count.
Bone marrow studies, reticulated platelets and platelet-
associated IgG have been done in the past to evaluate the
reason causing thrombocytopenia, but these are costly,
invasive and not easily available procedures. Recently, many
studies have taken the help of various platelet indices to
assess the cause of thrombocytopenia. Platelet indices are
easily available as most of the automated haematology
analysers calculate these values. We studied four platelet
parameters i.e., MPV, PDW, P-LCR and PCT in cases of
thrombocytopenia in order to interpret their importance, if
any, behind the mechanism of low platelet count and also
compared these values with those of the controls.
Our study included 155 patients of thrombocytopenia,
who were predominantly males, which was similar in many
studies.8,9,10 Correlation of severity of thrombocytopenia was
studied with the changes in the platelet count and the platelet
parameters. It was found that although as the platelet count
decreases there was reduction in the mean values of all the
platelet indices, only PCT showed a direct relationship with
the platelet count with P-value < 0.05. The mean PCT in cases
of mild, moderate and severe thrombocytopenia was 0.08 %,
0.06 % and 0.03 % respectively. Chandrashekhar V in 2013
also justified the importance of PCT in detecting quantitative
platelet disorders, where PCT can help determine the need
for transfusion in cases of low platelet count.11 This is
important as all the thrombocytopenia cases don’t require
platelet transfusion. Also mean MPV, Mean PDW and mean P-
LCR were least in cases with severe thrombocytopenia and
Jemds.com Original Research Article
J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 10 / Issue 07 / Feb. 15, 2021 Page 438
highest in mild thrombocytopenia, but a significant difference
was not observed.
Cases of thrombocytopenia were classified according to
the mechanism behind thrombocytopenia, and the
relationship between values of the platelet indices with the
cause was examined. The mean platelet count in group A and
group B was 103.7 (± 23.6) x 109 / L and 71.5 (± 32.3) x 109 /
respectively, showing significant difference between the two
and with the control group (mean = 249.7 ± 77.5 x 109 / L),
which was also the case in other studies.8,12,13 In this study, all
the four parameters showed a noteworthy difference when
group A i.e. cases of hyper destruction of platelets were
compared with the control group, with a high significance of
P < 0.001. Group B i.e. hypo production cases on comparison
with control group also showed a significant difference in
mean PCT (P < 0.001), mean PDW (P = 0.046), mean MPV (P =
0.001) and mean P-LCR (P = 0.001), all indices displayed a P-
value of less than 0.05. Mala K.G et al. in their study on
platelet count, MPV and PDW also found significant difference
when the groups were compared with the control.8 Studies by
Elsewefy DA et al. and Borkataky S et al. also showed
significant difference P = 0.035, P = 0.017 in mean P-LCR
values of patients with hypoproductive thrombocytopenia
with those of the control group.5,14,15 Significance in PCT was
similar to few other studies where the mean PCT in
hypoproduction group was 0.45 (± 0.44) % and in hyper
destruction group was 1.16 (± 0.48) % with a P value of
0.0001.6,16
On comparison between the two groups of
thrombocytopenia, mean PDW (P = 0.012), mean P-LCR (P =
0.023) and mean PCT (P < 0.001) showed a difference,
whereas P value for mean MPV was 0.59. PDW which was
associated with variability in platelet size was higher in the
cases of group A with the mean of 19.37 (± 3.04) fL as
compared to 17.60 (± 3.34) fL in group B. Other studies also
showed high PDW in hyper destruction thrombocytopenia
attributing to the release of heterogenous population of
platelets with anisocytosis, the reason behind it.15,17-20 While
one of the study stated that due to dysplasia in
megakaryopoiesis, there was high PDW in impaired
production group.21 MPV is a known marker of
megakaryocytic activity.22 A high value is seen when there is
excessive platelet lysis as it leads to increased bone marrow
production of immature platelets.23 Mean MPV was 13.66 fL
in group A as compared to 13.11 fL in group B, which was in
accordance with studies like Vinholt PJ et al., Borkataky S et
al. and Reddy RS et al.,2,15,17 but the difference was not
significant, which was the same in studies by Nakadate H et
al. and Baynesti RD et al.24,25 Mean P-LCR was 53.64 % and
48.85 % in group A and group B respectively, which was
consistent with other studies.14,26,27 The study by Babu E et al.
showed no statistically significant difference in P-LCR value
but it was also higher in hyper destructive cases as compared
to impaired production.5 PCT value measures the total
platelet mass, and is dependent on MPV.22 Its value varies
with platelet count and we found significantly higher values
in group A and lower in group B. In group B cases,
megakaryocytes also decrease in the bone marrow leading to
increased tendency of bleeding manifestation, so PCT along
with platelet count can prove to be a useful marker in
patients with bleeding diathesis.28
On reviewing the literature, many studies have shown
higher values of these parameters in hyper destructive group
as compared to hypo productive group, but their significance
has not been verified.29-31 As a result the cut off value has not
been set by which one can place a case in one of the two
categories. So further studies on platelet indices and with
other markers like immature platelet fraction should be done
so as to have a criterion for classifying thrombocytopenia
with the help of these easily available markers.
CONCLUSIONS
Platelet crit can help assess both quantitative as well as
qualitative platelet disorders and there is direct relation
between PCT and platelet count. Other parameters like PDW,
PLCR and MPV along with PCT can be used to interpret the
mechanism behind the low platelet count, where high values
of indices indicate increased breakdown of platelets in the
bloodstream and low values are possibly due to impaired
production due to primary or secondary bone marrow
disease. These parameters need to be studied more, as their
significance if recorded, can prove to be very useful in
establishing causes of thrombocytopenia and will also reduce
the need for the costly and invasive procedures at least in
routine cases.
Data sharing statement provided by the authors is available with the
full text of this article at jemds.com.
Financial or other competing interests: None.
Disclosure forms provided by the authors are available with the full
text of this article at jemds.com.
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