Let's talk about cytopenias in cirrhosis. Many patients with cirrhosis will have at least one cytopenia (sometimes pancytopenia) attributable to their liver disease, let's talk about some of the mechanisms! #medtwitter #hemetwitter

First up, thrombocytopenia! The potential mechanisms are laid out in the image below ( https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/cld.860):
- decreased thrombopoietin production
- sequestration
- alcohol/viral causes suppressing marrow
- peripheral destruction

Next up, anemia! The ddx should include the causes we think of in all anemia patients (nutritional, GI losses, hemolysis etc...) but what are some liver-specific etiologies? Spur-cell anemia ( https://ashpublications.org/blood/article/118/16/4304/28830/Reversibility-of-spur-cell-anemia) typically only reverses w/ transplant

Anemia cont. Zieve syndrome is the triad of jaundice, hyperlipidemia, and hemolytic anemia that can be seen with alcoholic liver dz particularly after alcohol withdrawal ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708965/). Hepatitis-associated aplastic anemia has been described as well

And now for leukopenia! This seems to be the least understood of the cytopenias linked to liver disease. We commonly invoke sequestration, alterations in G-CSF, and toxins (EtOH, viral causes of liver disease). The image below summarizes these ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721814/)

One rarer etiology to consider that can link together hepatic decompensation and cytopenias is PNH causing Budd-Chiari syndrome

Would love to hear about other drivers of cytopenias in chronic liver disease/cirrhosis that should be considered! @DxRxEdu @rabihmgeha @MaureenWhitsett @ebtapper @Bloodman

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