Etiopathogenesis of Anemia in Chronic Liver Disease

NCT ID: NCT04622449

Last Updated: 2021-09-28

Basic Information

• Recruitment Status: UNKNOWN
• Total Enrollment: 125 participants
• Study Classification: OBSERVATIONAL
• Study Start Date: 2020-09-01
• Study Completion Date: 2021-12-31

Brief Summary

Anemia is the most common complication of liver cirrhosis and is seen in 75% of cases. The etiology of anemia in liver disease is diverse and often multi-factorial. Given the diverse and sometimes multifactorial etiology of cirrhosis, it is difficult to determine the exact cause of anemia in these groups of patients. The most common type of anemia encountered in liver cirrhosis is normocytic normochromic anemia, attributable to the chronic inflammatory state. The key question in management of anemia in patients with liver disease which specific factor needs to be corrected to restore hemoglobin levels and improve overall clinical status and improve severity scores.

Detailed Description

Common causes of anemia include acute and chronic blood loss due to upper gastrointestinal (GI) bleeding, malnutrition, hemolysis, hypersplenism secondary to portal hypertension, and impaired coagulation. Alcohol causes anemia by its direct bone marrow toxicity, vitamin B12 and folate deficiency due to poor oral intake, and intestinal malabsorption. Treatment related anemia is seen in patients with chronic hepatitis C virus infection receiving ribavirin and interferon. Hepatitis associated aplastic anemia, characterized by pancytopenia and hypocellular bone marrow, is an entity seen concurrently with or within 6 months of infection with hepatotropic viruses such as hepatitis B, hepatitis C and Epstein-Barr virus. Acute and chronic blood loss from varices, portal hypertensive gastropathy and gastric antral vascular ectasia can give rise to iron-deficiency anemia, in which the picture is one of microcytic hypochromic anemia. Another common hematological abnormality seen in liver cirrhosis is macrocytosis. The causes of macrocytosis in liver cirrhosis are also multi factorial. Vitamin B12 and folate deficiency is also frequently seen in liver cirrhosis, particularly of alcoholic origin, due to malnutrition and increased intestinal permeability, and gut dysbiosis.

Patients with cirrhosis patients have a high incidence of sepsis which can trigger decompensation and may result in prolonged hospital stay and increased mortality. Many studies have estimated that about 30%-50% admissions of patients with cirrhosis have sepsis. Of those who don't have sepsis at presentation, about 15% patients admitted to hospital develop sepsis during the hospital stay. After infection develops, the patient may develop acute kidney injury (AKI), shock, encephalopathy or disseminated intravascular coagulation (DIC) further decreasing the chances of survival. Sepsis and the associated cytokines have a myelosuppressive effect and prevent the erythron from making blood cells. This results in an increase in ferritin as an inflammatory biomarker and alters iron metabolism by affecting the production of hepcidin in the liver. The worsening of anemia in patients with sepsis is well documented, and this is further impacted using drugs like antibiotics which trigger inflammation mediated suppression of the erythron and other hematopoietic precursors like megakaryocytes and leucoblasts.

In the study, after taking informed consent, participants will be evaluated for etiology of chronic liver disease with proper history, clinical examination and investigations which will include viral markers (HbsAg, Anti-HCV, Total anti-Hbc, AIH markers (Anti-nuclear antibody/ anti-smooth muscle antibody/anti- liver kidney microsomal antibody), serum ceruloplasmin, non-alcoholic fatty liver disease (NAFLD) work up and radiological investigations for cirrhosis. The severity of cirrhosis will be determined by Child-Pugh's and MELD/MELD-Na score.

To evaluate for anemia, following results would be noted: Complete hemogram with RBC indices, reticulocyte count and peripheral blood smear, RFT, LFT, INR, iron studies - serum iron, ferritin, total iron binding capacity and %transferrin saturation, serum vitamin B12, folate levels. Workup for hemolysis would include lactate dehydrogenase, serum haptoglobin, direct coombs test and plasma hemoglobin. Upper GI endoscopy findings will also be noted to evaluate the contribution of gastrointestinal blood loss in causing anemia.

Conditions

Anemia; Chronic Liver Disease

Study Design

• Observational Model Type: CASE_ONLY
• Study Time Perspective: PROSPECTIVE

Study Groups

Chronic liver disease with anemia

All patients with anemia as diagnosed by WHO criteria in patients with liver disease of any etiology.

No interventions assigned to this group

Eligibility Criteria

Inclusion Criteria

1. Age 18-75 years

2. Either gender

3. Patients with chronic liver disease with anemia (Hemoglobin in Non-pregnant women (18 years of age and above) <12g/dl and in men <13g/dl

Exclusion Criteria

1. Those who do not consent to participate in the study

2. Renal dysfunction (S. Creatinine ≥ 2mg/dL)

3. Pregnancy/Lactation

4. Post liver transplant patients

5. HIV infection

6. Patients who are on psychoactive drugs, like sedatives or antidepressants

7. Patients with uncontrolled sepsis

8. Patients who are too sick to carry out the protocol

9. Patients with ongoing active bleeding

10. Patients with known primary hematological disorders

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 75 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Post Graduate Institute of Medical Education and Research, Chandigarh

OTHER

Sponsor Role: lead

Responsible Party

Madhumita Premkumar

Assistant Professor, Department of Hepatology

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Madhumita Premkumar, MD, DM

Role: PRINCIPAL_INVESTIGATOR

Post Graduate Institute of Medical Education and Research, Chandigarh

Locations

PGIMER

Chandigarh, , India

Site Status: RECRUITING

Countries

India

Central Contacts

Madhumita Premkumar, MD, DM

Role: CONTACT

drmadhumitap1@gmail.com

+9101722756344

Arnav Aggarwal, MD

Role: CONTACT

arnav272@gmail.com

+918527459774

Facility Contacts

Madhumita Premkumar, MD, DM

Role: primary

drmadhumitap1@gmail.com

+9101722756344

Arnav Aggarwal, MD

Role: backup

arnav272@gmail.com

+918527459774

References

Gonzalez-Casas R, Jones EA, Moreno-Otero R. Spectrum of anemia associated with chronic liver disease. World J Gastroenterol. 2009 Oct 7;15(37):4653-8. doi: 10.3748/wjg.15.4653.

Reference Type: BACKGROUND

PMID: 19787828 (View on PubMed)

Premkumar M, Saxena P, Rangegowda D, Baweja S, Mirza R, Jain P, Bhatia P, Kumar G, Bihari C, Kalal C, Vyas T, Choudhury A, Sarin SK. Coagulation failure is associated with bleeding events and clinical outcome during systemic inflammatory response and sepsis in acute-on-chronic liver failure: An observational cohort study. Liver Int. 2019 Apr;39(4):694-704. doi: 10.1111/liv.14034. Epub 2019 Feb 7.

Reference Type: BACKGROUND

PMID: 30589495 (View on PubMed)

Nahon P, Nuraldeen R, Rufat P, Sutton A, Trautwein C, Strnad P. In alcoholic cirrhosis, low-serum hepcidin levels associate with poor long-term survival. Liver Int. 2016 Feb;36(2):185-8. doi: 10.1111/liv.13007. Epub 2015 Dec 6.

Reference Type: BACKGROUND

PMID: 26561367 (View on PubMed)

Mathurin SA, Aguero AP, Dascani NA, Prestera JA, Gianserra C, Londero E, Chiorra C. [Anemia in hospitalized patients with cirrhosis: prevalence, clinical relevance and predictive factors]. Acta Gastroenterol Latinoam. 2009 Jun;39(2):103-11. Spanish.

Reference Type: BACKGROUND

PMID: 19663083 (View on PubMed)

Stein J, Connor S, Virgin G, Ong DE, Pereyra L. Anemia and iron deficiency in gastrointestinal and liver conditions. World J Gastroenterol. 2016 Sep 21;22(35):7908-25. doi: 10.3748/wjg.v22.i35.7908.

Reference Type: BACKGROUND

PMID: 27672287 (View on PubMed)

Tan TC, Crawford DH, Franklin ME, Jaskowski LA, Macdonald GA, Jonsson JR, Watson MJ, Taylor PJ, Fletcher LM. The serum hepcidin:ferritin ratio is a potential biomarker for cirrhosis. Liver Int. 2012 Oct;32(9):1391-9. doi: 10.1111/j.1478-3231.2012.02828.x. Epub 2012 Jun 7.

Reference Type: BACKGROUND

PMID: 22676252 (View on PubMed)

Gkamprela E, Deutsch M, Pectasides D. Iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment. Ann Gastroenterol. 2017;30(4):405-413. doi: 10.20524/aog.2017.0152. Epub 2017 May 3.

Reference Type: BACKGROUND

PMID: 28655976 (View on PubMed)

Alexopoulou A, Vasilieva L, Kanellopoulou T, Pouriki S, Soultati A, Dourakis SP. Presence of spur cells as a highly predictive factor of mortality in patients with cirrhosis. J Gastroenterol Hepatol. 2014 Apr;29(4):830-4. doi: 10.1111/jgh.12473.

Reference Type: BACKGROUND

PMID: 24325340 (View on PubMed)

Paternostro R, Kapzan L, Mandorfer M, Schwarzer R, Benedikt S, Viveiros A, Bauer D, Ferlitsch M, Zoller H, Trauner M, Ferlitsch A. Anemia and iron deficiency in compensated and decompensated cirrhosis: Prevalence and impact on clinical outcomes. J Gastroenterol Hepatol. 2020 Sep;35(9):1619-1627. doi: 10.1111/jgh.14988. Epub 2020 Feb 26.

Reference Type: BACKGROUND

PMID: 31972057 (View on PubMed)

Intragumtornchai T, Rojnukkarin P, Swasdikul D, Israsena S. The role of serum ferritin in the diagnosis of iron deficiency anaemia in patients with liver cirrhosis. J Intern Med. 1998 Mar;243(3):233-41. doi: 10.1046/j.1365-2796.1998.00290.x.

Reference Type: BACKGROUND

PMID: 9627161 (View on PubMed)

Vassiliadis T, Mpoumponaris A, Vakalopoulou S, Giouleme O, Gkissakis D, Grammatikos N, Soufleris K, Kakafika A, Tziomalos K, Patsiaoura K, Papanikolaou V, Evgenidis N. Spur cells and spur cell anemia in hospitalized patients with advanced liver disease: Incidence and correlation with disease severity and survival. Hepatol Res. 2010 Feb;40(2):161-70. doi: 10.1111/j.1872-034X.2009.00590.x. Epub 2010 Jan 11.

Reference Type: BACKGROUND

PMID: 20070401 (View on PubMed)

Liangpunsakul S, Ulmer BJ, Chalasani N. Predictors and implications of severe hypersplenism in patients with cirrhosis. Am J Med Sci. 2003 Sep;326(3):111-6. doi: 10.1097/00000441-200309000-00001.

Reference Type: BACKGROUND

PMID: 14501224 (View on PubMed)

Simbrunner B, Beer A, Woran K, Schmitz F, Primas C, Wewalka M, Pinter M, Dolak W, Scheiner B, Puespoek A, Trauner M, Oberhuber G, Mandorfer M, Reiberger T. Portal hypertensive gastropathy is associated with iron deficiency anemia. Wien Klin Wochenschr. 2020 Jan;132(1-2):1-11. doi: 10.1007/s00508-019-01593-w. Epub 2020 Jan 7.

Reference Type: BACKGROUND

PMID: 31912289 (View on PubMed)

Bothou C, Ruschenbaum S, Kubesch A, Quenstedt L, Schwarzkopf K, Welsch C, Zeuzem S, Welzel TM, Lange CM. Anemia and Systemic Inflammation Rather than Arterial Circulatory Dysfunction Predict Decompensation of Liver Cirrhosis. J Clin Med. 2020 Apr 26;9(5):1263. doi: 10.3390/jcm9051263.

Reference Type: BACKGROUND

PMID: 32357568 (View on PubMed)

Other Identifiers

IM/2020/1624

Identifier Type: -

Identifier Source: org_study_id