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World J Clin Cases. Jan 21, 2022; 10(3): 777-789
Published online Jan 21, 2022. doi: 10.12998/wjcc.v10.i3.777
Anemia in cirrhosis: An underestimated entity
Manish Manrai, Saurabh Dawra, Rajan Kapoor, Sharad Srivastava, Anupam Singh
Manish Manrai, Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
Saurabh Dawra, Sharad Srivastava, Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
Rajan Kapoor, Department of Medicine, Command Hospital, Kolkata 70027, India
Anupam Singh, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
Author contributions: Manrai M had conceptualized the review and with Dawra S is equally involved with resources, formal analysis, data curation, writing, review, and editing; Kapoor R was involved in resources and validation; Srivastava S was involved with resources and analysis; Singh A was involved with review and editing.
Conflict-of-interest statement: There is no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Manish Manrai, MBBS, MD, Professor, Department of Internal Medicine, Armed Forces Medical College, Solapur Road, Pune 411040, India. manishmanrai@yahoo.com
Received: May 11, 2021
Peer-review started: May 11, 2021
First decision: June 23, 2021
Revised: July 18, 2021
Accepted: December 25, 2021
Article in press: December 25, 2021
Published online: January 21, 2022
Processing time: 249 Days and 2 Hours
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.