Prevalence of and risk factors for anaemia in patients with advanced chronic liver disease

Abstract

BackgroundAnaemia is common in advanced chronic liver disease (ACLD) as a result of various risk factors.Aims & MethodsWe evaluated the prevalence and severity of anaemia as well as the impact of anaemia on clinical outcomes in consecutive patients with ACLD and portal hypertension.ResultsAmong 494 patients, 324 (66%) patients had anaemia. Anaemic patients showed higher MELD (12 ± 4 vs 9 ± 3; P < .001), lower albumin (34 ± 6 vs 39 ± 5 g/dL; P < .001) and more often Child‐Pugh B/C stage (56% vs 17%; P < .001). The prevalence of moderate‐severe anaemia (haemoglobin <10 g/dL) increased with the degree of portal hypertension (HVPG: 6‐9 mm Hg: 22% vs HVPG: 10‐19 mm Hg: 24% vs HVPG ≥ 20 mm Hg: 36%; P = .031). The most common aetiologies of anaemia were gastrointestinal bleeding (25%) and iron deficiency (9%), while reason for anaemia remained unclear in 53% of cases. Male gender (odds ratio [OR]: 1.94 [95% CI: 1.09‐3.47]; P = .025), MELD (OR: 1.20 [95% CI: 1.09‐1.32]; P < .001), hepatic decompensation (OR: 4.40 [95% CI: 2.48‐7.82]; P < .001) and HVPG (OR per mm Hg: 1.07 [95% CI: 1.02‐1.13]; P = .004) were independent risk factors for anaemia. Anaemia was associated with hepatic decompensation (1 year: 25.1% vs 8.1%; 5 years: 60.3% vs 32.9%; P < .0001), hospitalization (73% vs 57%; P < .001) and a higher incidence rate of acute‐on‐chronic liver failure (0.05 [95% CI: 0.04‐0.07] vs 0.03 [95% CI: 0.01‐0.04]). Anaemic patients had worse overall survival (1 year: 87.1% vs 93.7%, 5 year survival: 50.5% vs 68.6%; P < .0001) and increased liver‐related mortality (1 year mortality: 9.7% vs 5.7%, 5 year mortality: 38.0% vs 26.9%; P = .003).ConclusionTwo‐thirds of patients with ACLD suffer from anaemia. The degree of hepatic dysfunction and of portal hypertension correlate with severity of anaemia. Anaemia is associated with decompensation, ACLF and increased mortality in patients with ACLD.

Association of liver cirrhosis severity with anemia: does it matter?

“…Lower Hb levels were associated with a higher MELD score. Similar findings were seen in a study conducted by Scheiner et al, where anemic patients showed a higher MELD (12±4 vs. 9±3; P<0.001) [12]. In a study conducted by Jain et al, 88 patients with alcoholic liver cirrhosis were divided into 5 groups according to their MELD scores.…”

“…The MELD score has been adopted since 2002 for organ allocation to patients listed for liver transplantation [11]. Lower hemoglobin (Hb) levels are associated with higher MELD scores and a poor prognosis [12].…”

Portal hypertensive gastropathy is associated with iron deficiency anemia

“…Anemia is a common feature in advanced chronic liver disease, affecting up to two thirds of patients with cirrhosis [32]. Anemia was recently associated with increased risk of decompensation and acute-on-chronic liver failure [32]. It is frequently caused by chronic blood loss from gastrointestinal bleeding.…”

“…It is frequently caused by chronic blood loss from gastrointestinal bleeding. Chronic GI bleeding is an important cause of iron-deficiency anemia which is associated with gastrointestinal and liver diseases as well as decreased physical and mental health and even increased mortality [32][33][34]. The diagnosis of IDA in patients with cirrhosis remains challenging since red blood cell indices, such as MCV and MCH are less reliable due to additional complex vitamin deficiencies and different composition of lipoproteins in erythrocyte membranes [30].…”

Clinical Factors Associated with Hepatocellular Iron Deposition in End-stage Liver Disease

“…Our observations are in line with recent studies that have linked severity of anemia and macrocytosis with the degree of hepatic dysfunction and portal hypertension in patients with advanced liver disease. 31,32 Regarding the alterations in red blood cell indices, because evidence for hemolysis was not systematically sought in our subjects, we speculate that the increase in MCV in Group A may be due to increased numbers of circulating reticulocytes, while the higher MCHC might reflect abnormal red blood cell shapes associated with hemolysis (spherocytes or irregularly contracted cells resembling spherocytes). 33 Alternatively, elevations in MCH and MCHC might reflect stimulation of heme and hemoglobin synthesis in erythroid cells driven by high levels of transferrin saturation in Group A.…”