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doi:10.1111/jgh.12473
H E PAT O L O G Y
Presence of spur cells as a highly predictive factor of mortality in patients with cirrhosis Alexandra Alexopoulou, Larisa Vasilieva, Theoni Kanellopoulou, Sophia Pouriki, Aspasia Soultati, Spyridon P Dourakis 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece
Key words cirrhosis, risk factor, spur cell anemia, survival. Accepted for publication 20 November 2013. Correspondence Dr Alexandra Alexopoulou, 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, 40 Konstantinoupoleos Street, Hilioupolis, Athens 16342, Greece. Email: [email protected]
Abstract Background and Aim: The presence of spur-cell anemia (SCA) is due to lipid disturbances of the erythrocyte membrane and may develop in patients with advanced liver cirrhosis. The accurate predicting value of SC for survival has not been clarified. The aim of this study was to evaluate SCA as a prognostic indicator in patients with cirrhosis. Methods: We prospectively evaluated clinical, laboratory parameters, and survival in patients with cirrhosis, with or without SCA, during the period 2008–2011. Patients who had at admission renal failure, other causes of hemolytic anemia, hepatocellular carcinoma, sepsis, and/or active bleeding, were excluded. One hundred sixteen patients with cirrhosis were included. The presence of SCA (SC rate higher or equal to 5% [≥ 5%]) was diagnosed in 36 (31%) patients. Results: Patients with SCA compared to those without had more advanced liver disease (higher Model for End-Stage Liver Disease [MELD], P < 0.001), higher total bilirubin (P < 0.001), and International Normalized Ratio (P < 0.001). Patients with SCA had worse survival (log rank P < 0.001). Survival of patients with SCA at the first, second, and third month of follow-up was 77%, 45%, and 33%, respectively. In multivariate Cox’s regression analysis, the presence of SCA was an independent predictor of mortality (hazard ratio = 3.17 [95% CI 1.55–6.48]). Conclusions: The presence of spur-cell anemia is not uncommon in cirrhosis and seems to be strongly associated with mortality. SCA can be used in combination with MELD as an additional predictor of early mortality.
Introduction
Material and methods
Spur-cells are acanthocytes with morphological abnormalities due to the increase of cholesterol to protein and cholesterol to phospholipid ratios in the red cell membrane.1 Their spike-like projections deform their shape and flexibility, making them susceptible to trapping and destruction by the spleen.2,3 Normal red blood cells, transfused into patients with spur-cell hemolytic anemia (SCA), acquire the spur cell irregular shape and therefore have a short survival.4 Spur-cell morphological abnormality is reversible in a non-cirrhotic microenvironment and is resolved after liver transplantation.5–7 The presence of SCA in liver cirrhosis has been associated with advanced disease8 and poor prognosis.9,10 Nevertheless, the exact impact of the presence of SCA on mortality is poorly documented. The aim of this prospective study is to investigate (i) whether the presence of SCA is related to severity and etiology of liver disease and (ii) to clarify the accurate impact of the presence of SC on predicting survival in patients with cirrhosis.
Study population. All patients with cirrhosis admitted to the 2nd Department of Internal Medicine of Hippokration General Hospital from 2008 to 2011 were included in the study, unless they satisfied an exclusion criterion. In particular, patients with renal failure, other causes of hemolytic anemia, hepatocellular carcinoma, sepsis, and/or active bleeding were excluded. Patients with either acute alcoholic hepatitis or recent alcohol abuse were not included in the study. Some of the previously excluded patients might be enrolled later after resolution of renal failure, sepsis, or active bleeding episodes. Twenty seven patients were enrolled in the study at least 1 month after resolution of the acute episode mentioned above. The presence of spur cells and the Model for EndStage Liver Disease (MELD) calculation were done at enrollment. Admission etiologies of patients who were enrolled in the study were as follows: “Severe anemia—decompensated liver cirrhosis,” “Refractory ascites,” “Therapeutic paracentecis of ascites” and “Decompensated liver cirrhosis.”
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Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
A Alexopoulou et al.
For the diagnosis of cirrhosis, we used liver histological and/or imaging methods as well as endoscopic or clinical findings. Cirrhosis is considered to be decompensated in patients with history of ascites, variceal bleeding, hepatic encephalopathy, and jaundice of non-obstructive cause (bilirubin > 3 mg/dL for non-cholestatic and > 10 mg/dL for cholestatic causes of cirrhosis). The study protocol was approved by the Hospital Ethical Committee. All patients signed a written informed consent before their inclusion in the study. Hematological parameters and spur cell anemia diagnosis. Complete blood count and reticulocyte measurement was analyzed by using ADVIA 2120 hematology system (Siemens Healthcare Diagnostics), and peripheral blood smear films were stained according to May-Grunwald-Giemsa method. Red blood cells morphology was examined for the presence of spur cells with Olympus BH2 microscope at × 100 magnification under oil immersion. Spur cells were recognized by the presence of multiple irregular thorny projections of variable length or width and counted manually as a percentage of total red blood cells. The peripheral blood samples were evaluated in duplicates by two different hematologists, and all clinical data were blinded to them. None of the duplicates had a variation higher than 4% in spur cell measurements. Average of two separate measurements was used for the final analysis. Following previous investigators,9,11 patients with spur-cell anemia were considered those exhibiting spur cell rate ≥ 5%. Patients with lower rates were considered as not having spur-cell hemolytic anemia. Direct antiglobulin test and hemoglobin electrophoresis for the presence of hemoglobinopathies were performed before including a patient in the study. No patients were found with abetalipoproteinemia or Wilson disease. Clinical data. Demographic and clinical data (such as age, gender, cause of liver cirrhosis), as well as laboratory parameters (hemoglobin value, reticulocyte and spur cell rate, iron overload markers, biochemical, lipid, and clotting profile) were recorded on admission. Based on these data, liver specific prognostic scores (MELD) were evaluated. All patients were followed-up until death or orthotopic liver transplantation. Statistical analysis. Statistical analysis was carried out using the Stata/SE 11.0 for Windows statistical package (Stata CorpLP Lakeway Drive College Station, Texas, USA). The characteristics of our patients were assessed using median accompanied by the interquartile range for continuous variables and count (percentage) for categorical variables. In order to test for differences in the univariate analysis between the patients with spur cell rate ≥ 5% compared to those with spur cell 0–4%, we used the Mann–Whitney test for continuous variables and chi-squared test for categorical variables. Survival rates were evaluated using the Kaplan–Meier estimator and were compared between groups by the log-rank test. Multivariate analysis was undertaken via Cox proportional hazards regression and involved factors which were associated with poor prognosis in the literature.12–14 Statistical significance within Cox model was tested using the Wald test. A two-tailed P-value less than 0.05 was considered statistically significant.
Spur-cells as predictor of mortality
Results Patient characteristics. In total, 116 consecutive patients with cirrhosis were included in our study. There were 89 (77%) males and 27 (23%) females, with median age 59 years (50–72) years. The cause of cirrhosis was chronic hepatitis B or C in 44 (37.9%), alcohol abuse in 40 (34.5%), and other in 32 (27.6%) of patients. In the later group, 16 patients had cyptogenic, five nonalcoholic steatohepatitis, three primary sclerosing cholangitis, three primary biliary cirrhosis, and five autoimmune hepatitis. The median MELD score on admission was 16 (11–22). Eighty patients had 0–4% spur cell rate. The presence of SC rate ≥ 5% was diagnosed in 36 (31%) patients (Table 1). Nineteen patients had SC rate between 5% and 25% and seventeen at ≥ 25%.
Follow-up. The median follow-up was 6.6 months (2–18.7). Patients with SC rate ≥ 5% were followed up for a median of 1.9 months (1.1–6.3) and those with 0–4% for a median of 9.2 months (3.2–26). Of the 116 patients, 67 (57.8%) died. Of 36 patients with spur cell rate ≥ 5%, 25 (69.4%) died.
Patients with SCA compared to those without SCA. Patients with SC rate ≥ 5% compared to those with 0–4% had more advanced liver disease (higher MELD 21.5 [15–25.5] vs 14 [10–20.5], respectively, P < 0.001), higher total bilirubin, (9.5 [5.2–14.2] vs 3.3 mg/dL [1.7–6.4], P < 0.001), and higher International Normalized Ratio (INR; 1.8 [1.6–2.3] vs 1.5 [1.3–1.8], P < 0.001). Hemolysis was more evident in the former group than the latter showing lower hemoglobin (8.9 [8.5–10.3] vs 10.3 g/dL [9–11.8], [P = 0.013]), higher corrected reticulocytes (4 [2.5–6] vs 3% [2–5], P = 0.05) and more iron overload as it was indicated by high ferritin (341 [138–1000] vs 199 μg/L [58–420], P = 0.015). There was no difference in age, total iron binding capacity levels, causes of liver disease, total cholesterol, Na, cholesterol fractions, triglyceride, creatinine, and albumin values (Table 1). The comparison of spur cell rate in patients with alcoholic cirrhosis versus the remaining etiologies did not demonstrate any difference. The proportions of patients with spur cell rate from ≥ 5% to < 25% or ≥ 25% were 44% or 56% in alcoholic cirrhosis and 50% or 50% in the remaining etiologies group (P = 0.7). Patients with SC rate ≥ 5% compared to those with 0–4% had a worse survival as it is shown in Kaplan–Mayer survival curve (log rank P < 0.001) (Fig. 1). In particular, the median survival of the former compared to the latter was 1.9 and 16 months, respectively. It is noteworthy that survival of patients with SC rate ≥ 5% at the first, second, and third month of follow-up was 77%, 45%, and 33%, respectively. Univariate Cox analysis showed that the variables exhibiting a significant association to mortality were MELD (P < 0.001), total bilirubin (P < 0.001), INR (P = 0.002), albumin (P = 0.025), creatinine (P = 0.001), Na (P < 0.001), and presence of spur cell rate ≥ 5% (P = 0.002) (Table 2). In multivariate Cox’s proportional hazards regression analysis, age (P = 0.001), MELD (P = 0.006), Na (P = 0.011), INR (P = 0.029), albumin (P = 0.006), and the presence of spur cells ≥ 5% (P < 0.001) were independently associated with mortality. After adjustment for age, gender, MELD, Na, total bilirubin, albumin, INR and creatinine,
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
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Table 1
A Alexopoulou et al.
Main and laboratory characteristics of cirrhotic patients overall, with spur cells 0–4% and spur cells higher or equal to 5%
Characteristic
Age (years) Sex (Male %) Etiology of liver disease Alcoholic (n, %) Viral (n, %) Other (n, %) MELD Na (mEq/L) Total bilirubin (mg/dL) INR Reticulocytes (%) Hemoglobin (g/dL) Ferritin (μg/L) TIBC (μg/dL) Cholesterol (mg/dL) LDL (mg/dL) HDL (mg/dL) VLDL (mg/dL) Triglycerides (mg/dL) Albumin (g/dL) Creatinine (mg/L)
All patients (n = 116)
Spur cells 0–4% (n = 80)
59 (50–72) 89 (76.7%)
62 (52–72) 57 (71%)
40 (34.5%) 44 (37.9%) 32 (27.6%) 16 (11–22) 133.5 (129–137) 4.3 (2.1–9.2) 1.6 (1.4–1.9) 3 (2–5) 9.7 (8.7–11) 231 (62–563) 250 (191–320) 105 (81–141) 73 (54–97) 17 (8–26) 16 (11–22) 78 (54–109) 3.2 (2.8–3.6) 0.9 (0.7–1.6)
24 (30%) 34 (42.5%) 22 (27.5%) 14 (10–20.5) 134 (129.5–138) 3.3 (1.7–6.4) 1.5 (1.3–1.8) 3 (1.5–4) 10.3 (9–11.8) 199 (58–420) 263 (200–348) 109 (81–146) 72 (47–100) 19 (10–28) 15 (11–22) 74 (55–108) 3.3 (2.9–3.7) 0.9 (0.7–1.4)
Spur cells ≥ 5% (n = 36)
P-value*
55 (49–65.5) 32 (89%)
0.064 0.038 0.232
16 (44.4%) 10 (27.8%) 10 (27.8%) 21.5 (15–25.5) 132 (129–136) 9.5 (5.2–14.2) 1.8 (1.6–2.3) 4 (2.5–6) 8.9 (8.5–10.3) 341 (138–1000) 248 (176–280) 99 (82–126) 75 (64–92) 11 (7–23) 16 (10–23) 81 (50–110) 3.2 (2.8–3.5) 1.1 (0.8–1.7)
< 0.001 0.104 < 0.001 < 0.001 0.050 0.013 0.015 0.065 0.512 0.612 0.063 0.866 0.816 0.314 0.210
*P-value was calculated using Mann–Whitney test for continuous variables and chi-squared test for categorical variables. Continuous variables are expressed as median (interquartile range) and categorical variables as frequency (percentage). HDL, high-density lipoprotein; INR, International Normalized Ratio; LDL, low-density lipoprotein; MELD, Model for End-Stage Liver Disease; VLDL, very low-density lipoprotein.
Discussion
Figure 1 Kaplan–Meier survival curves for patients with spur cells ≥ 5% and those with spur cells 0–4% (Log rank, P < 0.001). , spur cells = 0–4%; , spur cells = 5% or greater.
patients with spur cells ≥ 5% had a three times higher risk for death compared to those with spur cells 0–4% (hazard ratio [HR] = 3.17 [95% CI 1.55–6.48]). Taking 5% and 25% spur cell rates as thresholds, we divided the patients into three groups; (i) from 0 to < 5%, (ii) from ≥ 5% to < 25%, and (iii) ≥ 25%. According to the multivariate Cox’s regression analysis, after adjustment for age, gender, MELD, Na, total bilirubin, albumin, INR, and creatinine, patients with spur cells from ≥ 5% to < 25% had a similar risk for death to those with spur cells ≥ 25% (Table 3). 832
Hemolytic anemia due to spur cells or acanthocytes is an acquired disorder, causing severe anemia not responding to blood transfusions, since transfused erythrocytes quickly acquire the bizarre “spiky” shape of spur cells.4 Several investigators so far delineated SCA in the setting of alcoholic cirrhosis.15,16 However, we demonstrated that the cause of underlying liver disease is not necessarily alcoholic, but SCA may be evident in any cause of cirrhosis. A few years ago, Vassiliadis et al.9 also demonstrated that SCA may be present in liver disease regardless of etiology. It has been found that in SCA, red cell membrane is impaired due to abnormal ratio of cholesterol and phospholipids. This disturbance can be attributed to changes in high density lipoprotein and apolipoprotein A-II within the serum in patients with this disorder.17 We have demonstrated a trend to lower high-density lipoprotein (HDL) levels, probably reflecting low apolipoproteins in patients with SCA, but not significant differences in lipids, probably because of the presence of advanced liver disease in the vast majority of our patients. Previous investigators have found low lipid levels, including cholesterol apolipoprotein/A-1 and triglyceride levels, in advanced liver disease.18 High ferritin and low total iron-binding capacity, indicating iron accumulation, are evident in the current study. Short life span of both transfused and native red cells, enhanced intestinal absorption of iron in hemolysis and repeated blood transfusion may all contribute to increased iron storage.19 In our Center, we usually avoid transfusing patients with SCA, as transfusion has not got the desired effect, yet there may be circumstances when transfusion is inevitable.
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
A Alexopoulou et al.
Table 2
Spur-cells as predictor of mortality
Hazard ratios (HR) for death according to mortality risk factors. Crude and fully adjusted values by the use of Cox’s regression analysis
Factor
Crude HR (95% CI)
P-value
Fully adjusted† HR (95% CI)
P-value
Age Sex MELD (per 5 units increment) Na (mEq/L) Total bilirubin (per 5 units increment) INR (per 1 unit increment) Albumin Creatinine Hemoglobin Spur cells (≥ 5% vs 0–4%)
1.01 (0.99–1.03) 1.07 (0.62–1.86) 1.43 (1.24–1.64) 0.92 (0.90–0.95) 1.25 (1.11–1.41) 1.67 (1.21–2.30) 0.64 (0.43–0.94) 1.41 (1.15–1.73) 0.91 (0.81–1.03) 2.59 (1.55–4.32)
0.182 0.809 < 0.001 < 0.001 < 0.001 0.002 0.025 0.001 0.137 < 0.001
1.04 (1.02–1.07) 1.71 (0.91–3.25) 1.70 (1.16–2.48) 0.92 (0.86–0.98) 1.07 (0.85–1.34) 0.43 (0.20–0.92) 0.49 (0.29–0.81) 0.91 (0.62–1.32) 1.02 (0.87–1.19) 3.17 (1.55–6.48)
0.001 0.098 0.006 0.011 0.586 0.029 0.006 0.663 0.804 0.002
†
All factors included in the first column of Table 2 are mutually adjusted in the fully adjusted model. INR, International Normalized Ratio; MELD, Model for End-Stage Liver Disease; Na, sodium.
Table 3
Hazard ratios (HR) for death according to spur cell rates. Crude and fully adjusted values by the use of Cox’s regression analysis Crude HR (95% CI)
Spur cells 0–4% ≥ 5% and < 25% ≥ 25% †
Reference 2.42 (1.27–4.63) 2.78 (1.44–5.36)
P-value
0.007 0.002
Fully adjusted† HR (95% CI)
Reference 3.20 (1.45–7.04) 3.09 (1.05–9.07)
P-value
0.004 0.040
All factors included in the first column of Table 2 are mutually adjusted in the fully adjusted model.
In SCA, hemolysis arises of not only abnormal red cell shape and reduced flexibility but also hypersplenism and destruction of acanthocytes within the spleen. The bizarre shape is not enough for hemolysis, given that spur cells are observed in abetalipoproteinemia, yet hemolysis does not occur.20 Advanced liver disease appears to accelerate this process, rendering SCA an important marker of poor prognosis. We actually found that SCA is usually present in advanced cirrhosis as the vast majority of our patients with SCA had high MELD scores. SCA is an insufficiently studied entity and its clinical importance has not been documented. There have been a few reports on survival for several decades.9,10,15,16,21 A recent study about survival in patients with SCA included only nine patients with spur cell rate higher or equal to 5%.9 In addition, in the same study, the exact impact of SCA as an independent risk factor of survival was not determined since no further statistical analysis was used. In that study, seven out of nine patients with spur cell rate higher or equal to 5% died within 3 months, and all nine patients died or transplanted in the first year of follow-up. In the present study, the two thirds of 36 patients with spur cell rate higher or equal to 5% died within 3 months. No patient transplanted due to shortage of liver transplants. The presence of spur cell rate higher or equal to 5% is a strong independent predictor of mortality and merits further investigation as a prognostic indicator in patients awaiting liver transplantation. In addition, the risk of mortality associated with the severity of SCA has been independently analyzed. It was demonstrated that the mortality risk remained the same with increasing spur cell rate. The finding strengthens the spur cell threshold of 5% as an independent predictor of mortality.
Certainly, the study was not designed to estimate the prevalence of spur cell anemia in cirrhosis. However, it seems that the disorder is not uncommon in advanced liver disease. Thus, it can be used as an ancillary marker in combination with MELD for the prognosis of liver disease, particularly in liver transplantation candidates. In conclusion, spur cell hemolytic anemia may be present in a subset of patients with advanced liver disease and is associated with iron overload. It is an ominous disorder in cirrhotic patients indicating poor prognosis. Spur cell anemia should be considered as a surrogate marker for liver transplantation.
References 1 Arienti G, Carlini E, Scionti L, Puxeddu E, Brunetti P. Liver alcoholic cirrhosis and spur-cell (acanthocytic) anemia. A study of erythrocyte ghost composition and fluidity. Scand. J. Gastroenterol. 1995; 30: 1204–9. 2 Cooper RA, Diloy Puray M, Lando P, Greenverg MS. An analysis of lipoproteins, bile acids, and red cell membranes associated with target cells and spur cells in patients with liver disease. J. Clin. Invest. 1972; 51: 3182–92. 3 Cooper RA, Kimball DB, Durocher JR. Role of the spleen in membrane conditioning and hemolysis of spur cells in liver disease. N. Engl. J. Med. 1974; 290: 1279–84. 4 Allen DW, Manning N. Cholesterol-loading of membranes of normal erythrocytes inhibits phospholipid repair and arachidonoyl-CoA:1-palmitoyl-sn-glycero-3-phosphocholine acyl transferase. A model of spur cell anemia. Blood 1996; 87: 3489–93. 5 Malik P, Bogetti D, Sileri P et al. Spur cell anemia in alcoholic cirrhosis: cure by orthotopic liver transplantation and recurrence after liver graft failure. Int. Surg. 2002; 87: 201–4.
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6 Thomson A, Kerlin P, Clouston A, Cobcroft R. Spur cell anemia resolves after orthotopic liver transplantation (OLT). Aust. N. Z. J. Med. 1997; 27: 198–9. 7 Chitale AA, Sterling RK, Post AB, Silver BJ, Mulligan DC, Schulak JA. Resolution of spur cell anemia with liver transplantation: a case report and review of the literature. Transplantation 1998; 65: 993–5. 8 Sundaram V, Al-Osaimi AM, Lewis JJ, Lisman T, Caldwell SH. Severe prolongation of the INR in spur cell anemia of cirrhosis: true-true and related? Dig. Dis. Sci. 2006; 51: 1203–5. 9 Vassiliadis T, Mpoumponaris A, Vakalopoulou S et al. Spur cells and spur cell anemia in hospitalized patients with advanced liver disease: incidence and correlation with disease severity and survival. Hepatol. Res. 2010; 40: 161–70. 10 Ricard MP, Martínez ML, Ruiz J. Spur cell hemolytic anemia of severe liver disease. Haematologica 1999; 84: 654. 11 Sousa JM, Giraldez A, De Blas JM et al. Spur cell anemia in hepatic cirrhosis: incidence, prognosis and reversibility after liver transplantation [Abstract]. J. Hepatol. 2002; 36 (Suppl.) 64A. 12 Kamath PS, Wiesner RH, Malinchoc M et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464–70. 13 Biggins SW, Rodriguez HJ, Bacchetti P, Bass NM, Roberts JP, Terrault NA. Serum sodium predicts mortality in patients listed for liver transplantation. Hepatology 2005; 41: 32–9.
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14 Zoli M, Cordiani MR, Marchesini G et al. Prognostic indicators in compensated cirrhosis. Am. J. Gastroenterol. 1991; 86: 1508–13. 15 Doll DC, Doll NJ. Spur cell anemia. South. Med. J. 1982; 75: 1205–10. 16 Haruta I, Hashimoto E, Kabutake A, Taniai M, Tokushige K, Shiratori K. Spur cell anemia associated with a cirrhotic non-alcoholic steatohepatitis patient. Hepatol. Res. 2007; 37: 482–5. 17 Duhamel G, Forgez P, Nalpas B, Berthelot P, Chapman MJ. Spur cells in patients with alcoholic liver cirrhosis are associated with reduced plasma levels of apoA-II, HDL3, and LDL. J. Lipid Res. 1983; 24: 1612–25. 18 Tietge UJ, Boker KH, Bahr MJ et al. Lipid parameters predicting liver function in patients with cirrhosis and after liver transplantation. Hepatogastroenterology 1998; 45: 2255–60. 19 Pascoe A, Kerlin P, Jones D. Spur cell anemia explains the iron overload in advanced cirrhosis (C282Y negative). Hepatology 2000; 32: 159. 20 Cooper RA, Durocher JR, Leslie MH. Decreased fluidity of red cell membrane lipids in abetalipoproteinemia. J. Clin. Invest. 1977; 60: 115–21. 21 Martin M, Lesesve JF. Transfusion medicine illustrated. Spur cell anemia associated with primary biliary cirrhosis. Transfusion 2013; 53: 260.
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
doi:10.1111/jgh.12473
H E PAT O L O G Y
Presence of spur cells as a highly predictive factor of mortality in patients with cirrhosis Alexandra Alexopoulou, Larisa Vasilieva, Theoni Kanellopoulou, Sophia Pouriki, Aspasia Soultati, Spyridon P Dourakis 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece
Key words cirrhosis, risk factor, spur cell anemia, survival. Accepted for publication 20 November 2013. Correspondence Dr Alexandra Alexopoulou, 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, 40 Konstantinoupoleos Street, Hilioupolis, Athens 16342, Greece. Email: [email protected]
Abstract Background and Aim: The presence of spur-cell anemia (SCA) is due to lipid disturbances of the erythrocyte membrane and may develop in patients with advanced liver cirrhosis. The accurate predicting value of SC for survival has not been clarified. The aim of this study was to evaluate SCA as a prognostic indicator in patients with cirrhosis. Methods: We prospectively evaluated clinical, laboratory parameters, and survival in patients with cirrhosis, with or without SCA, during the period 2008–2011. Patients who had at admission renal failure, other causes of hemolytic anemia, hepatocellular carcinoma, sepsis, and/or active bleeding, were excluded. One hundred sixteen patients with cirrhosis were included. The presence of SCA (SC rate higher or equal to 5% [≥ 5%]) was diagnosed in 36 (31%) patients. Results: Patients with SCA compared to those without had more advanced liver disease (higher Model for End-Stage Liver Disease [MELD], P < 0.001), higher total bilirubin (P < 0.001), and International Normalized Ratio (P < 0.001). Patients with SCA had worse survival (log rank P < 0.001). Survival of patients with SCA at the first, second, and third month of follow-up was 77%, 45%, and 33%, respectively. In multivariate Cox’s regression analysis, the presence of SCA was an independent predictor of mortality (hazard ratio = 3.17 [95% CI 1.55–6.48]). Conclusions: The presence of spur-cell anemia is not uncommon in cirrhosis and seems to be strongly associated with mortality. SCA can be used in combination with MELD as an additional predictor of early mortality.
Introduction
Material and methods
Spur-cells are acanthocytes with morphological abnormalities due to the increase of cholesterol to protein and cholesterol to phospholipid ratios in the red cell membrane.1 Their spike-like projections deform their shape and flexibility, making them susceptible to trapping and destruction by the spleen.2,3 Normal red blood cells, transfused into patients with spur-cell hemolytic anemia (SCA), acquire the spur cell irregular shape and therefore have a short survival.4 Spur-cell morphological abnormality is reversible in a non-cirrhotic microenvironment and is resolved after liver transplantation.5–7 The presence of SCA in liver cirrhosis has been associated with advanced disease8 and poor prognosis.9,10 Nevertheless, the exact impact of the presence of SCA on mortality is poorly documented. The aim of this prospective study is to investigate (i) whether the presence of SCA is related to severity and etiology of liver disease and (ii) to clarify the accurate impact of the presence of SC on predicting survival in patients with cirrhosis.
Study population. All patients with cirrhosis admitted to the 2nd Department of Internal Medicine of Hippokration General Hospital from 2008 to 2011 were included in the study, unless they satisfied an exclusion criterion. In particular, patients with renal failure, other causes of hemolytic anemia, hepatocellular carcinoma, sepsis, and/or active bleeding were excluded. Patients with either acute alcoholic hepatitis or recent alcohol abuse were not included in the study. Some of the previously excluded patients might be enrolled later after resolution of renal failure, sepsis, or active bleeding episodes. Twenty seven patients were enrolled in the study at least 1 month after resolution of the acute episode mentioned above. The presence of spur cells and the Model for EndStage Liver Disease (MELD) calculation were done at enrollment. Admission etiologies of patients who were enrolled in the study were as follows: “Severe anemia—decompensated liver cirrhosis,” “Refractory ascites,” “Therapeutic paracentecis of ascites” and “Decompensated liver cirrhosis.”
830
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
A Alexopoulou et al.
For the diagnosis of cirrhosis, we used liver histological and/or imaging methods as well as endoscopic or clinical findings. Cirrhosis is considered to be decompensated in patients with history of ascites, variceal bleeding, hepatic encephalopathy, and jaundice of non-obstructive cause (bilirubin > 3 mg/dL for non-cholestatic and > 10 mg/dL for cholestatic causes of cirrhosis). The study protocol was approved by the Hospital Ethical Committee. All patients signed a written informed consent before their inclusion in the study. Hematological parameters and spur cell anemia diagnosis. Complete blood count and reticulocyte measurement was analyzed by using ADVIA 2120 hematology system (Siemens Healthcare Diagnostics), and peripheral blood smear films were stained according to May-Grunwald-Giemsa method. Red blood cells morphology was examined for the presence of spur cells with Olympus BH2 microscope at × 100 magnification under oil immersion. Spur cells were recognized by the presence of multiple irregular thorny projections of variable length or width and counted manually as a percentage of total red blood cells. The peripheral blood samples were evaluated in duplicates by two different hematologists, and all clinical data were blinded to them. None of the duplicates had a variation higher than 4% in spur cell measurements. Average of two separate measurements was used for the final analysis. Following previous investigators,9,11 patients with spur-cell anemia were considered those exhibiting spur cell rate ≥ 5%. Patients with lower rates were considered as not having spur-cell hemolytic anemia. Direct antiglobulin test and hemoglobin electrophoresis for the presence of hemoglobinopathies were performed before including a patient in the study. No patients were found with abetalipoproteinemia or Wilson disease. Clinical data. Demographic and clinical data (such as age, gender, cause of liver cirrhosis), as well as laboratory parameters (hemoglobin value, reticulocyte and spur cell rate, iron overload markers, biochemical, lipid, and clotting profile) were recorded on admission. Based on these data, liver specific prognostic scores (MELD) were evaluated. All patients were followed-up until death or orthotopic liver transplantation. Statistical analysis. Statistical analysis was carried out using the Stata/SE 11.0 for Windows statistical package (Stata CorpLP Lakeway Drive College Station, Texas, USA). The characteristics of our patients were assessed using median accompanied by the interquartile range for continuous variables and count (percentage) for categorical variables. In order to test for differences in the univariate analysis between the patients with spur cell rate ≥ 5% compared to those with spur cell 0–4%, we used the Mann–Whitney test for continuous variables and chi-squared test for categorical variables. Survival rates were evaluated using the Kaplan–Meier estimator and were compared between groups by the log-rank test. Multivariate analysis was undertaken via Cox proportional hazards regression and involved factors which were associated with poor prognosis in the literature.12–14 Statistical significance within Cox model was tested using the Wald test. A two-tailed P-value less than 0.05 was considered statistically significant.
Spur-cells as predictor of mortality
Results Patient characteristics. In total, 116 consecutive patients with cirrhosis were included in our study. There were 89 (77%) males and 27 (23%) females, with median age 59 years (50–72) years. The cause of cirrhosis was chronic hepatitis B or C in 44 (37.9%), alcohol abuse in 40 (34.5%), and other in 32 (27.6%) of patients. In the later group, 16 patients had cyptogenic, five nonalcoholic steatohepatitis, three primary sclerosing cholangitis, three primary biliary cirrhosis, and five autoimmune hepatitis. The median MELD score on admission was 16 (11–22). Eighty patients had 0–4% spur cell rate. The presence of SC rate ≥ 5% was diagnosed in 36 (31%) patients (Table 1). Nineteen patients had SC rate between 5% and 25% and seventeen at ≥ 25%.
Follow-up. The median follow-up was 6.6 months (2–18.7). Patients with SC rate ≥ 5% were followed up for a median of 1.9 months (1.1–6.3) and those with 0–4% for a median of 9.2 months (3.2–26). Of the 116 patients, 67 (57.8%) died. Of 36 patients with spur cell rate ≥ 5%, 25 (69.4%) died.
Patients with SCA compared to those without SCA. Patients with SC rate ≥ 5% compared to those with 0–4% had more advanced liver disease (higher MELD 21.5 [15–25.5] vs 14 [10–20.5], respectively, P < 0.001), higher total bilirubin, (9.5 [5.2–14.2] vs 3.3 mg/dL [1.7–6.4], P < 0.001), and higher International Normalized Ratio (INR; 1.8 [1.6–2.3] vs 1.5 [1.3–1.8], P < 0.001). Hemolysis was more evident in the former group than the latter showing lower hemoglobin (8.9 [8.5–10.3] vs 10.3 g/dL [9–11.8], [P = 0.013]), higher corrected reticulocytes (4 [2.5–6] vs 3% [2–5], P = 0.05) and more iron overload as it was indicated by high ferritin (341 [138–1000] vs 199 μg/L [58–420], P = 0.015). There was no difference in age, total iron binding capacity levels, causes of liver disease, total cholesterol, Na, cholesterol fractions, triglyceride, creatinine, and albumin values (Table 1). The comparison of spur cell rate in patients with alcoholic cirrhosis versus the remaining etiologies did not demonstrate any difference. The proportions of patients with spur cell rate from ≥ 5% to < 25% or ≥ 25% were 44% or 56% in alcoholic cirrhosis and 50% or 50% in the remaining etiologies group (P = 0.7). Patients with SC rate ≥ 5% compared to those with 0–4% had a worse survival as it is shown in Kaplan–Mayer survival curve (log rank P < 0.001) (Fig. 1). In particular, the median survival of the former compared to the latter was 1.9 and 16 months, respectively. It is noteworthy that survival of patients with SC rate ≥ 5% at the first, second, and third month of follow-up was 77%, 45%, and 33%, respectively. Univariate Cox analysis showed that the variables exhibiting a significant association to mortality were MELD (P < 0.001), total bilirubin (P < 0.001), INR (P = 0.002), albumin (P = 0.025), creatinine (P = 0.001), Na (P < 0.001), and presence of spur cell rate ≥ 5% (P = 0.002) (Table 2). In multivariate Cox’s proportional hazards regression analysis, age (P = 0.001), MELD (P = 0.006), Na (P = 0.011), INR (P = 0.029), albumin (P = 0.006), and the presence of spur cells ≥ 5% (P < 0.001) were independently associated with mortality. After adjustment for age, gender, MELD, Na, total bilirubin, albumin, INR and creatinine,
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
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Table 1
A Alexopoulou et al.
Main and laboratory characteristics of cirrhotic patients overall, with spur cells 0–4% and spur cells higher or equal to 5%
Characteristic
Age (years) Sex (Male %) Etiology of liver disease Alcoholic (n, %) Viral (n, %) Other (n, %) MELD Na (mEq/L) Total bilirubin (mg/dL) INR Reticulocytes (%) Hemoglobin (g/dL) Ferritin (μg/L) TIBC (μg/dL) Cholesterol (mg/dL) LDL (mg/dL) HDL (mg/dL) VLDL (mg/dL) Triglycerides (mg/dL) Albumin (g/dL) Creatinine (mg/L)
All patients (n = 116)
Spur cells 0–4% (n = 80)
59 (50–72) 89 (76.7%)
62 (52–72) 57 (71%)
40 (34.5%) 44 (37.9%) 32 (27.6%) 16 (11–22) 133.5 (129–137) 4.3 (2.1–9.2) 1.6 (1.4–1.9) 3 (2–5) 9.7 (8.7–11) 231 (62–563) 250 (191–320) 105 (81–141) 73 (54–97) 17 (8–26) 16 (11–22) 78 (54–109) 3.2 (2.8–3.6) 0.9 (0.7–1.6)
24 (30%) 34 (42.5%) 22 (27.5%) 14 (10–20.5) 134 (129.5–138) 3.3 (1.7–6.4) 1.5 (1.3–1.8) 3 (1.5–4) 10.3 (9–11.8) 199 (58–420) 263 (200–348) 109 (81–146) 72 (47–100) 19 (10–28) 15 (11–22) 74 (55–108) 3.3 (2.9–3.7) 0.9 (0.7–1.4)
Spur cells ≥ 5% (n = 36)
P-value*
55 (49–65.5) 32 (89%)
0.064 0.038 0.232
16 (44.4%) 10 (27.8%) 10 (27.8%) 21.5 (15–25.5) 132 (129–136) 9.5 (5.2–14.2) 1.8 (1.6–2.3) 4 (2.5–6) 8.9 (8.5–10.3) 341 (138–1000) 248 (176–280) 99 (82–126) 75 (64–92) 11 (7–23) 16 (10–23) 81 (50–110) 3.2 (2.8–3.5) 1.1 (0.8–1.7)
< 0.001 0.104 < 0.001 < 0.001 0.050 0.013 0.015 0.065 0.512 0.612 0.063 0.866 0.816 0.314 0.210
*P-value was calculated using Mann–Whitney test for continuous variables and chi-squared test for categorical variables. Continuous variables are expressed as median (interquartile range) and categorical variables as frequency (percentage). HDL, high-density lipoprotein; INR, International Normalized Ratio; LDL, low-density lipoprotein; MELD, Model for End-Stage Liver Disease; VLDL, very low-density lipoprotein.
Discussion
Figure 1 Kaplan–Meier survival curves for patients with spur cells ≥ 5% and those with spur cells 0–4% (Log rank, P < 0.001). , spur cells = 0–4%; , spur cells = 5% or greater.
patients with spur cells ≥ 5% had a three times higher risk for death compared to those with spur cells 0–4% (hazard ratio [HR] = 3.17 [95% CI 1.55–6.48]). Taking 5% and 25% spur cell rates as thresholds, we divided the patients into three groups; (i) from 0 to < 5%, (ii) from ≥ 5% to < 25%, and (iii) ≥ 25%. According to the multivariate Cox’s regression analysis, after adjustment for age, gender, MELD, Na, total bilirubin, albumin, INR, and creatinine, patients with spur cells from ≥ 5% to < 25% had a similar risk for death to those with spur cells ≥ 25% (Table 3). 832
Hemolytic anemia due to spur cells or acanthocytes is an acquired disorder, causing severe anemia not responding to blood transfusions, since transfused erythrocytes quickly acquire the bizarre “spiky” shape of spur cells.4 Several investigators so far delineated SCA in the setting of alcoholic cirrhosis.15,16 However, we demonstrated that the cause of underlying liver disease is not necessarily alcoholic, but SCA may be evident in any cause of cirrhosis. A few years ago, Vassiliadis et al.9 also demonstrated that SCA may be present in liver disease regardless of etiology. It has been found that in SCA, red cell membrane is impaired due to abnormal ratio of cholesterol and phospholipids. This disturbance can be attributed to changes in high density lipoprotein and apolipoprotein A-II within the serum in patients with this disorder.17 We have demonstrated a trend to lower high-density lipoprotein (HDL) levels, probably reflecting low apolipoproteins in patients with SCA, but not significant differences in lipids, probably because of the presence of advanced liver disease in the vast majority of our patients. Previous investigators have found low lipid levels, including cholesterol apolipoprotein/A-1 and triglyceride levels, in advanced liver disease.18 High ferritin and low total iron-binding capacity, indicating iron accumulation, are evident in the current study. Short life span of both transfused and native red cells, enhanced intestinal absorption of iron in hemolysis and repeated blood transfusion may all contribute to increased iron storage.19 In our Center, we usually avoid transfusing patients with SCA, as transfusion has not got the desired effect, yet there may be circumstances when transfusion is inevitable.
Journal of Gastroenterology and Hepatology 29 (2014) 830–834 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
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Table 2
Spur-cells as predictor of mortality
Hazard ratios (HR) for death according to mortality risk factors. Crude and fully adjusted values by the use of Cox’s regression analysis
Factor
Crude HR (95% CI)
P-value
Fully adjusted† HR (95% CI)
P-value
Age Sex MELD (per 5 units increment) Na (mEq/L) Total bilirubin (per 5 units increment) INR (per 1 unit increment) Albumin Creatinine Hemoglobin Spur cells (≥ 5% vs 0–4%)
1.01 (0.99–1.03) 1.07 (0.62–1.86) 1.43 (1.24–1.64) 0.92 (0.90–0.95) 1.25 (1.11–1.41) 1.67 (1.21–2.30) 0.64 (0.43–0.94) 1.41 (1.15–1.73) 0.91 (0.81–1.03) 2.59 (1.55–4.32)
0.182 0.809 < 0.001 < 0.001 < 0.001 0.002 0.025 0.001 0.137 < 0.001
1.04 (1.02–1.07) 1.71 (0.91–3.25) 1.70 (1.16–2.48) 0.92 (0.86–0.98) 1.07 (0.85–1.34) 0.43 (0.20–0.92) 0.49 (0.29–0.81) 0.91 (0.62–1.32) 1.02 (0.87–1.19) 3.17 (1.55–6.48)
0.001 0.098 0.006 0.011 0.586 0.029 0.006 0.663 0.804 0.002
†
All factors included in the first column of Table 2 are mutually adjusted in the fully adjusted model. INR, International Normalized Ratio; MELD, Model for End-Stage Liver Disease; Na, sodium.
Table 3
Hazard ratios (HR) for death according to spur cell rates. Crude and fully adjusted values by the use of Cox’s regression analysis Crude HR (95% CI)
Spur cells 0–4% ≥ 5% and < 25% ≥ 25% †
Reference 2.42 (1.27–4.63) 2.78 (1.44–5.36)
P-value
0.007 0.002
Fully adjusted† HR (95% CI)
Reference 3.20 (1.45–7.04) 3.09 (1.05–9.07)
P-value
0.004 0.040
All factors included in the first column of Table 2 are mutually adjusted in the fully adjusted model.
In SCA, hemolysis arises of not only abnormal red cell shape and reduced flexibility but also hypersplenism and destruction of acanthocytes within the spleen. The bizarre shape is not enough for hemolysis, given that spur cells are observed in abetalipoproteinemia, yet hemolysis does not occur.20 Advanced liver disease appears to accelerate this process, rendering SCA an important marker of poor prognosis. We actually found that SCA is usually present in advanced cirrhosis as the vast majority of our patients with SCA had high MELD scores. SCA is an insufficiently studied entity and its clinical importance has not been documented. There have been a few reports on survival for several decades.9,10,15,16,21 A recent study about survival in patients with SCA included only nine patients with spur cell rate higher or equal to 5%.9 In addition, in the same study, the exact impact of SCA as an independent risk factor of survival was not determined since no further statistical analysis was used. In that study, seven out of nine patients with spur cell rate higher or equal to 5% died within 3 months, and all nine patients died or transplanted in the first year of follow-up. In the present study, the two thirds of 36 patients with spur cell rate higher or equal to 5% died within 3 months. No patient transplanted due to shortage of liver transplants. The presence of spur cell rate higher or equal to 5% is a strong independent predictor of mortality and merits further investigation as a prognostic indicator in patients awaiting liver transplantation. In addition, the risk of mortality associated with the severity of SCA has been independently analyzed. It was demonstrated that the mortality risk remained the same with increasing spur cell rate. The finding strengthens the spur cell threshold of 5% as an independent predictor of mortality.
Certainly, the study was not designed to estimate the prevalence of spur cell anemia in cirrhosis. However, it seems that the disorder is not uncommon in advanced liver disease. Thus, it can be used as an ancillary marker in combination with MELD for the prognosis of liver disease, particularly in liver transplantation candidates. In conclusion, spur cell hemolytic anemia may be present in a subset of patients with advanced liver disease and is associated with iron overload. It is an ominous disorder in cirrhotic patients indicating poor prognosis. Spur cell anemia should be considered as a surrogate marker for liver transplantation.
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