Anemia in cirrhosis: An underestimated entity

Abstract

Anemia in a patient with cirrhosis is a clinically pertinent but often overlooked clinical entity. Relevant guidelines highlight the algorithmic approach of managing a patient of cirrhosis presenting with acute variceal hemorrhage but day-to-day management in hospital and out-patient raises multiple dilemmas: Whether anemia is a disease complication or a part of the disease spectrum? Should iron, folic acid, and vitamin B complex supplementation and nutritional advice, suffice in those who can perform tasks of daily living but have persistently low hemoglobin. How does one investigate and manage anemia due to multifactorial etiologies in the same patient: Acute or chronic blood loss because of portal hypertension and bone marrow aplasia secondary to hepatitis B or C viremia? To add to the clinician’s woes the prevalence of anemia increases with increasing disease severity. We thus aim to critically analyze the various pathophysiological mechanisms complicating anemia in a patient with cirrhosis with an emphasis on the diagnostic flowchart in such patients and proposed management protocols thereafter.

Keywords: Anemia; Cirrhosis; Iron deficiency anemia; Macrocytic anemia; Normocytic anemia

Core Tip: Anemia in a patient with cirrhosis is an important but often neglected disease association. The presence of anemia increases the risk of hepatic decompensation and liver-related mortality. Increased severity of anemia is directly proportional to worsening severity indices like model for end-stage liver disease score. Thus, understanding the underlying pathophysiological processes giving rise to anemia, its diagnosis, and management is an important management aspect. Moreover, no validated guidelines are dealing with this pertinent clinical aspect.