Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH

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Serum lactate dehydrogenase (LDH) is emerging as a potential biomarker for diagnosing severe ITP. We evaluated the diagnostic utility of LDH and its correlation with clinical severity in ITP patients. Methods This prospective observational study included 62 patients diagnosed with primary or secondary ITP. Baseline demographic and clinical data were collected, and serum LDH along with platelets were analyzed at recruitment. The diagnostic utility of serum LDH in distinguishing severe from non-severe ITP was evaluated. Results A total of 62 patients with ITP were studied, 64.5% had severe thrombocytopenia and 35.4% had non-severe thrombocytopenia. The median serum LDH level was significantly higher in severe ITP (276 [216–307]) compared to non-severe ITP (209 [184–275]), p=0.03. LDH showed a negative correlation with platelet count (ρ = -0.817, p = 0.01) and plateletcrit (p = -0.26, p = 0.03), while no correlation was observed with MPV. The cut-off value of LDH was 234U/L, with a specificity of 62.5% and sensitivity of 63.6%, respectively for diagnosing severe thrombocytopenia. Conclusion There was a significant elevation of serum LDH levels in patients with severe ITP compared to non-severe ITP. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-1425/v1", "name": "Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia:..." } } ] } Home Browse Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ashok Kamath P, Shetty A, Muttickal Swaminathan S et al. Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :1425 ( https://doi.org/10.12688/f1000research.172439.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] Poonam Ashok Kamath https://orcid.org/0009-0006-0632-6468 1 , Alekhya Shetty https://orcid.org/0009-0006-3573-1972 1 , Shilna Muttickal Swaminathan 2 , Shivashankara Kaniyoor Nagri https://orcid.org/0009-0003-2323-6964 1 , Sindhu Sujeeth Hegde 1 , Shubhada Karanth https://orcid.org/0000-0002-1813-538X 1 Poonam Ashok Kamath https://orcid.org/0009-0006-0632-6468 1 , Alekhya Shetty https://orcid.org/0009-0006-3573-1972 1 , [...] Shilna Muttickal Swaminathan 2 , Shivashankara Kaniyoor Nagri https://orcid.org/0009-0003-2323-6964 1 , Sindhu Sujeeth Hegde 1 , Shubhada Karanth https://orcid.org/0000-0002-1813-538X 1 PUBLISHED 22 Dec 2025 Author details Author details 1 Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India 2 Department of Nephrology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India Poonam Ashok Kamath Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Alekhya Shetty Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Shilna Muttickal Swaminathan Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Shivashankara Kaniyoor Nagri Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Sindhu Sujeeth Hegde Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Shubhada Karanth Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. Abstract Background The diagnosis of immune thrombocytopenia (ITP) relies on clinical manifestations, as no definitive gold standard exists. Serum lactate dehydrogenase (LDH) is emerging as a potential biomarker for diagnosing severe ITP. We evaluated the diagnostic utility of LDH and its correlation with clinical severity in ITP patients. Methods This prospective observational study included 62 patients diagnosed with primary or secondary ITP. Baseline demographic and clinical data were collected, and serum LDH along with platelets were analyzed at recruitment. The diagnostic utility of serum LDH in distinguishing severe from non-severe ITP was evaluated. Results A total of 62 patients with ITP were studied, 64.5% had severe thrombocytopenia and 35.4% had non-severe thrombocytopenia. The median serum LDH level was significantly higher in severe ITP (276 [216–307]) compared to non-severe ITP (209 [184–275]), p=0.03. LDH showed a negative correlation with platelet count (ρ = -0.817, p = 0.01) and plateletcrit (p = -0.26, p = 0.03), while no correlation was observed with MPV. The cut-off value of LDH was 234U/L, with a specificity of 62.5% and sensitivity of 63.6%, respectively for diagnosing severe thrombocytopenia. Conclusion There was a significant elevation of serum LDH levels in patients with severe ITP compared to non-severe ITP. READ ALL READ LESS Keywords Immune thrombocytopenia, LDH, Platelet indices Corresponding Author(s) Shubhada Karanth ( [email protected] ) Close Corresponding author: Shubhada Karanth Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Ashok Kamath P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ashok Kamath P, Shetty A, Muttickal Swaminathan S et al. Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :1425 ( https://doi.org/10.12688/f1000research.172439.1 ) First published: 22 Dec 2025, 14 :1425 ( https://doi.org/10.12688/f1000research.172439.1 ) Latest published: 22 Dec 2025, 14 :1425 ( https://doi.org/10.12688/f1000research.172439.1 ) Introduction Immune thrombocytopenic purpura (ITP) is an acquired autoimmune disorder where IgG autoantibodies target circulating platelets, occurring as primary ITP. Secondary ITP is caused by chronic infections and autoimmune disease. 1 ITP increases the risk of hemorrhagic episodes and causes isolated thrombocytopenia and purpura. The disease can affect both adults and children. ITP is mostly diagnosed by ruling out other recognized causes of thrombocytopenia. ITP is considered to be a benign disease with no higher mortality rate than the general population. However some patients are unresponsive to several therapies, and they could die from infections or hemorrhages brought on by immunosuppressive treatment. 2 The American Society of Hematology defines ITP as a condition characterized by a generalized purpuric rash, a platelet count below 100,000/μL, and normal white blood cell (WBC) count and hemoglobin levels. In adults, primary ITP accounts for about 80% of cases, while secondary ITP comprises the remaining 20%. 3 The annual incidence of primary ITP is about 3.3 per 100,000 individuals, with a frequency of up to 9.5 per 100,000 adults. 4 Clinically, ITP can be divided into three stages: newly diagnosed (during the first three months of diagnosis), chronic (lasting more than 12 months), and persistent (lasting 3 to 12 months). 5 The most reliable technique for determining the cause of ITP is bone marrow analysis. However, regarding its importance in assessing ITP, the controversy remains. It is not advised as a first-line diagnostic method because of its invasiveness and potential to cause discomfort to the patient. The lack of conclusive clinical and laboratory characteristics, ITP is still considered an excluding diagnosis. 6 Recently several studies have reported elevated serum Lactate dehydrogenase (LDH) levels in patients with ITP. Numerous cell types, including platelets, contain the enzyme LDH, which is essential for the body’s metabolic processes. Platelets are known to have significant levels of LDH activity. 7 There are five distinct LDH isoenzymes that are found in different tissues. Studies revealed that, in comparison to other LDH isoenzymes, isoenzymes 2 and 3 were more common in platelets. The enzyme LDH is present in the heart, liver, kidneys, muscles, and blood, and is essential for the metabolism of cellular energy. When cells are damaged, an internal enzyme called LDH is released into the circulation. In the clinical setting, high serum LDH levels are a useful biomarker for prognosis prediction, treatment evaluation, and disease monitoring. 8 Although LDH is primarily used as a marker for red blood cell destruction, limited research has explored its elevation in cases of increased platelet turnover without concurrent erythrocyte destruction, such as isolated thrombocytopenia. Previous studies have reported an inverse relationship between LDH levels and thrombocytopenia. However, no studies have specifically examined the correlation between LDH and the severity of ITP or its association with bleeding in ITP. The purpose of this study was to assess the correlation between LDH levels and the degree of thrombocytopenia in ITP. Since ITP is a diagnosis of exclusion, with no specific parameters for its diagnosis or severity grading, assessing LDH levels in newly diagnosed ITP patients may provide valuable insights into disease severity. Methodology Study population This prospective observational study was performed at Kasturba Medical College, Manipal, India. The study was adhered to the principles outlined in the Declaration of Helsinki and was approved by Kasturba Medical College and Kasturba Hospital institutional Ethics Committee (IEC No 494/2022). Informed written consent was obtained from all participants. A total of 62 patients with ITP were studied from July 2022 to April 2024. Inclusion criteria The inclusion criteria for this study consist of newly diagnosed cases of ITP, including both primary and secondary causes above 18 years of age. Secondary ITP cases included were those whose autoimmune serology were only weakly positive. Exclusion criteria Patients with hemolytic anemia, such as Evans syndrome, or those with a positive direct antiglobulin test, patients with vitamin B12 or folate deficiency anemia, drug-induced thrombocytopenia, active infections, muscular disorders, or malignancy were excluded from the study. SLE with nephritis, catastrophic APLA, patients with HIV, hepatitis B, or hepatitis C who have progressed to cirrhosis also were excluded. Data collection Patients whose platelet counts were recently found to be low were included and platelet indices including “mean platelet volume (MPV), plateletcrit (PCT); platelet distribution width (PDW)”, and serum LDH levels were analyzed before starting treatment. Platelet indices were analyzed using the Beckman Coulter DXH 900, while serum LDH was measured on the Cobas 8000 (Roche Diagnostics) using an enzymatic immunoassay. Test for anti-neutrophil antibodies test (ANA profile) by immunofluorescence for diagnosing secondary ITP due to SLE, APLA were done. Bone marrow biopsy was done to rule out haematological malignancies and hypo proliferative marrow, biopsies that showed peripheral destruction of platelets were considered as immune thrombocytopenia. Other additional tests like Coombs tests, serum b12, folate, HIV, hepatitis B serology, and CPK were done to rule out other causes of thrombocytopenia that cause LDH elevation. Direct Coombs antigen test was done in patients with autoimmune etiology to rule out underlying hemolytic anemia and hence associated LDH elevation. Based on the severity of thrombocytopenia; “mild to moderate thrombocytopenia was considered as non-severe thrombocytopenia while platelet count <20,000 was considered as severe thrombocytopenia”. In this study, bleeding severity in immune ITP was classified based on the ITP Bleeding Scale. Grade 0 and Grade 1 bleeding were categorized as non-severe, while Grade 2 bleeding was considered severe. Statistical analysis The normal distribution of the variables was evaluated using the Shapiro test. Continuous variables are represented by mean ± SD, whereas non-continuous variables are represented by median with interquartile range. Percentages of categorical variables were compared using chi-square or Fisher exact test. We used t-tests and the Mann-Whitney U test to compare the mean and median for continuous variables. One-way ANOVA was performed to compare the platelet indices among different grades of clinical severity of ITP. Bonferroni was employed for post hoc paired-wise comparison. The cut-off value of serum LDH in separating severe ITP from non-severe ITP was determined using receiver operating characteristic curve analysis. Results 40 (64.5%) of the 62 ITP patients that were studied had severe thrombocytopenia, while 22 (35.4%) had non-severe thrombocytopenia. Primary ITP was more prevalent, accounting for 59.7% of cases. The demographic and clinical characteristics of the overall population are summarized in Table 1 . The mean age of the cohort was 41.72 ± 12.2 years, with a female predominance (67.7% vs. 32.3%). Fever was observed in 16.1% of patients, while 30.6% reported fatigue. Table 1. Baseline demographic and clinical characteristics. Variables Proportion N = 62 Age, years a 41.72 ± 12.2 Gender, n (%) Female 42(67.7) Male 20(32.3) Fever, n (%) 10(16.1) Fatigue, n (%) 19(30.6) Bleeding, n (%) 13(20.9) Malena, n (%) 3(4.8) Hematuria, n (%) 2(3.2) Menorrhagia, n (%) 10(16.1) Subdural hemorrhage, n (%) 1(1.6) Petechiae, n (%) 12(19.3) Ecchymosis, n (%) 9(14.5) Platelet count, ×10 3 /μL b 24(50-37) Mean platelet volume, fl a 10.7 ± 2.1 Plateletcrit,% 20(6.0-31) Platelet distribution width a 16.7 ± 2.3 serum LDH b U/L 241(205-290) Clinical Severity, n (%) Grade 0 20(31.6) Grade 1 7(11.3) Grade 2 35(56.5) Severity of ITP, n (%) Severe 40(64.5) Non-severe 22(35.5) Types of ITP, n (%) Primary 37(59.7) Secondary 25(36.2) a Mean and SD; b Median with interquartile range; ITP, Immune thrombocytopenia; LDH, Lactate dehydrogenase. Among clinical manifestations of ITP, 41.2% of patients presented with symptoms, with bleeding being the most common (20.9%). Notably, seven patients experienced gum bleeding accompanied by epistaxis. Purpura was reported in 33.8% of cases, with petechiae (19.3%) and ecchymosis (19.3%) being the predominant findings. Regarding clinical severity, Grade 2 ITP was the most frequently observed (56.5%). The median serum LDH level for the entire cohort was 241 U/L (interquartile range: 205–290 U/L). We further compared the clinical and laboratory parameters between severe and non-severe ITP ( Table 2 ). Patients with severe ITP had a higher incidence of fever (18.0% vs. 15.2%) and fatigue (32.5% vs. 27.3%) compared to those with non-severe ITP. Grade 2 severity was significantly more common in the severe ITP group (77.5%), whereas Grade 0 was more frequently observed in non-severe cases (72.7%) (p = 0.01). Table 2. Comparison of clinical and laboratory factors. Variables Severe (N = 40) Non-severe (N = 22) P value Fever, n (%) 6(18.0) 4(15.2) 0.23 Fatigue, n (%) 13(32.5) 6(27.3) 0.39 Severity, n (%) 0.01 Grade 0 4(10.2) 16(72.7) Grade1 5(12.5) 2(9.1) Grade 2 31(77.5) 4(18.2) Types, n (%) 0.13 Primary 23(57.5) 14(63.6) Secondary 15(37.5) 8(36.3) Plateletcount, 10 3 /μL a 7.6(3.0-11) 51(33-73) 0.01 MPV,fl b 10.8 ± 1.8 10.5 ± 2.6 0.42 serum LDH a U/L 271(216-307) 209(184-275) 0.03 a Median with interquartile range; b Mean with SD; MPV, Mean platelet volume; LDH, lactate dehydrogenase. In both groups, primary ITP was the predominant type, reported in 57.5% of severe cases, 63.6% of non-severe cases, and 2 patients were diagnosed as RVD-associated ITP. Among secondary ITP cases three cases were diagnosed with SLE, two with APLA and rheumatoid arthritis, 2 patients were HIV positive, while the other patients had positive autoimmune. Thrombocytopenia due to peripheral destruction was observed in the bone marrow biopsy of 36 patients. The remaining biopsies revealed either dilute marrow or reactive hypercellularity. Bone marrow biopsy was not performed in 20 patients, of whom two tested positive for anti-platelet antibodies, while other autoimmune markers, including ANA profile and APLA antibodies, were negative. However, the mean level of MPV did not differ significantly between the groups (p = 0.42). The median serum LDH level was significantly higher in severe ITP (276 [216–307]) compared to non-severe ITP (209 [184–275]), p = 0.03. We further compared the clinical and laboratory parameters between severe and non-severe ITP. Patients with severe ITP showed a higher incidence of fever (18.0% vs. 15.2%) and fatigue (32.5% vs. 27.3%) compared to those with non-severe ITP. Grade 2 severity was significantly more common in the severe ITP group (77.5%), whereas Grade 0 was more frequently observed in non-severe cases (72.7%) (p = 0.01) ( Table 2 ). On analysis of the association between platelet indices and LDH with clinical severity of ITP ( Table 3 ). Among the platelet indices assessed, only the median platelet count and Plateletcrit demonstrated significant differences across severity grades. On further post hoc analysis it was revealed that platelet count and plateletcrit only differed significantly between grades 0 and 2 (p = 0.01) ( Table 4 ). The median platelet counts progressively decreased with increasing severity, from 52 (24–77) in Grade 0 to 11 (7.0–35) in Grade 1 and 10 (3.0–13) in Grade 2 (p = 0.01). Similarly, the median plateletcrit was 47.1 (16–77) and showed a gradual decline as severity worsened (p = 0.01). Table 3. Association of platelet indices and LDH with clinical severity of ITP. Variables Grade 0 Grade 1 Grade 2 P value Plateletcount, 10 3 /μL a 52(24-77) 11(7.0-35) 10(3.0-13) 0.01 MPV, fl 10.3 + 1.2 11.1 + 1.0 11.2 + 2.1 0.188 Plateletcrit, % 47.1(16-77) 13.0(7.2-38.6) 1.2(0.3-1.5) 0.01 PDW, fl 16.2 + 2.4 17.8 + 1.3 16.6 + 2.5 0.831 LDH, U/L 235(185-289) 275(168-392) 241(208-288) 0.721 a Median with interquartile range; MPV, mean platelet volume; PDW, platelet distribution width; LDH, lactate dehydrogenase. Table 4. Post-hoc analysis (p value). Variable Grade 0 vs Grade1 Grade 0 vs Grade 2 Grade 1 vs Grade 2 Platelet count 0.11 0.01 0.50 Plateletcrit 0.64 0.01 0.68 Spearman’s rank correlation coefficient was calculated for plasm LDH with platelet indices as shown in Table 5 . LDH showed a negative correlation with platelet count (ρ = -0.817, p = 0.01) and plateletcrit (ρ = -0.26, p = 0.03), while MPV (ρ = 0.05, p = 0.68) did not exhibit any correlation. Table 5. Correlation analysis of serum LDH. Parameters Platelet count MPV Plateletcrit PDW LDH Spearman’s ρ -0.817 0.05 -0.26 0.17 p-value 0.01 0.68 0.03 0.19 Diagnostic utility of serum LDH in ITP On ROC analysis, the area under the curve (AUC) was 0.676 (95%CI 0.53-0.81) at a cut-off value of 234 U/L, with the specificity of 62.5% and 63.6%, respectively for diagnosing severe thrombocytopenia ( Figure 1 ). Figure 1. Diagnostic utility curve of LDH. Discussion Immune thrombocytopenia is an acquired hematologic disorder caused by autoantibodies, primarily of the IgG type, produced by B lymphocytes. 1 These autoantibodies target platelet membrane glycoproteins, such as GPIIb/IIIa, leading to platelet destruction. The presentation can range from mild bruising to life-threatening hemorrhage, potentially resulting in death. Among the various causes of thrombocytopenia, ITP remains one of the least studied etiological factors. Studies on its clinical severity, grading, and evaluation are scarce. The conclusive diagnosis of ITP remains a clinical challenge globally. Although LDH is widely used as a marker of erythrocyte destruction, there is a lack of published data on LDH elevation in cases of increased platelet turnover without concurrent erythrocyte destruction, such as in ITP. 3 In this study, we analyzed LDH levels in patients with ITP and examined their correlation with types of ITP and clinical severity. We observed a mean age of 41.72±12.2 and a female predominance in our cohort, which aligns with several previous studies. A prospective study by Mikias et al., reported a similar distribution, with 63% of patients being female and 36.3% male, with a mean age of 41 ± 17.8. 9 Another study by Emrah et al found 66.8% of female prevalence in those who diagnosed with ITP. 10 In our study, primary ITP cases were more prevalent than secondary ITP. In contrast, Sadia et al. reported a significantly higher proportion of secondary ITP in a cross-sectional study in southern Pakistan where 64.8% had secondary ITP and 35.2% had primary ITP. 11 Among clinical manifestations of ITP, 41.2% of patients presented with symptoms, with bleeding being the most common (20.9%). Notably, seven patients experienced gum bleeding accompanied by epistaxis. Purpura was reported in 33.8% of cases, with petechiae (19.3%) and ecchymosis (19.3%) being the predominant findings. The incidence of melena and hematuria was relatively low. In a cross-sectional study of 417 patients diagnosed with ITP, 43.16% presented with hemorrhagic manifestations, while 56.8% were asymptomatic. Among the symptomatic cases, gum bleeding occurred in 32.7%, epistaxis in 40.8%, and similar to our findings, melena, and hematuria were reported in fewer cases (2.0% and 4.0%, respectively). Platelet count was significantly lower in severe ITP compared to non-ITP, and among the platelet indices assessed, only the median platelet count and plateletcrit demonstrated significant differences across severity grades. We found that the mean serum LDH was 271 (216-307) in severe ITP and the cut-off value was 234 μ/l to diagnose severe ITP. In a case-control study by Hanny et al the median LDH was 215 μ/l and the control group had 210 μ/l. They also found the LDH elevation with no association with patient age, gender, or remission status. However, an inverse correlation was observed between LDH levels and platelet count in their cohort, which was consistent with our findings. This suggests that LDH elevation is at least partially driven by increased platelet turnover. 12 Emrah et al. analyzed serum LDH levels in 226 ITP patients and compared them with healthy controls, reporting LDH levels of 218 IU/L in ITP patients and 159 IU/L in controls. They also found an inverse correlation between LDH levels and platelet counts. Additionally, subgroup analysis revealed that LDH levels correlated with the treatment group but not with the untreated ITP group. Comparison of LDH levels between pre-treatment and post-treatment ITP groups showed a mean of 241.8 IU/L in the pre-treatment group and 225.7 IU/L in the post-treatment group. LDH levels were moderately elevated in ITP patients at diagnosis and showed a slight improvement after treatment. 10 We considered it important to investigate whether LDH levels increase in ITP patients with bleeding symptoms due to hemolysis of extravascular erythrocytes. Therefore, we compared LDH as the clinical severity worsens (from grade 0 to grade 2). We observed that LDH did not exhibit any correlation with the clinical severity of ITP (bleeding and non-bleeding cases). Similarly, Emrah et al. also reported that there was no correlation of LDH with bleeding symptoms, where LDH levels were 246 IU/L in those who had bleeding and 199 IU/L in patients without bleeding symptoms. 10 LDH levels may rise due to massive bleeding and hematomas; however, since none of the patients experienced such bleeding, the observed differences were solely related to platelet count. The study limitation includes the single-centered cross-sectional design, lack of estimation of LDH isoenzymes. Conclusion A significant proportion of our cohort was diagnosed with severe ITP. Platelet count was significantly lower in severe ITP compared to non-ITP, and among the platelet indices assessed, only the platelet count and Plateletcrit demonstrated significant differences across severity grades. There was a significant elevation of serum LDH levels in patients with severe ITP compared to non-severe ITP. While the LDH level did not elevate significantly as the severity of bleeding worsened. However, the optimum LDH cut-off value for clinical application will need to be determined by more large-scale prospective cohort studies. Further testing of the LDH isoenzyme will be helpful in the evaluation of ITP and its severity. Data availability Underlying data Figshare: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH. https://doi.org/10.6084/m9.figshare.30753284 13 The project contains following underlying data • Data.xlsx Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) Reporting guidelines Figshare: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum. https://doi.org/10.6084/m9.figshare.30418603 14 The project contains following underlying data • Strobe checklist Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) Extended data 1. Figshare: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum. https://doi.org/10.6084/m9.figshare.30556697 15 This project contains the following underlying data: • Protocol. Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH. Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) 2. Figshare: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum. https://doi.org/10.6084/m9.figshare.30556715 16 This project contains the following underlying data: • Proforma. Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH. Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) References 1. Cines DB, Blanchette VS: Immune thrombocytopenic purpura. N. Engl. J. Med. 2002 Mar 28; 346 (13): 995–1008. Publisher Full Text 2. Portielje JE, Westendorp RG, Kluin-Nelemans HC, et al. : Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. Blood, The Journal of the American Society of Hematology. 2001 May 1; 97 (9): 2549–2554. Publisher Full Text 3. Cines DB, Bussel JB, Liebman HA, et al. : The ITP syndrome: pathogenic and clinical diversity. Blood, The Journal of the American Society of Hematology. 2009 Jun 25; 113 (26): 6511–6521. Publisher Full Text 4. Terrell DR, Beebe LA, Vesely SK, et al. : The incidence of immune thrombocytopenic purpura in children and adults: a critical review of published reports. Am. J. Hematol. 2010 Mar; 85 (3): 174–180. PubMed Abstract | Publisher Full Text 5. Rodeghiero F, Stasi R, Gernsheimer T, et al. : Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood, The Journal of the American Society of Hematology. 2009 Mar 12; 113 (11): 2386–2393. Publisher Full Text 6. ITP A: British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br. J. Haematol. 2003; 120 (1): 574–96. PubMed Abstract | Publisher Full Text 7. Hule V: Isoenzymes of lactic dehydrogenase in human platelets. Clin. Chim. Acta. 1966 Apr 1; 13 (4): 431–434. Publisher Full Text 8. Rifai N: Tietz Textbook of Clinical Chemistry and Molecular Diagnostics-E-Book. Elsevier Health Sciences; 2017 Jan 16. 9. Negash M, Tsegaye A, G/Medhin A: Diagnostic predictive value of platelet indices for discriminating hypo productive versus immune thrombocytopenia purpura in patients attending a tertiary care teaching hospital in Addis Ababa, Ethiopia. BMC hematology. 2016 Dec; 16 : 1–8. Publisher Full Text 10. Kılıçaslan E, Sayın S, Yıldırım M, et al. : Serum Lactate Dehydrogenase Elevates and Inversely Correlates with Platelet Count in Immune Thrombocytopenia: A Case-control Study in Adults. 11. Sadia Sultan FC, Ahmed SI, Murad S, et al. : Primary versus secondary immune thrombocytopenia in adults; a comparative analysis of clinical and laboratory attributes in newly diagnosed patients in Southern Pakistan. Med. J. Malaysia. 2016 Oct; 71 (5): 269–274. PubMed Abstract 12. Al-Samkari H, Kuter DJ: Lactate dehydrogenase is elevated in immune thrombocytopenia and inversely correlates with platelet count. Br. J. Haematol. 2019 Nov 1; 187 (3): e61–e64. PubMed Abstract | Publisher Full Text 13. Shubhada K, et al. : Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH Data. Figshare. 2025. Publisher Full Text 14. Shubhada K, et al. : Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH: STROBE. Figshare. 2025. Publisher Full Text 15. Shubhada K, et al. : Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum;Protocol. Figshare. 2025. Publisher Full Text 16. Shubhada K, et al. : Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH; Proforma. Figshare. 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 22 Dec 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India 2 Department of Nephrology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India Poonam Ashok Kamath Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Alekhya Shetty Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Shilna Muttickal Swaminathan Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Shivashankara Kaniyoor Nagri Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Sindhu Sujeeth Hegde Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Shubhada Karanth Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 22 Dec 2025, 14:1425 https://doi.org/10.12688/f1000research.172439.1 Copyright © 2025 Ashok Kamath P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Ashok Kamath P, Shetty A, Muttickal Swaminathan S et al. Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :1425 ( https://doi.org/10.12688/f1000research.172439.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 22 Dec 2025 Views 0 Cite How to cite this report: QI J and Han Y. Reviewer Report For: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :1425 ( https://doi.org/10.5256/f1000research.190162.r444577 ) The direct URL for this report is: https://f1000research.com/articles/14-1425/v1#referee-response-444577 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Jan 2026 Jiaqian QI , Soochow University, Suzhou, Jiangsu, China Yue Han , Hematology, Institution: First Affiliated Hospital of Soochow University (Ringgold ID: 74566), Suzhou, Jiangsu, China Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.190162.r444577 This prospective observational study evaluates whether serum lactate dehydrogenase (LDH) and platelet indices can help discriminate “severe” from “non-severe” thrombocytopenia among adults diagnosed with immune thrombocytopenia (ITP). The authors report higher LDH in the severe thrombocytopenia group (platelet count <20,000/µL), ... Continue reading READ ALL This prospective observational study evaluates whether serum lactate dehydrogenase (LDH) and platelet indices can help discriminate “severe” from “non-severe” thrombocytopenia among adults diagnosed with immune thrombocytopenia (ITP). The authors report higher LDH in the severe thrombocytopenia group (platelet count <20,000/µL), a strong inverse correlation between LDH and platelet count, and a modest ROC performance (AUC ~0.68) with a proposed LDH cut-off of 234 U/L. The topic is clinically relevant because ITP remains a diagnosis of exclusion and additional readily available biomarkers would be helpful. However, the current manuscript has several major conceptual and methodological limitations—especially regarding diagnostic claims, potential confounding by hemolysis-related disorders (including Evans syndrome and other ITP mimics), and pre-analytical issues influencing LDH—that must be addressed before the conclusions can be considered reliable. I therefore recommend major revision (Approved with Reservations) . 1.“Diagnostic utility” is overstated; the study does not diagnose ITP The manuscript title and parts of the abstract imply that LDH has “diagnostic utility” for ITP. However, the analysis is performed only within a cohort already labeled as ITP , and the primary outcome is severity of thrombocytopenia (platelet threshold) rather than diagnosis. Without an external comparator group (e.g., other causes of thrombocytopenia or healthy controls), the study cannot support statements that LDH helps “diagnose ITP.” 2.ITP is a diagnosis of exclusion; LDH is highly vulnerable to confounding by hemolysis and ITP mimics (Evans syndrome, TMA, etc.) This is the most important concern. LDH is non-specific and is classically elevated in hemolysis and many systemic conditions (tissue injury, liver disease, infection/inflammation, muscle injury). In the context of thrombocytopenia, several disorders can closely mimic ITP but involve hemolysis or tissue injury, and these can substantially inflate LDH. In particular, Evans syndrome (ITP + autoimmune hemolytic anemia) can be clinically close to ITP—sometimes evolving over time—and would directly confound any LDH-based interpretation. In addition, thrombotic microangiopathy (TTP/HUS), DIC, severe infection/sepsis , and other hemolytic states can present with thrombocytopenia and elevated LDH. Although the manuscript lists exclusion criteria (e.g., “hemolytic anemia/Evans syndrome, DAT positive”), the actual diagnostic work-up is not described in sufficient detail to ensure that hemolysis/TMA and Evans syndrome were robustly excluded across the whole cohort. 3. Pre-analytical and analytical issues with LDH measurement must be addressed (serum vs plasma; sample hemolysis) LDH is strongly affected by in vitro hemolysis during phlebotomy/processing . The manuscript states LDH was measured from serum; however, serum LDH can also be influenced by release during clotting, and the effect may differ by platelet count. Importantly, the reported direction (higher LDH in more severe thrombocytopenia) is not straightforwardly explained by platelet release into serum and raises concern for confounding or pre-analytical variability. In addition, the Methods mention “enzymatic immunoassay,” which is likely inaccurate for LDH (typically an enzymatic rate assay). 4. Statistical approach and reporting need tightening; provide effect sizes and uncertainty The ROC AUC (~0.676) indicates modest discrimination . The manuscript should provide more complete reporting and ensure consistency with non-normal distributions. There are also multiple apparent typographical/statistical inconsistencies (e.g., tables, notation, and some values/units). 5. Clinical interpretation: does LDH add actionable information beyond platelet count? Because “severe ITP” is defined by a platelet threshold, and LDH is strongly correlated with platelet count, the incremental value of LDH for severity classification may be limited. A more clinically meaningful endpoint might be bleeding, need for treatment/hospitalization, response to therapy, or relapse , where LDH could potentially contribute beyond platelet count. The current analysis shows no association with bleeding grade, which further limits clinical impact. Minor comments and editorial issues Multiple typographical/format issues should be corrected (e.g., “Malena” → “Melena”; inconsistent units and notation; “plasm LDH” vs “serum LDH”; p-values vs correlation coefficients). Table 1 values appear inconsistent (e.g., platelet count reporting format and plateletcrit units). Please verify all numbers and units. Clarify definition of “secondary ITP” and what “weakly positive autoimmune serology” means (which tests, titers, and criteria). Provide a participant flow diagram (screened → excluded with reasons → included) to support the exclusion of hemolysis/infection/malignancy. Please ensure that the shared dataset includes a clear data dictionary and matches the analyses in the manuscript. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Clinical hematology; Autoimmune cytopenias (including ITP/Evans syndrome); Platelet biology; Thrombotic microangiopathy (TMA); Hemostasis and thrombosis We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT QI J and Han Y. Reviewer Report For: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :1425 ( https://doi.org/10.5256/f1000research.190162.r444577 ) The direct URL for this report is: https://f1000research.com/articles/14-1425/v1#referee-response-444577 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 22 Dec 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 22 Dec 25 read Jiaqian QI , Soochow University, Suzhou, China Yue Han , Institution: First Affiliated Hospital of Soochow University (Ringgold ID: 74566), Suzhou, China Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 QI J et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Jan 2026 | for Version 1 Jiaqian QI , Soochow University, Suzhou, Jiangsu, China Yue Han , Hematology, Institution: First Affiliated Hospital of Soochow University (Ringgold ID: 74566), Suzhou, Jiangsu, China 0 Views copyright © 2026 QI J et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This prospective observational study evaluates whether serum lactate dehydrogenase (LDH) and platelet indices can help discriminate “severe” from “non-severe” thrombocytopenia among adults diagnosed with immune thrombocytopenia (ITP). The authors report higher LDH in the severe thrombocytopenia group (platelet count <20,000/µL), a strong inverse correlation between LDH and platelet count, and a modest ROC performance (AUC ~0.68) with a proposed LDH cut-off of 234 U/L. The topic is clinically relevant because ITP remains a diagnosis of exclusion and additional readily available biomarkers would be helpful. However, the current manuscript has several major conceptual and methodological limitations—especially regarding diagnostic claims, potential confounding by hemolysis-related disorders (including Evans syndrome and other ITP mimics), and pre-analytical issues influencing LDH—that must be addressed before the conclusions can be considered reliable. I therefore recommend major revision (Approved with Reservations) . 1.“Diagnostic utility” is overstated; the study does not diagnose ITP The manuscript title and parts of the abstract imply that LDH has “diagnostic utility” for ITP. However, the analysis is performed only within a cohort already labeled as ITP , and the primary outcome is severity of thrombocytopenia (platelet threshold) rather than diagnosis. Without an external comparator group (e.g., other causes of thrombocytopenia or healthy controls), the study cannot support statements that LDH helps “diagnose ITP.” 2.ITP is a diagnosis of exclusion; LDH is highly vulnerable to confounding by hemolysis and ITP mimics (Evans syndrome, TMA, etc.) This is the most important concern. LDH is non-specific and is classically elevated in hemolysis and many systemic conditions (tissue injury, liver disease, infection/inflammation, muscle injury). In the context of thrombocytopenia, several disorders can closely mimic ITP but involve hemolysis or tissue injury, and these can substantially inflate LDH. In particular, Evans syndrome (ITP + autoimmune hemolytic anemia) can be clinically close to ITP—sometimes evolving over time—and would directly confound any LDH-based interpretation. In addition, thrombotic microangiopathy (TTP/HUS), DIC, severe infection/sepsis , and other hemolytic states can present with thrombocytopenia and elevated LDH. Although the manuscript lists exclusion criteria (e.g., “hemolytic anemia/Evans syndrome, DAT positive”), the actual diagnostic work-up is not described in sufficient detail to ensure that hemolysis/TMA and Evans syndrome were robustly excluded across the whole cohort. 3. Pre-analytical and analytical issues with LDH measurement must be addressed (serum vs plasma; sample hemolysis) LDH is strongly affected by in vitro hemolysis during phlebotomy/processing . The manuscript states LDH was measured from serum; however, serum LDH can also be influenced by release during clotting, and the effect may differ by platelet count. Importantly, the reported direction (higher LDH in more severe thrombocytopenia) is not straightforwardly explained by platelet release into serum and raises concern for confounding or pre-analytical variability. In addition, the Methods mention “enzymatic immunoassay,” which is likely inaccurate for LDH (typically an enzymatic rate assay). 4. Statistical approach and reporting need tightening; provide effect sizes and uncertainty The ROC AUC (~0.676) indicates modest discrimination . The manuscript should provide more complete reporting and ensure consistency with non-normal distributions. There are also multiple apparent typographical/statistical inconsistencies (e.g., tables, notation, and some values/units). 5. Clinical interpretation: does LDH add actionable information beyond platelet count? Because “severe ITP” is defined by a platelet threshold, and LDH is strongly correlated with platelet count, the incremental value of LDH for severity classification may be limited. A more clinically meaningful endpoint might be bleeding, need for treatment/hospitalization, response to therapy, or relapse , where LDH could potentially contribute beyond platelet count. The current analysis shows no association with bleeding grade, which further limits clinical impact. Minor comments and editorial issues Multiple typographical/format issues should be corrected (e.g., “Malena” → “Melena”; inconsistent units and notation; “plasm LDH” vs “serum LDH”; p-values vs correlation coefficients). Table 1 values appear inconsistent (e.g., platelet count reporting format and plateletcrit units). Please verify all numbers and units. Clarify definition of “secondary ITP” and what “weakly positive autoimmune serology” means (which tests, titers, and criteria). Provide a participant flow diagram (screened → excluded with reasons → included) to support the exclusion of hemolysis/infection/malignancy. Please ensure that the shared dataset includes a clear data dictionary and matches the analyses in the manuscript. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Clinical hematology; Autoimmune cytopenias (including ITP/Evans syndrome); Platelet biology; Thrombotic microangiopathy (TMA); Hemostasis and thrombosis We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (0) QI J and Han Y. Peer Review Report For: Evaluation of Platelet Indices and serum LDH in Immune Thrombocytopenia: Diagnostic Utility of serum LDH [version 1; peer review: 1 approved with reservations] . 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