A patient with severe liver disease may develop a hemolytic anemia associated with spur cells in the peripheral blood. This finding is typically associated with a poor prognosis.


Spur cells are erythrocytes with an abnormal spiculated shape (acanthocytes) associated with an excess of cholesterol relative to phospholipids in their membranes. This results in decreased deformability and shortened survival.



(1) presence of spur cells in a patient with severe liver disease

(2) hemolytic anemia with increased total bilirubin


While the diagnosis is more certain if other causes of anemia are excluded, all too often a patient with end-stage liver disease will have multiple conditions occurring at the same time.


Differential diagnosis:

(1) hemolytic anemia associated with DIC

(2) hemolytic anemia associated with heavy alcohol use (Zieve Syndrome)

(3) megaloblastic anemia

(4) gastrointestinal hemorrhage

(5) hypersplenism

(6) bone marrow depression


The anemia often disappears following liver transplant.


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