Anemia – The overlooked factor in bleeding related to liver disease

Several elegant studies, summarised in their review by the Coagulation in Liver Disease Study Group, have helped in changing the paradigm of bleeding related to liver disease, from abnormal coagulation profile to haemostatic alterations secondary to portal hypertension, endogenous heparinoids, sepsis, and renal failure [1]. However, one of the key omissions in this respect is the role of anemia in worsening the haemorrhagic tendency of liver dysfunction. Anemia is common in individuals with chronic liver disease and is likely to be of multifactorial etiology including folate deficiency, hypersplenism, hemodilution, haemolysis, bone marrow suppression due to viruses or ethanol, renal insufficiency, and, most importantly, variceal bleeding.