Anemia in cirrhosis: An underestimated entity

Exploring Multimorbidity Patterns in older hospitalized Norwegian patients using Network Analysis modularity

BACKGROUND

Understanding Multimorbidity Patterns (MPs) is crucial for planning healthcare interventions, allocating resources, and improving patients' outcomes.

OBJECTIVE

We aim to demonstrate the use of Network Analysis (NA) to explore the MPs in hospitalized Norwegian older patients.

METHODS

We utilized data from the Norwegian Patient Registry (NPR) of all admissions between 2017 and 2019. The study population included patients ≥ 65 years old with two or more different conditions. Multimorbidity was defined as the co-occurrence of two or more associated chronic conditions. Chronic conditions were identified using the Chronic Condition Indicator Refined (CCIR) list. The association between chronic conditions was determined by calculating Relative Risk (RR) and Phi-correlation to detect pairs of conditions that co-occur beyond chance. A multimorbidity network was created, and MPs were detected using Louvain method for community detection. We suggested a clinical interpretation for these MPs.

RESULTS

A total of 539 chronic conditions were used to create a multimorbidity network revealing several MPs. These modules included patterns of vision and hearing disorders, cardiorenal syndrome, metabolic and cardiovascular disorders, respiratory disorders, endocrine and skin conditions, autoimmune and musculoskeletal disorders, as well as mental and behavioral disorders. Using NA centrality measures, we identified the most influential conditions in each module. An interactive network and sunburst graphs for each module are publicly available.

CONCLUSION

The study demonstrates the use of NA modularity detection in identifying MPs. The findings highlight the complex interaction of chronic conditions in the elderly and the potential of NA methodology in exploring these relationships.

Mitigating renal dysfunction in liver cirrhosis: Therapeutic role of ferrous sulphate, folic acid, and its co-administration

The liver and kidneys are vital organs for detoxification and metabolic regulation. Regular consumption of alcohol and acetaminophen can cause liver cirrhosis. Cirrhosis increases oxidative stress in kidneys by disrupting the balance between reactive oxygen species (ROS) and antioxidants, leading to cell damage. Folic acid and ferrous sulfate are two anti-anemic drugs treat various diseases, have a high reactive oxygen radical quenching ability, resulting in protection against oxidative damage in aerobic cell. The aim of this study was to investigate mitigating renal dysfunction in liver cirrhosis and therapeutic potential effect of ferrous sulfate, folic acid and its co-administration caused by alcohol-acetaminophen induced liver cirrhosis. Animals were divided into six groups. Rats of normal control group received water and normal diet ad libitum; AC and LC group received 4.5 % alcohol and a combination of 4.5 % alcohol and acetaminophen (300 mg/kg bw) via drinking water respectively for seven days. After seven days, rats of LC+FS, LC+FA and LC+FS+FA received FS (5 mg/kg bw), FA (5 mg/kg bw) and FS+FA (5 mg/kg bw) respectively via drinking water for four weeks. Enzyme activity and protein expression were measured by semi-quantitative RT PCR and western blotting respectively. Results revealed that FS and FA treatment individually and together restored the antioxidant enzyme activity and the levels of glycolytic pathway towards normal which were affected due to liver cirrhosis. FS and FA are well known anti-anemic drugs and proved to be efficient agents for antioxidant and glycolytic enzymes alteration in liver cirrhosis. This novel approach could lead to new treatments.

Improvement of Physical Functions in Elderly Patients with Heart Failure Depends on the Hepatic Reserve

OBJECTIVES

In recent years, the number of elderly heart failure patients with multiorgan failure has been increasing. Furthermore, the combination of heart failure and decreased hepatic reserve can cause severe skeletal muscle impairment and decreased survival rates. This study investigated whether the degree of improvement in the five repetitions of sit-to-stand (5STS) and walking speed (WS) differs depending on hepatic reserve in elderly heart failure patients.

METHODS

The patients were divided into the following two groups: good hepatic reserve (albumin-bilirubin score [ALBI score] ≤-2.25) and poor hepatic reserve (ALBI score >-2.25). Propensity score matching was performed using the brain natriuretic peptide level. A two-way analysis of variance (ANOVA) was performed to examine the main effects of the hepatic reserve and time points (admission or discharge).

RESULTS

After propensity score matching, 28 out of the 33 (84.8%) patients in the good hepatic reserve (age, 83.74 ± 9.25 years and ALBI score, -2.55 ± 0.19 points) and 27 out of 40 (67.5%)patients in the poor hepatic reserve (age, 85.85 ± 7.53 years and ALBI score, -1.93 ± 0.26 points) were analyzed. Two-way ANOVA showed that the 5STS (p = 0.04) and WS (p = 0.01) in poor hepatic reserve tended to be worse than in good hepatic reserve. Furthermore, the 5STS (p = 0.04) and WS tended to improve at discharge in both groups. However, the improvement in WS was not significant (p = 0.15).

CONCLUSIONS

Our study suggests that the hepatic reserve in elderly heart failure patients may be an important factor in the assessment of physical functions.

Prognostic value of liver outcome score and hemoglobin in autoimmune liver disease overlap syndromes

This letter addresses the study by Jayabalan et al, which underscores the liver outcome score (LOS) and hemoglobin (Hb) as key prognostic markers for patients with autoimmune liver disease overlap syndromes (AILDOS), with particular relevance to the autoimmune hepatitis-primary biliary cholangitis (AIH-PBC) subgroup. The findings indicate that an LOS threshold of 6 achieves high sensitivity and specificity in predicting liver-related mortality among AIH-PBC patients. Moreover, low Hb levels emerge as a significant mortality predictor across all AILDOS cases. These results contribute valuable perspectives on risk stratification in AILDOS, highlighting the promise of non-invasive prognostic tools. Future studies with larger cohorts are needed to substantiate LOS and Hb as robust markers for clinical application.

Deciphering the role of hepcidin in iron metabolism and anemia management

One of the most common diseases worldwide is anemia, which is characterized by insufficient erythrocyte production. Numerous complex factors, such as chronic diseases, genetic mutations, and nutritional inadequacies, contribute to this widespread syndrome. This review focuses specifically on anemias caused by defective hepcidin production. Hepcidin, a peptide hormone produced primarily by liver cells, plays a crucial role in regulating iron levels by controlling its absorption. Hepcidin's mechanism of action involves binding to the ferroportin iron transporter, causing its internalization. Disturbances in iron metabolism can have far-reaching consequences, affecting not only the blood but also organs like the liver, kidneys, and brain. Iron homeostasis is crucial for maintaining optimal physiological function. Several blood-based markers are employed to assess iron stores. However, these markers have inherent limitations. Hepcidin, a key regulator of iron metabolism, plays a pivotal role in preventing iron release into the plasma from absorptive enterocytes and macrophages. Elucidating the structure and function of hepcidin is essential for understanding its role in iron homeostasis, which has significant implications for the diagnosis and management of various anemia subtypes. A well-established correlation exists between hepcidin dysregulation and iron deficiency. Despite its potential as a biomarker, the clinical application of hepcidin is hindered by the lack of a commercially available, clinically validated assay. This review aims to provide a comprehensive overview of hepcidin's role in regulating blood iron concentrations and elucidate its implications in the pathogenesis of various anemia subtypes, paving the way for its future applications in research and clinical practice.

Factors related to mean corpuscular volume in HFE p.C282Y homozygotes

Introduction

The aim of this study was to define the relationships between factors other than transferrin saturation (TS) to mean corpuscular volume (MCV) and macrocytosis (MCV > 100 fL) in HFE p.C282Y (rs1800562) homozygotes.

Methods

We studied white post-screening participants with p.C282Y homozygosity who did not have anemia, report cirrhosis or pregnancy, or use medications that increase MCV. We analyzed relations of MCV and macrocytosis with age, sex, diabetes reports, daily alcohol consumption, swollen or tender 2nd/3rd metacarpophalangeal (MCP) joints, TS, and serum ferritin (SF).

Results

There were 257 participants (110 men and 147 women). Median alcohol consumption, median TS, median SF, and macrocytosis prevalence were significantly greater in men. Relative risk of macrocytosis in men was 2.81. In men and women, there were significant positive Pearson's correlations of MCV versus age and Spearman's correlations of MCV versus alcohol consumption and TS. Mean MCV and macrocytosis prevalence were significantly greater in participants with than without swollen or tender 2nd/3rd MCP joints. Linear regression on MCV revealed positive associations: age (p < 0.0001), alcohol consumption (p = 0.0007), and TS (p < 0.0001). Logistic regression on macrocytosis revealed an odds ratio for age of 1.04 (95% confidence interval: 1.00, 1.07).

Conclusions

MCV in HFE p.C282Y homozygotes is positively related to age, daily alcohol consumption, TS, and swollen or tender 2nd/3rd MCP joints.

Comparison of different severity scores in correlating hemoglobin levels with the severity of hepatic decompensation: An observational study

BACKGROUND

Chronic liver disease is a growing global health problem, leading to hepatic decompensation characterized by an array of clinical and biochemical complications. Several scoring systems have been introduced in assessing the severity of hepatic decompensation with the most frequent ones are Child-Pugh score, model of end-stage liver disease (MELD) score, and MELD-Na score. Anemia is frequently observed in cirrhotic patients and is linked to worsened clinical outcomes. Although studies have explored anemia in liver disease, few have investigated the correlation of hemoglobin level with the severity of hepatic decompensation.

AIM

To determine the relationship between hemoglobin levels and the severity of decompensated liver disease and comparing the strength of this correlation using the Child-Pugh, MELD, and MELD-Na scores.

METHODS

This cross-sectional study was conducted at a tertiary care hospital with 652 decompensated liver disease patients enrolled in the study. Data was collected on demographics, clinical history, and laboratory findings, including hemoglobin levels, bilirubin, albumin, prothrombin time (international normalized ratio), sodium, and creatinine. The Child-Pugh, MELD, and MELD-Na scores were calculated. Statistical analysis was performed using Statistical Package for the Social Sciences version 26, and correlations between hemoglobin levels and severity scores were assessed using Spearman's correlation coefficient.

RESULTS

The study included 405 males (62.1%) and 247 females (37.9%) with an average age of 58.8 years. Significant inverse correlations were found between hemoglobin levels and Child-Pugh, MELD, and MELD-Na scores (P < 0.01), with the MELD scoring system being the strongest correlator among all. One-way analysis of variance revealed significant differences in hemoglobin levels across the severity groups of each scoring system (P = 0.001). Tukey's post hoc analysis confirmed significant internal differences among each severity group.

CONCLUSION

Understanding the correlation between hemoglobin and liver disease severity can improve patient management by offering insights into prognosis and guiding treatment decisions.

Development and validation of a machine learning-based prediction model for hepatorenal syndrome in liver cirrhosis patients using MIMIC-IV and eICU databases

Hepatorenal syndrome (HRS) is a key contributor to poor prognosis in liver cirrhosis. This study aims to leverage the database to build a predictive model for early identification of high-risk patients. From two sizable public databases, we retrieved pertinent information about the cirrhosis patients' therapies, comorbidities, laboratory results, and demographics. Patients from the eICU database served as a test set for external validation, while patients from the MIMIC database were divided into training and validation groups. Variables were screened using LASSO regression, Extreme Gradient Boosting (XG Boost), and Random Forest (RF). Core risk factors were determined from the intersection of the three methods. A predictive model was constructed using multivariable logistic regression and visualized via a nomogram. Model performance was assessed using ROC curves, decision curve analysis (DCA), clinical impact curves (CIC), and calibration curves. Eight critical variables associated with HRS were identified using machine learning methods. The final predictive model, based on five key variables-spontaneous bacterial peritonitis, red blood cell count, creatinine, activated partial thromboplastin time, and total bilirubin-showed excellent discrimination, with AUCs of 0.832 (95% CI 0.8069-0.8563) in the training set and 0.8415 (95% CI 0.8042-0.8789) in the validation set. The AUC in the external test set was 0.8212 (95% CI 0.7784-0.864). By integrating the MIMIC-IV database and machine learning algorithms, we developed an effective predictive model for HRS in liver cirrhosis patients, providing a robust tool for early clinical intervention.

Absolute and functional iron deficiency: Biomarkers, impact on immune system, and therapy

Iron is essential for numerous physiological processes and its deficiency often leads to anemia. Iron deficiency (ID) is a global problem, primarily affecting reproductive-age women and children, especially in developing countries. Diagnosis uses classical biomarkers like ferritin or transferrin saturation. Recent advancements include using soluble transferrin receptor (sTfR) or hepcidin for improved detection and classification of absolute and functional iron deficiencies, though mostly used in research. ID without anemia may present symptoms like asthenia and fatigue, even without relevant clinical consequences. ID impacts not only red-blood cells but also immune system cells, highlighting its importance in global health and immune-related comorbidities. Managing ID, requires addressing its cause and selecting appropriate iron supplementation. Various improved oral and intravenous products are available, but further research is needed to refine treatment strategies. This review updates on absolute and functional iron deficiencies, their relationships with the immune system and advancements in diagnosis and therapies.

Acute Variceal Hemorrhage in Germany-A Nationwide Study of 65,357 Hospitalized Cases: Variceal Hemorrhage in Germany

Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.

The effects of iron deficient and high iron diets on SARS-CoV-2 lung infection and disease

Introduction

The severity of Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is often dictated by a range of comorbidities. A considerable literature suggests iron deficiency and iron overload may contribute to increased infection, inflammation and disease severity, although direct causal relationships have been difficult to establish.

Methods

Here we generate iron deficient and iron loaded C57BL/6 J mice by feeding standard low and high iron diets, with mice on a normal iron diet representing controls. All mice were infected with a primary SARS-CoV-2 omicron XBB isolate and lung inflammatory responses were analyzed by histology, immunohistochemistry and RNA-Seq.

Results

Compared with controls, iron deficient mice showed no significant changes in lung viral loads or histopathology, whereas, iron loaded mice showed slightly, but significantly, reduced lung viral loads and histopathology. Transcriptional changes were modest, but illustrated widespread dysregulation of inflammation signatures for both iron deficient vs. controls, and iron loaded vs. controls. Some of these changes could be associated with detrimental outcomes, whereas others would be viewed as beneficial.

Discussion

Diet-associated iron deficiency or overload thus induced modest modulations of inflammatory signatures, but no significant histopathologically detectable disease exacerbations.

Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm

BACKGROUND

Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair.

METHODS

Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches.

RESULTS

There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01).

CONCLUSION

In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Relationship between Circadian System Status, Child-Pugh Score, and Clinical Outcome in Cirrhotic Patients on Waiting Lists for Liver Transplantation

Background/Objectives: Many patients suffering from liver cirrhosis are eventually added to waiting lists for liver transplantation whose priority is established based on scales such as the Child-Pugh score. However, two marker rhythms of the circadian system, motor activity and distal temperature, are not evaluated. Methods: To determine the relationship between the functional status of the circadian system and the Child-Pugh scale in patients awaiting liver transplantation, distal temperature, motor activity, and light exposure rhythms were monitored for a full week using a wrist device (Kronowise 6.0) in 63 patients (17 women, 46 men) aged between 20 and 76 years. Results: Circadian parameters (amplitude, regularity, and fragmentation) of motor activity rhythms, distal temperature, and light exposure worsen in close association with liver disease severity as assessed by using the Child-Pugh score. Likewise, the worsening of rhythmic parameters and liver disease is associated with a deterioration in the markers of the red series: count, hemoglobin, and hematocrit. Conclusions: These results indicate the utility of ambulatory monitoring of marker rhythms to complement the clinical information provided by the Child-Pugh scale and to help establish nutrition, physical exercise, and sleep guidelines that promote better survival and quality of life in these patients.

Exploring Haematological Complications in Cirrhosis of the Liver: A Comprehensive Review

Various chronic liver diseases inevitably end up with cirrhosis of the liver, and this comes with a whole range of haematological complications. Therefore, this detailed review has discussed pathophysiology, clinical manifestations, diagnostic measures, and treatment plans for these anomalies. Closely related are conditions such as anaemia, thrombocytopenia, coagulopathy, leukopenia, and haemolytic disorders, which are known to contribute to morbidity and mortality in cirrhotic patients significantly. Therefore, we need to understand the causes of these problems to find ways of helping our patients better. For this reason, multidisciplinary management will be key in ensuring proper monitoring, timely intervention, and preventive measures for haematological abnormalities in cirrhosis. Additionally, there have been tremendous advancements in therapeutic options, like adjunctive therapies or haematopoietic growth factors, which hold much promise regarding patient outcomes. This article emphasizes the proactive management of haematological complications associated with cirrhosis while highlighting the need for further research coupled with collaboration aimed at strengthening prevention strategies, diagnostic methods, and curative interventions.

Anemia and Its Connections to Inflammation in Older Adults: A Review

Anemia is a common hematological disorder that affects 12% of the community-dwelling population, 40% of hospitalized patients, and 47% of nursing home residents. Our understanding of the impact of inflammation on iron metabolism and erythropoiesis is still lacking. In older adults, anemia can be divided into nutritional deficiency anemia, bleeding anemia, and unexplained anemia. The last type of anemia might be caused by reduced erythropoietin (EPO) activity, progressive EPO resistance of bone marrow erythroid progenitors, and the chronic subclinical pro-inflammatory state. Overall, one-third of older patients with anemia demonstrate a nutritional deficiency, one-third have a chronic subclinical pro-inflammatory state and chronic kidney disease, and one-third suffer from anemia of unknown etiology. Understanding anemia's pathophysiology in people aged 65 and over is crucial because it contributes to frailty, falls, cognitive decline, decreased functional ability, and higher mortality risk. Inflammation produces adverse effects on the cells of the hematological system. These effects include iron deficiency (hypoferremia), reduced EPO production, and the elevated phagocytosis of erythrocytes by hepatic and splenic macrophages. Additionally, inflammation causes enhanced eryptosis due to oxidative stress in the circulation. Identifying mechanisms behind age-related inflammation is essential for a better understanding and preventing anemia in older adults.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis

INTRODUCTION

There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.

METHODS

We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed.

RESULTS

Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044).

CONCLUSIONS

On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Causes for the absence of thrombocytopenia in patients with liver cirrhosis and portal vein thrombosis: A case-control study

Background: Complications of liver cirrhosis (LC), such as thrombocytopenia and portal vein thrombosis (PVT), have similar pathophysiology. However, the association between PVT and platelet count in LC patients is contradictory. Aim: To assess factors affecting the platelet count in patients with LC and PVT. Materials and methods: This was a retrospective case-control study. The cases were 114 patients with LC of various etiologies and newly diagnosed PVT unrelated to invasive hepatocellular carcinoma. From the database of LC patients without PVT, 228 controls were randomly selected with stratification by gender, age and etiology of cirrhosis. The patients from both groups were divided into subgroups with thrombocytopenia ( 150 × 109/L) and without thrombocytopenia (≥ 150 × 109/L). We analyzed the LC etiology, portal hypertension severity (ascites, hepatic encephalopathy, gastroesophageal varices and associated bleedings, the spleen length, and portal vein diameter), laboratory parameters (white blood cell counts, neutrophils, lymphocytes, hemoglobin levels, total protein, albumin, total bilirubin, fibrinogen, neutrophil-to-lymphocyte ratio, and prothrombin); also, the rates of newly diagnosed malignant tumors was assessed. The statistical analysis included calculation of odds ratios (OR) and 95% confidence intervals (CI), logistic regression models with assessment of the model accuracy, and the area under the ROC curve (AUC). Results: There were no differences in the severity of thrombocytopenia between the case and control groups: thrombocytopenia was severe in 15.8% (18 patients) vs 13.6% (31 patients, p = 0.586); moderate, in 41.2% (47 patients) vs 46.1% (105 patients, p = 0.398) and mild, in 31.6% (36 patients) vs 24.5% (56 patients, p = 0.168). The proportion of the patients without thrombocytopenia was 11.4% (13 patients) in the case group and 15.8% (36 patients) in the control group, with the between-group difference being non-significant (p = 0.276). In the subgroups of patients without thrombocytopenia (both in the cases and in the controls), the proportion alcoholic etiology of LC, white blood cells counts, neutrophils, lymphocytes, and fibrinogen concentrations were significantly higher (p 0.05) than in those with thrombocytopenia. The model based on the outcome "absence of thrombocytopenia" included white blood cells counts, hemoglobin and albumin levels, the presence of newly diagnosed malignant tumors in the case group (model accuracy 90.4%, AUC 0.873), and neutrophil counts and spleen length in the control group (model accuracy 86.4%, AUC 0.855). In the patients with PVT and platelet counts of ≥ 150 × 109/L, the OR for all newly diagnosed malignant tumors was 26.3 (95% CI 7.37–93.97, р 0.0001), for newly diagnosed hepatocellular carcinoma without portal vein invasion 17.42 (95% CI 4.84–62.65, р 0.0001). Conclusion: In LC patients, the prevalence and severity of thrombocytopenia are not different depending on the PVT presence or absence. The absence of thrombocytopenia in PVT patients is associated with a higher risk of malignant tumors identification, primarily that of hepatocellular carcinoma.

Predictors of anemia without active bleeding signs in patients referred for endoscopy

Objective: The objective of the present study is to clarify the value of clinic, endoscopic, and histologic variables that may predict anemia in patients performing esophagogastroduodenoscopy for gastrointestinal complaints in the absence of bleeding signs or lower digestive disease.

Methods: This study included 654 patients referred for endoscopy that were divided based on biological parameters performed in the same day in the study group (306 patients diagnosed with anemia) and the control group (348 patients without anemia).

Results: Anemia is frequent in elderly patients, especially in the presence of premalignant gastric lesions, and it is associated with multiple comorbidities. In two multivariate regression models antivitamin K oral anticoagulants were found to be independently associated with anemia (p = 0.01), but not with antiplatelet therapy, or with non-antivitamin K anticoagulants. Multiple regression models support that epigastric pain and heartburn are inversely associated with anemia, while weight loss remained an independent predictor for simultaneous anemia and premalignant lesions. Non-infectious chronic gastritis (p<0.001) is an independent predictor for anemia and premalignant gastric lesions, increasing the odds of anemia by 2.2 times, while reactive gastropathy is inversely associated. Gastric erosions and ulcer remained independent predictors for concomitant anemia and premalignant lesions.

Conclusions: Chronic inactive gastritis and premalignant gastric histologic lesions are predictors for anemia in endoscopic population, while active H. pylori infection is not. Dyspeptic symptoms, epigastric pain (p<0.001,OR 0.2-0.5) and heartburn (p<0.001,OR 0.07-0.3) are inversely associated with anemia alone or associated with premalignant gastric lesions.

Spur cells in liver cirrhosis are predictive of acute-on-chronic liver failure and liver-related mortality regardless of severe anaemia

Chronic anaemia in advanced liver disease is a frequent finding. The aim was to explore the clinical impact of spur cell anaemia, a rare entity typically associated with end-stage of the disease. One-hundred and nineteen patients (73.9% males) with liver cirrhosis of any etiology were included. Patients with bone marrow diseases, nutrients deficiencies and hepatocellular carcinoma were excluded. In all patients, a blood sample was collected to check for the presence of spur cells on blood smear. A complete blood biochemical panel was recorded together with Child-Pugh (CP) score and Model for End-Stage Liver Disease (MELD) score. For each patients, clinically relevant events, such as acute-on-chronic liver failure (ACLF) and 1 year liver-related mortality, were registered. Patients were then grouped according to the percentage of spur cells at smear (> 5%, 1-5%, < 1%). Severe anaemia was defined as haemoglobin levels lower than 8 g/dL. 9.2% of subjects had > 5% spur cells, only 2 had evidence of haemolysis. In patients with > 5% spur cells, haemoglobin and albumin were lower compared with the other sub-group, while MELD score, CP score, International Normalized Ratio, ferritin, creatinine and unconjugated bilirubin were higher. Patients with more spur cells were more decompensated and developed more frequently ACLF. ACLF and liver-related mortality were significantly and independently associated with the presence of > 5% spur cells but not with baseline severe anaemia. Cirrhotic patients have a fairly high prevalence of spur cells, not always associated with severe haemolytic anaemia. The presence of spur red cells is per se associated with a worse prognosis and, therefore, should be always evaluated to prioritize patients for intensive management and eventually liver transplantation.

Hematological Abnormalities in Cirrhosis: A Narrative Review

Liver cirrhosis remains a major public health issue. Liver fibrosis leading to cirrhosis is the terminal stage of various chronic liver diseases. Inflammatory cytokines are involved in the pathogenesis. Patients with cirrhosis often have hematological abnormalities, such as anemia and thrombocytopenia, which have multifactorial etiologies. Anemia in cirrhosis could be related to bleeding leading to iron deficiency anemia or other nutritional anemia such as vitamin B12 and folate deficiency. The pathophysiology of thrombocytopenia in liver cirrhosis has been postulated to range from splenic sequestration to bone marrow suppression from toxic agents, such as alcohol. It often complicates management due to the risk of bleeding with severely low platelets. This review aimed to highlight pathogenesis of liver cirrhosis, hematological abnormalities in liver cirrhosis, and their clinical significance.