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Anemia in Chronic Liver Disease and Liver Failure in Adults-A Clinical Study

Introduction: Chronic liver disease with or without liver failure is associated with considerable morbidity and mortality and affects the quality of life as usually they are progressive and often non-reversible. In the present study we have attempted to look at the clinical presentation, etiologies and anemia profile for chronic liver disease patients in our population. Curent study aimed to assess the clinical profile and type of anemia in chronic liver disease and liver failure in adult patients. Material and Methods: This was a prospective observational hospital-based study carried out in the department of General Medicine at, over a period of eighteen months. A total of 38 patients with chronic liver disease with/without liver failure were studied for patient demographics, clinical presentation, symptomatology, for etiology of the disease, for degree of anemia and morphologic type of anemia. Results: The patient age ranged from 19 to 76 years and the male to female ratio was 2.8:1. CLD was most common in the fifth and sixth decades of life. Malaise, nausea, emesis, jaundice, anemia and hepatomegaly were the most common clinical features. Most (44.7%) cases were of chronic hepatitis with cirrhosis. Alcoholic liver disease and HBV infection were the most common causes for CLD and liver failure. A total of 33 (86.8%) patients had anemia and the normocytic normochromic type of anemia was the most common (39.4%) type seen. Conclusion: Chronic liver disease and liver failure are more common in the fifth and sixth decades of life and are most often caused by alcoholic liver disease and HBV infection in India. CLD has varied clinical presentation with symptoms often related to the gastrointestinal tract and organomegaly. It is frequently associated with moderate degree of anemia which is often of normocytic type.


INTRODUCTION
Chronic liver disease (CLD) with or without liver failure is associated with considerable morbidity and mortality and affects the quality of life as usually they are progressive and often non-reversible. 1 The etiological causes for cirrhosis are diverse and vary with the geographical populations worldwide. Countries with high alcohol consumption have higher rates of alcoholic cirrhosis, whereas others have shown viral hepatitis as the most common cause for cirrhosis. 2 Liver cirrhosis is largely preventable. The etiologies of CLD vary from chronic heavy alcohol consumption, hepatitis B and C infections, autoimmune diseases, nonalcoholic steatohepatitis (NASH), biliary cirrhosis, cardiac cirrhosis, genetic disorders like hemochromatosis, Wilson's disease, α1 antitrypsin deficiency to unknown causes known as cryptogenic cirrhosis. 2 Mortality associated with CLD and liver failure has been on the rise in India since 1980, as has alcohol consumption. Also the prevalence of hepatitis B and C and diabetes (a major risk factor for nonalcoholic fatty liver disease/(NAFLD have been increasing. 1 Liver plays an important role in normal erythropoiesis and CLDs are frequently associated with hematological abnormalities. Almost 75% of patients with decompensated CLD have some degree of anemia. The CLD with conocomitant anemia can worsen the prognosis for the patient. 3 In the present study we have attempted to look at the clinical presentation, etiologies and anemia profile for chronic liver disease patients in our population. Curent study aimed to assess the clinical profile and type of anemia in chronic liver disease and liver failure in adult patients.

MATERIAL AND METHODS
This was a prospective observational hospital-based study carried out in the department of General Medicine over a period of eighteen months from January 2017 to july 2018

Unexplained hepatomegaly
Exclusion criteria 1. Acute hepatitis or any hepatitis less than 6 months duration 2. Follow up patients on their repeat visit were excluded A detailed clinical history was taken for all the patients followed by complete general and systemic examination. Special emphasis was given on drug history, blood transfusions, travel history, dietary habits, social habits, addictions, occupation and family history. Routine investigations of complete blood picture, ESR, blood glucose, serum electrolytes, urine analysis, C-reactive protein were done. Renal function test, liver function tests, viral marker tests (HBsAg, HBeAg, Anti HBc, Anti HCV), HIV 1 and 2, autoimmunity related tests like antinuclear antibody profile, Lupus erythematosus (LE) cell test, coagulation tests of prothrombin time and activated partial thromboplastin time were done. Ophthalmic consultation was taken for all the patients. Liver FNAC and/or biopsy was done in a few patients. A total of 38 patients who were diagnosed as chronic liver disease with or without liver failure were studied. The patient demographics, clinical presentation, etiologies, degree of anemia based on hemoglobin level and morphologic type of anemia based on the peripheral smear examination were studied.

STATISTICAL ANALYSIS
Descriptive statistics like mean and percentages were used for the analysis.

RESULTS
A total of 38 patients who were diagnosed as chronic liver disease with or without liver failure were studied. The patient age ranged from 19 years to 76 years. There were 28 (73.6%) males and 10 (26.3%) females and the male to female ratio was 2.8:1. Most number of cases (23 cases, 51.5%) were seen in the fifth and sixth decades of life (table-1). Malaise, nausea, emesis, jaundice and anemia and hepatomegaly were the most common clinical features (

DISCUSSION
In the present study a total of 38 patients with chronic liver disease and liver failure were studied for patient demographics, clinical symptomatology, clinicopathologic categories and possible etiologies. There are various definitions of ACLF. In general, patients with either diagnosed or undiagnosed chronic liver disease occasionally present with an acute deterioration of liver function caused by various insults to the liver. This is known as ACLF.
The Asian Pacific Association for the Study of the Liver (APASL) consensus defines ACLF as "an acute hepatic insult manifesting as jaundice (serum bilirubin ≥ 5 mg/dL) and coagulopathy (INR ≥ 1.5), complicated within 4 wk by ascites and/or encephalopathy in patients with previously diagnosed or undiagnosed chronic liver disease/cirrhosis, and is associated with a high 28-d mortality". 6 The European Association for the Study of the Liver-chronic liver failure (EASL-CLIF) Consortium defined ACLF as acute decompensation of cirrhosis in the form of one or more major complications of liver disease, including ascites, hepatic encephalopathy, gastrointestinal bleeding, and bacterial infection, associated with at least two organ failures with one being renal failure (serum creatinine ≥ 1.5 mg/dL) and high 28-d mortality of greater than 15%. 7 In our study we had 6 (15.7%) cases of malignant disease of the liver including primary and secondary neoplasms. It is estimated that ACLF is present in between 24% and 40% of patients with cirrhosis admitted to the hospital. 8 Viral hepatitis, alcohol or a combination of both are the predominant causes of underlying chronic liver disease in ACLF globally. 9 Clinical features: Most common symptomatology in our study for CLD was that of malaise, fatigue, fever, loss of weight and appetite, jaundice, pain in abdomen, organomegaly and especially hepatomegaly. The liver failure patients in addition had altered sensorium and hepatic encephalopathy. Mallik et al 4 also observed fatigue, fever, loss of weight and loss of appetite, jaundice in most of their study patients.
Anemia: In our study, moderate degree of anemia was more common in chronic liver disease ie hemoglobin in the 6 to 8.9 gm/dl range. The peripheral smear showed predominantly normocytic type of anemia. Liver has an active role in normal erythropoiesis. Any chronic liver diseases eventually give rise to hematological abnormalities. Anemia of diverge etiology occurs in about 75% patients with DCLD. 3  2010 considering world-wide numbers, occurred in India alone. This emphasizes the need for us to take adequate and appropriate steps to control the risk factors of chronic liver disease, cirrhosis and liver failure. 10

CONCLUSION
Chronic liver disease and liver failure are more common in the fifth and sixth decades of life and are most often caused by alcoholic liver disease and HBV infection in India. CLD has varied clinical presentation with symptoms often related to the gastrointestinal tract and organomegaly. It is frequently associated with moderate degree of anemia which is often of normocytic type.