An increase in mean platelet volume after admission is associated with higher mortality in critically ill patients
© Zampieri et al.; licensee Springer 2014
Received: 31 December 2013
Accepted: 23 May 2014
Published: 27 June 2014
Platelet activation and consumption are common in critically ill patients and are associated with poorer prognosis. Mean platelet volume is a simple surrogate for platelet activation, with higher MPV being associated with worse clinical condition on a large array of clinical diagnoses. We therefore aimed to investigate associations between changes in platelet count and mean platelet volume (MPV) with prognosis and inflammatory cytokine values in critically ill patients.
This study prospectively included 84 critically ill patients. Patients were stratified into four groups according to proportional changes in MPV (ΔMPV24h) and platelet count (ΔPlat24h) in the first 24 hours after admission. Mortality between groups was compared using the χ2 test. Logistic regression was performed using hospital mortality as outcome and Simplified Acute Physiology Score (SAPS 3), ΔPlat24h and ΔMPV24h as covariates. Concentrations of the following inflammatory mediators were measured using Miliplex® technology: IL1β, IL6, IL8, IL10, epidermal growth factor, vascular endothelial growth factor, TNFα and IFNα. Cytokine concentrations were compared between groups using the Kruskal-Wallis test with Bonferroni correction.
Patients in whom MPV increased and platelet count decreased had higher mortality rates (46%). According to logistic regression, ΔMPV24h was independently associated with increased mortality (OR 1.28 per 1% increase; 95% CI 1.08 to 1.48). No strong associations between inflammatory mediators and changes in MPV and platelet count were found.
An increase in MPV after admission to an ICU is independently associated with higher hospital mortality.
KeywordsPlatelet Critical illness Inflammation Endothelial activation
Inflammation is ubiquitous during the course of critical illness, regardless of its cause []. One of the hallmarks of inflammation, endothelial dysfunction, is involved in the pathway of organ dysfunction and may be associated with platelet activation and consumption [,]. Therefore, it is not surprising that absolute platelet count and trends in this variable are reportedly to be strongly associated with prognosis in critically ill patients [,].
Inflammatory and thrombotic conditions may also alter platelet size, which can be detected on routine blood cell analysis by evaluation of mean platelet volume (MPV) [–]. Furthermore, the MPV is affected by aging of platelets and varies according to the balance between production and destruction. In several inflammatory clinical conditions, the degree of inflammation and changes in MPV appear to be correlated; however, the impact of this is controversial [–]. A prospective study of neonatal sepsis concluded that septic newborns have greater MPVs than those without sepsis, whereas a prospective study in adults suggested that low platelet volumes are associated with poorer prognoses in septic adults [–]. Furthermore, because there is a strong inverse correlation between platelet count and MPV in healthy individuals, trends in platelet count should be considered when evaluating MPV [].
This study aimed to evaluate the impact of changes in MPV and platelet count in the first 24 hours after ICU admission on hospital mortality in an unselected sample of critically ill patients. Our initial hypothesis was that both an increase in MPV and decrease in platelet count in the first 24 hours after ICU admission would be associated with higher hospital mortality in critically ill patients. As secondary endpoints, we sought to evaluate the association between concentrations of several cytokines on admission and changes in MPV and platelet count.
This study was a sub-analysis of a prospective observational study that aimed to evaluate the inflammation and acid-base status of critically ill patients. The study was approved by Hospital das Clinicas’ Ethics Committee (registry number 1207/09). Exclusion criteria for the study were: age < 18 years; pregnancy; history of HIV with criteria for acquired immunodeficiency syndrome; current diagnosis of cancer on chemotherapy; previous diagnosis of acute or chronic hematologic cancer; use of chronic immunosuppressant medication other than steroids. Low platelet count was not an exclusion criterion. All patients or their legal surrogates provided written informed consent for inclusion in the study.
Of the 87 patients enrolled in the main study from February 2010 to January 2012, 84 had valid measurements of MPV on admission to the ICU and were included on this analysis. Relevant clinical variables and illness severity (as assessed by the Simplified Acute Physiology Score (SAPS 3) score []) were recorded in all patients.
Blood sample and measurements
Concentrations of inflammatory mediators (cytokines and chemokines) were measured using Miliplex® technology (Merck, Genese Diagnostics, Darmstadt, Germany), a multiplex method for cytokine analysis. Miliplex-assessed concentrations of the following cytokines are included on this analysis: IL1β, IL6, IL8, IL10, epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), TNFα and IFN.
Two different approaches were employed to evaluate the impact of changes in ΔMPV24h and ΔPlat24h on hospital mortality. First, mortality was compared between the aforementioned four groups. Second, logistic regression was performed using hospital mortality as the outcome of interest and SAPS 3 score, ΔMPV24h and ΔPlat24h as predictors. Because platelet count and MPV may be correlated, interactions between ΔMPV24h and ΔPlat24h were included in the model. We assessed collinearity between variables through measurement of variance inflation factor (VIF). A stepwise selection method was then performed to remove variables from the model. The results of the final model were further confirmed in a bootstrap analysis on 10,000 replications. We planned to evaluate the discriminative capability of hospital mortality for the model obtained from linear regression and SAPS 3 score through a receiver operating characteristics (ROC) curve and computation of the area under curve (AUC). The ROC curves for SAPS 3 and for the model obtained were compared using DeLong´s test. Calibration was evaluated through Hosmer-Lemeshow test and through a calibration plot obtained after 10,000 bootstrap replications. Because platelet count may reach its nadir up to four days after ICU admission, another logistic regression analysis was performed comparing changes in MPV and platelet count on the fifth day of ICU stay (ΔMPVday5 and ΔPlatday5) with admission values; the fifth day values were calculated similarly to ΔMPV24h and ΔPlat24h.
Cytokine concentrations were also compared between the four patient groups. Associations between admission MPV, ΔMPV24h, admission platelet count and ΔPlat24h in the whole sample and concentrations of each of the measured cytokines were evaluated by linear regression.
The association between platelet count and MPV at admission and between ΔMPV24h and ΔPlat24h was also evaluated by linear regression analysis.
All analyses were performed using R project software (www.r-project.org) version 2.15.2 and Sigmaplot version 12.0 (Systat Software, California, USA).
Characteristics of included patients
(n = 84)
(n = 60)
(n = 24)
Age, mean (SD)
Male sex, n (%)
SAPS 3 score, median (IQ)
SOFA score, median (IQ)
Admission due to sepsis, n (%)
Vasopressors at admission, n (%)
Need for renal replacement therapy, n (%)
Comorbidities, n (%)
Chronic kidney disease
Creatinine, mg/dL (SD)
Lactate, mmol/L (IQ)
Leukocyte count, units/mm3
Platelet count at admission, 103 units/mm3
Mean platelet volume at admission, fL
Platelet count at 24 hours, 103 units/mm3a
Mean platelet volume at 24 hours, fLa
Platelet count at 48 hours, 103 units/mm3b
Mean platelet volume at 48 hours, fLb
Platelet count at 72 hours, 103 units/mm3c
Mean platelet volume at 72 hours, fLc
The numbers of patients in each group according to platelet evaluation were as follows: 24 (29%) patients in the ΔPlat24h ≤ 0/ΔMPV24h ≤ 0 group; 26 (31%) in the ΔPlat24h ≤ 0/ΔMPV24h > 0 group; 22 (27%) in the ΔPlat24h > 0/ΔMPV24h ≤ 0 group and 11 (13%) in the ΔPlat24h > 0/ΔMPV24h > 0 group. The general characteristics of all study patients (stratified as survivors and non-survivors), as well as MPV and platelet count values at admission and on the first three days of ICU stay, are shown in Table 1.
Platelet counts at 24 and 48 hours after admission were lower in non-survivors. MPVs were similar between survivors and non-survivors at each time point evaluated. Both ΔMPV24h and ΔPlat24h were associated with mortality according to univariate analysis. Platelet count was negatively associated with MPV at admission (β = −3.12; P < 0.001; model r2 = 0.16). There was a significant but weak linear association between ΔMPV24h and ΔPlat24h (β = −0.04; P = 0.015; model r2 = 0.05).
Cytokine levels in each patient group
Cytokine (pg/mL), median (IQ)
ΔPlat24h ≤ 0
ΔPlat24h ≥ 0
ΔMPV24h ≤ 0
ΔMPV24h ≥ 0
ΔMPV24h ≤ 0
ΔMPV24h ≥ 0
Our study has two important findings. First, despite having similar MPV values on admission, non-survivors had higher ΔMPV24h than did survivors. Patients with decreased platelet counts and increased MPVs at 24 hours had the highest mortality rates of all patient groups. Second, according to logistic regression analysis, only higher ΔMPV24h values and SAPS 3 scores were associated with increased mortality; changes in platelet count in the first 24 hours had no impact on short-term prognosis. The addition of ΔMPV24h to SAPS 3 tended to improve the discriminative capacity of SAPS 3 score, although the difference did not reach statistical significance. Nevertheless, calibration of SAPS 3 score was improved when ΔMPV24h was added to the model, with important reduction of systematic errors in prognostication.
MPV is a useful prognostic marker in myriad medical conditions, including ischemic heart disease, infective endocarditis and cerebral infarction [–]. Only a few studies have assessed MPV in critical illnesses. Four of these, case series performed in the 1980s and 1990s, highlighted that sepsis is associated with increased MPV [–]. More recently, in a larger prospective study, Oncel et al. also reported high MPVs in septic newborns []. Aydemir et al. reported that increases in MPV in septic adults persist for days, being more prolonged in patients with fungal infections []. Becchi et al. evaluated the impact of MPV and platelet count on prognosis of critically ill septic patients and concluded that lower MPVs on admission were associated with increased mortality []. However, these authors also highlighted that MPV tends to increase in non-survivors and decrease in survivors, with platelet counts having an inverse trend []. Taken together, these findings suggest that trends in changes in MPV and platelet counts may be more reliable markers of poor prognosis than the corresponding absolute values. The discrepancies between baseline MPV values in previous reports may be related to variations in sources of samples (septic versus non-septic, newborns versus adults) [,].
Because inflammation and endothelial activation are reportedly universally present in the acutely ill [,], we tried to expand the patient groups in which changes in MPV may be relevant to prognosis by studying a broader range of critically ill patients. In our study, survivors and non-survivors had similar admission MPVs. Nevertheless, we found that patients in the ΔPlat24h ≤ 0/ΔMPV24h > 0 group had a higher mortality than those in the other patient groups. According to logistic regression analysis, ΔMPV24h but neither ΔPlat24h nor the interaction between ΔMPV24h and ΔPlat24h were associated with higher hospital mortality. This suggests that progressive platelet activation after the initial insult may be a marker of increasing endothelial injury, thus indicating a more severe illness []. There are two possible explanations for the absence of association between changes in platelet count and mortality. First, a 24-hour interval may be too short to evaluate fluctuations in platelet count during an ICU stay []. We therefore performed a secondary logistic regression analysis on data from the fifth day after ICU admission. The results of this analysis were similar, suggesting that the time window is not the sole factor responsible for the lack of association between changes in platelet count and mortality. Second, it is conceivable that changes in platelet count were a surrogate for changes in MPV in the previous studies [,]. In our study, even before stepwise regression, ΔPlat24h was not associated with hospital mortality. Another important difference between our analysis and previous studies is that we have included thrombocytopenic patients []. Therefore, it is conceivable that MPV is more sensitive to prognosis than platelet count when this population is taken into account.
Despite the complex and important interplay between cytokine concentrations and platelets [], we could not find any significant differences between the four study groups in measured cytokine concentrations on ICU admission. The apparent absence of such an association may reflect the small size of our sample and the very wide distribution of cytokine values; this combination of factors could have prevented our findings from reaching statistical significance. Moreover, we did not measure direct markers of endothelial injury and activation such as adhesion molecules, von Willebrand factor and thrombomodulin, which are reportedly more closely linked to platelet activation and consumption []. Therefore, our failure to identify an association does not necessarily denote that reductions in platelet counts and increases in MPV are not associated with increased inflammation; rather, it could mean that other mechanisms, including endothelial injury, play a more important role [].
Our study has several limitations. First, in similarity to previous analysis, we did not account for variations in platelet measurement essays. Platelets also display a nycthemeral variation. We tried to minimize this bias by always collecting samples at the same time during ICU admission. Being a single center study, it may have been subject to local bias. We tried to overcome the effects of small sample size and minimize type II error by performing a robust and restrictive statistical analysis. In addition, as mentioned before, the small sample size may have limited the study’s power to detect differences in cytokine concentrations. We also had no data on markers of endothelial injury. Finally, the use of dynamic markers of illness severity (such as daily changes in Sequential Organ Failure Assessment (SOFA) score) could have been useful to further interpret the association between ΔMPV and prognosis. Therefore, our results should be seen as a hypothesis-generating analysis for further prospective studies.
In a diverse group of critically ill patients, an increase in MPV in the first 24 hours after admission was independently associated with increased mortality. There was no significant association between inflammatory cytokine concentrations and changes in MPV and platelet count after ICU admission.
chronic obstructive pulmonary disease
epidermal growth factor
Mean platlet volume
Receiver operating characteristics
Simplified Acute Physiology Score
Sequential Organ Failure Assessment
Tumor necrosis factor
vascular endothelial growth factor
- Kellum JA, Decker JM: The immune system: relation to sepsis and multiple organ failure. AACN Clin Issues 1996,7(3):339–350. quiz 459–360 10.1097/00044067-199608000-00002View ArticlePubMedGoogle Scholar
- Aird WC: The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 2003,101(10):3765–3777. 10.1182/blood-2002-06-1887View ArticlePubMedGoogle Scholar
- Warkentin TE, Aird WC, Rand JH: Platelet-endothelial interactions: sepsis, HIT, and antiphospholipid syndrome. Hematology Am Soc Hematol Educ Program 2003,2003(1):497–519. 10.1182/asheducation-2003.1.497View ArticleGoogle Scholar
- Vanderschueren S, De Weerdt A, Malbrain M, Vankersschaever D, Frans E, Wilmer A, Bobbaers H: Thrombocytopenia and prognosis in intensive care. Crit Care Med 2000,28(6):1871–1876. 10.1097/00003246-200006000-00031View ArticlePubMedGoogle Scholar
- Moreau D, Timsit JF, Vesin A, Garrouste-Orgeas M, de Lassence A, Zahar JR, Adrie C, Vincent F, Cohen Y, Schlemmer B, Azoulay E: Platelet count decline: an early prognostic marker in critically ill patients with prolonged ICU stays. Chest 2007,131(6):1735–1741. 10.1378/chest.06-2233View ArticlePubMedGoogle Scholar
- Becchi C, Al Malyan M, Fabbri LP, Marsili M, Boddi V, Boncinelli S: Mean platelet volume trend in sepsis: is it a useful parameter? Minerva Anestesiol 2006,72(9):749–756.PubMedGoogle Scholar
- Oncel MY, Ozdemir R, Yurttutan S, Canpolat FE, Erdeve O, Oguz SS, Uras N, Dilmen U: Mean platelet volume in neonatal sepsis. J Clin Lab Anal 2012,26(6):493–496. 10.1002/jcla.21552View ArticlePubMedGoogle Scholar
- Gasparyan AY, Ayvazyan L, Mikhailidis DP, Kitas GD: Mean platelet volume: a link between thrombosis and inflammation? Curr Pharm Des 2011,17(1):47–58. 10.2174/138161211795049804View ArticlePubMedGoogle Scholar
- Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR: SAPS 3 - From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med 2005,31(10):1345–1355. 10.1007/s00134-005-2763-5PubMed CentralView ArticlePubMedGoogle Scholar
- Keppel G: Design and Analysis: A Researcher´s Handbook. Englewood Cliffs, NJ, US, Prentice-Hall, Inc; 1991.Google Scholar
- Ki YJ, Park S, Ha SI, Choi DH, Song H: Usefulness of mean platelet volume as a biomarker for long-term clinical outcomes after percutaneous coronary intervention in Korean cohort: a comparable and additive predictive value to high-sensitivity cardiac troponin T and N-terminal pro-B type natriuretic peptide. Platelets 2013, ᅟ: ᅟ. Epub ahead of printGoogle Scholar
- Gunebakmaz O, Kaya MG, Kaya EG, Ardic I, Yarlioglues M, Dogdu O, Kalay N, Akpek M, Sarli B, Ozdogru I: Mean platelet volume predicts embolic complications and prognosis in infective endocarditis. Int J Infect Dis 2010,14(11):e982-e985. 10.1016/j.ijid.2010.05.019View ArticlePubMedGoogle Scholar
- D'Erasmo E, Aliberti G, Celi FS, Romagnoli E, Vecci E, Mazzuoli GF: Platelet count, mean platelet volume and their relation to prognosis in cerebral infarction. J Intern Med 1990,227(1):11–14. 10.1111/j.1365-2796.1990.tb00111.xView ArticlePubMedGoogle Scholar
- Bessman JD, Gardner FH: Platelet size in thrombocytopenia due to sepsis. Surg Gynecol Obstet 1983,156(2):177–180.PubMedGoogle Scholar
- Van der Lelie J, Von dem Borne AK: Increased mean platelet volume in septicaemia. J Clin Pathol 1983,36(6):693–696. 10.1136/jcp.36.6.693PubMed CentralView ArticlePubMedGoogle Scholar
- Dastugue N, Picheloup F, Sie P, Genestal M, Cathala B, Boneu B: Increase in mean platelet volume in shock-related thrombocytopenia. Nouv Presse Med 1982,11(39):2899–2901.PubMedGoogle Scholar
- O'Connor TA, Ringer KM, Gaddis ML: Mean platelet volume during coagulase-negative staphylococcal sepsis in neonates. Am J Clin Pathol 1993,99(1):69–71.PubMedGoogle Scholar
- Aydemir H, Piskin N, Akduman D, Kokturk F, Aktas E: Platelet and mean platelet volume kinetics in adult patients with sepsis. Platelets 2012, ᅟ: ᅟ. Epub ahead of printGoogle Scholar
- Karabacak M, Dogan A, Turkdogan AK, Kapci M, Duman A, Akpinar O: Mean platelet volume is increased in patients with hypertensive crises. Platelets 2013, ᅟ: ᅟ. Epub ahead of printGoogle Scholar
- Levi M, van der Poll T: Endothelial injury in sepsis. Intensive Care Med 2013,39(10):1839–1842. 10.1007/s00134-013-3054-1View ArticlePubMedGoogle Scholar
- Burstein SA: Cytokines, platelet production and hemostasis. Platelets 1997,8(2–3):93–104. 10.3109/09537109709169324View ArticlePubMedGoogle Scholar
- Reinhart K, Bayer O, Brunkhorst F, Meisner M: Markers of endothelial damage in organ dysfunction and sepsis. Crit Care Med 2002,30(5 Suppl):S302-S312. 10.1097/00003246-200205001-00021View ArticlePubMedGoogle Scholar