Anemia due to liver disease
Introduction
Introduction to anemia caused by liver disease Anemia caused by liver disease refers to anemia complications that occur during the course of liver disease and is common in most patients with chronic liver disease. Due to the different causes of liver disease, the degree of anemia and clinical manifestations vary. Generally mild to moderate anemia, severe anemia is rare. Patients with cirrhosis without complications are mostly positive cells, positive hemoglobin anemia, and a small number of patients with alcoholic cirrhosis and biliary cirrhosis can suddenly develop sputum erythrocyte hemolytic anemia several months before liver function deteriorates to death. basic knowledge The proportion of illness: 0.02% Susceptible population: common in most patients with chronic liver disease Mode of infection: non-infectious Complications: hemolytic anemia upper gastrointestinal bleeding
Cause
Causes of anemia caused by liver disease
(1) Causes of the disease
Liver disease anemia is most common in Laennec cirrhosis, biliary cirrhosis, hemochromatosis, post-necrotic cirrhosis, acute hepatitis, hepatolenticular degeneration, etc. can also cause liver disease anemia,
(two) pathogenesis
The pathogenesis of anemia in liver disease is not fully understood, but has been shown to be related to the following factors:
1. Hematopoietic factor deficiency The liver is an important organ of the body's metabolism and plays an important role in the maintenance of the normal physiological functions of the blood system, including:
(1) Reserves of hematopoietic raw materials: folic acid, vitamin B12, and iron are stored in the liver for use, and many proteins and lipids are also synthesized in the liver.
(2) Coagulation factor synthesis: Coagulation factors I, II, V, VII, IX, X, XII, XIII, etc. are synthesized in the liver,
(3) Secretion of part of erythropoietin: The liver is the main site of extrarenal erythropoietin.
Therefore, when liver disease occurs, the above functions may cause folic acid, vitamin B12 deficiency leads to megaloblastic anemia; blood clotting mechanism causes bleeding, resulting in iron deficiency anemia,
2. Red blood cell survival shortening Red blood cell survival shortening can be seen in alcoholic liver disease, biliary cirrhosis, obstructive jaundice, infectious hepatitis and other liver diseases, even when the above diseases are not associated with anemia, red blood cell life is shortened, about 70% The life expectancy of red blood cells in patients with liver disease is shortened. The exact cause of shortening the life span of red blood cells in liver diseases is still not fully understood. When patients cross blood transfusion with healthy people, the red blood cell survival time of patients is significantly prolonged in healthy people, and the red blood cells of healthy people are shortened in patients. The shortening of red blood cell survival is caused by extra-erythrocytic hemolytic factor. The following factors are related to the shortening of red blood cell life of patients:
(1) splenomegaly: congestive splenomegaly may be associated with hypersplenism in liver disease, causing excessive destruction of red blood cells in the spleen. The test with 51Cr-labeled red blood cells proves that the red blood cell life of patients with splenomegaly is less likely to be associated with splenomegaly. Shortening, foreign experiments have shown that in patients with myeloproliferative diseases, for every 1 kg increase in splenomegaly weight, the amount of red blood cell damage per day in the spleen increases hematocrit by 1%.
(2) Abnormal red blood cell metabolism: The metabolism of pentose phosphate pathway in red blood cells of patients with liver disease is low, which reduces the production of reduced glutathione in cells, and hemoglobin is easily oxidized, which leads to the formation of Heinz bodies, red blood cells are easily destroyed, and pentose phosphate Pathway low metabolism may be related to the reduction of nicotinamide adenine dinucleotide phosphate (NADP) or other causes are still unknown. In addition, patients often have hypophosphatemia, which causes ATP levels in red blood cells to decrease, and membrane deformability can be reduced. Hemolysis,
(3) erythrocyte membrane lipid abnormality: erythrocyte membrane is composed of double-layer lipid, the outer side of the membrane is free cholesterol and two phospholipids, namely phosphatidylcholine and sphingomyelin, and the inner two phospholipids of the membrane are phosphatidylserine and Phosphatidylethanolamine is the main type. In patients with hepatitis, cirrhosis and obstructive jaundice, the free cholesterol and phosphatidylcholine outside the erythrocyte membrane are increased by 20% to 50% than normal, resulting in an increase in the surface area of red blood cells to form a specific thin type. Giant cells and target red blood cells, which persist for a long time through the spleen sinus, are easily destroyed by mononuclear macrophages. In addition, sialidase activity increases in patients with biliary obstruction, and sialic acid secretion increases on the surface of red blood cells. Lead to a decrease in red blood cell viability,
(4) Acanthocyte hemolytic anemia: the patient's erythrocyte membrane cholesterol increased significantly and phosphatidylcholine did not increase correspondingly, resulting in decreased red blood cell deformability. When passing through the spleen, the cell membrane was partially covered by mononuclear macrophages. Phagocytosis causes the red blood cell surface area to shrink and eventually becomes spiny red blood cells. The mechanism of erythrocyte membrane lipid changes is known to be related to the following factors:
1 ratio of cholesterol to phospholipid in low-density lipoprotein in blood: mature red blood cells can not synthesize lipids themselves, and need to rely on the supply of lipoproteins in plasma to update, lipoprotein abnormalities in plasma make lipid components on red blood cell membrane change, but why some patients The mechanism of abnormal plasma lipoproteins is still unclear.
2 plasma phosphatidylcholine-cholesterol acyltransferase activity is reduced,
3 plasma bile retention,
4 Other factors: Alcohol-induced liver disease patients often produce alcohol-induced vitamin E deficiency, resulting in a decrease in various unsaturated fatty acids on the erythrocyte membrane, causing membrane deformation, decreased resistance to oxidants, in addition, portal hypertension, splenomegaly may also be hepatic hemolysis part of the reason,
3. Bone marrow hematopoietic function reduces plasma iron turnover rate, iron utilization rate in red blood cells, iron renewal rate in red blood cells is normal or decreased, indicating that bone marrow hematopoietic function is reduced, but there are also reports of increased, may be combined with patients Related to the disease, erythrocyte hematopoietic function is significantly inhibited in patients with alcoholic liver disease, manifested as macroscopic changes in the red blood cells of the bone marrow, young red, vesicles in the cytoplasm of granulocytes, and increased number of ring-shaped iron granules, indicating red It is pathological hematopoiesis, and the above phenomenon disappears after drinking alcohol.
4. Increased plasma volume Most patients with chronic liver disease have anemia, and their plasma volume is about 15% higher than that of normal people. The red blood cell volume of some patients with anemia is not reduced, so blood dilution is also one of the causes of liver disease anemia.
5. Hemorrhagic cirrhosis with bleeding in different reports is 24% to 75%, alcoholic cirrhosis patients with major bleeding sites for the gastrointestinal tract, followed by hemorrhoids, uterine bleeding, patients with abnormal blood coagulation mechanism, hemorrhage is also liver disease One of the causes of anemia in patients,
Prevention
Prevention of anemia caused by liver disease
Mainly for the treatment of liver disease, avoid drinking, strengthen nutrition, and actively adopt the liver protection treatment. Surgical treatment of patients with upper gastrointestinal bleeding and splenomegaly. Supplementing the necessary hematopoietic substances, including folic acid, vitamin B and iron, some patients can achieve certain effects. Avoid eating monotonously, avoiding unreasonable preparation, especially long-term partial eclipse. When eating iron-containing foods, it should not be used in the same way as amaranth, fresh bamboo shoots and strong tea containing higher oxalic acid or tannic acid. Avoid drinking high-concentration liquor, avoid drinking more coffee, strong tea, and avoid smoking.
Complication
Anemia complications caused by liver disease Complications hemolytic anemia upper gastrointestinal bleeding
The most common complications are hemolytic anemia and upper gastrointestinal bleeding.
Symptom
Symptoms of anemia caused by liver disease Common symptoms Jaundice biliary cirrhosis hemolytic anemia palm yellow
Due to the different causes of liver diseases, the degree of anemia and clinical manifestations vary from one to another. Generally, it is mild to moderate anemia. Severe anemia is rare. Patients with cirrhosis without complications are mostly positive cells, hemoglobin anemia, and a few alcohol-toxic livers. In patients with cirrhosis, biliary cirrhosis can suddenly cause sputum erythrocyte hemolytic anemia several months before liver function deteriorates, but if liver function improves, hemolysis will relieve itself, in patients with alcoholic liver disease, and even liver function is slightly affected. When there is damage, there may be paroxysmal hemolytic anemia. This hemolytic anemia is often mild to moderate, with self-limiting, recurrent, 2 to 3 weeks after abstinence, and can be induced again when drinking again. If the patient is accompanied by jaundice and hyperlipidemia, it is called "Zieve syndrome".
Examine
Examination of anemia caused by liver disease
1. Peripheral blood is positive cells, positive pigmented anemia, but can also be giant cell-like anemia, thrombocytopenia, but generally no less than 50 × 109 / L, white blood cells are generally normal, but the classification shows that the proportion of lymphocytes is reduced, Reduction or increase of neutrophils, neutrophil chemotactic inhibitory factor can be determined in plasma, which can reduce whole blood cells. When combined with hemorrhage, reticulocyte count increases.
2. Bone marrow hyperplasia is normal or obviously active, erythroid hyperplasia is often active, and the ratio of granule/red is decreased. Commonly, there are big red blood cells, which means young red blood cells with increased red blood cell volume and normal chromatin structure, but about 20 % of patients have macroscopic erythrocytosis in the bone marrow.
According to the condition, clinical manifestations, symptoms can be selected for X-ray, B-ultrasound, CT, liver function, biochemistry and other tests.
Diagnosis
Diagnosis and diagnosis of anemia caused by liver disease
Light to moderate anemia occurs on the basis of various causes of liver disease, blood cells are positive cells, positive pigments, or visible thin, target thick red blood cells, spinous red blood cells or oral red blood cells, bone marrow erythroid hyperplasia is active, visible With large red or giant red blood cells, the diagnosis can be initially established.
When the patient has hemorrhage, hemolysis, hypersplenism, vitamin B12 deficiency, there may be a corresponding clinical manifestations, pay attention to identification, especially attention to liver disease caused by hemolytic anemia and other causes of hemolytic anemia identification,
