title: Spur cells and spur cell anemia in hospitalized patients with advanced liver disease: Incidence and correlation with disease severity and survival.
abstract: OBJECTIVE
  Spur cell anemia (SCA) is a form of acquired hemolytic anemia seen in patients with advanced cirrhosis and particularly in patients with alcoholic cirrhosis. The aim of the present study was to evaluate the incidence of spur cells and spur cell anemia in patients with advanced liver disease and to correlate the presence of spur cell anemia with survival.
  
  
  METHODS
  During a 33-month period, all patients with advanced cirrhosis (Child-Pugh-Turcott score [CPT]>/=7] who were hospitalized in our department for various reasons were included in this study.
  
  
  RESULTS
  A total of 54 patients were included in the study; 26 patients had spur cells on peripheral blood smear (median 4, range 1-14). Patients with spur cells had more advanced liver disease compared with those without spur cells (CPT score, P < 0.0001 and MELD score, P < 0.0001), lower hemoglobin levels (P < 0.0001), higher bilirubin levels (total/unconjugated, P < 0.0001), higher reticulocyte count (P < 0.0001) and more prolonged international normalized ratio (INR; P < 0.0001). Patients with 5% spur cells or more had more advanced disease compared with patients with 1-4% spur cells (CPT score, P = 0.004 and MELD score, P = 0.003), lower hemoglobin levels (P = 0.033), more elevated bilirubin levels (total/unconjugated, P = 0.006) and more prolonged INR (P = 0.04). Three-month survival was lower in patients with spur cells compared with patients without spur cells (P = 0.017 and P = 0.104, respectively). Patients with 5% spur cells or more had lower 3-month survival compared with those with 1-4% spur cells (P = 0.014).
  
  
  CONCLUSIONS
  Presence of spur cells in patients with advanced cirrhosis is not always accompanied by spur cell anemia. The presence of 5% spur cells or more and/or hemolytic anemia is associated with poor prognosis and these patients might have to be given priority for liver transplantation.
authors.affiliation: Gastroenterology and Hepatology Division, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
authors.forename: Themistoklis
authors.initials: T
authors.lastname: Vassiliadis
authors.forename: Alexander
authors.initials: A
authors.lastname: Mpoumponaris
authors.forename: Sofia
authors.initials: S
authors.lastname: Vakalopoulou
authors.forename: Olga
authors.initials: O
authors.lastname: Giouleme
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Gkissakis
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Grammatikos
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Soufleris
authors.forename: Anna
authors.initials: A
authors.lastname: Kakafika
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Tziomalos
authors.forename: Kaliopi
authors.initials: K
authors.lastname: Patsiaoura
authors.forename: Vassilios
authors.initials: V
authors.lastname: Papanikolaou
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Evgenidis