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Anemia Is a Major Determinant of Fatigue in Patients with Cirrhosis

Fatigue is a common complaint among patients with cirrhosis with many possible contributing factors, including severity of liver disease, anemia, and cardiopulmonary complications. In this study, researchers determined the relationship between fatigue and quality of life in cirrhotic patients and the factors that contribute to fatigue.

One hundred ambulatory cirrhotic patients attending a liver transplant clinic underwent a comprehensive clinical evaluation for severity of liver disease, anemia (Hemoglobin (Hgb) < 11 gm/dl) and the presence of cardiopulmonary disease. Patients with renal failure were excluded.

Fatigue was assessed with the Fisk Fatigue Severity Scale (FFSS) and the 6-Minute Walk Test (6MWT), a standardized exercise test that measures distance walked in 6 minutes. Quality of life (QOL) was assessed with the NIDDK-QA.

Severity of fatigue was correlated with quality of life scores. Multivariate analyses were performed to identify independent factors associated with fatigue and poor performance on the 6MWT. Then the additional influence of anemia was tested for each.


Fatigue was a common complaint. Mean FFSS was 60.2 ± 40.8 (range 0 to 158), and 6MWT was 266 ± 99 m (range 50 to 450). Increased FFSS was correlated with impaired 6MWT (r = -0.46; p < 0.0001). Mean QOL score was 129.9 ± 41.8 (range 35.6 to 213.9). Increased fatigue score correlated with poor quality of life (r = -0.79; p < 0.0001).

Mean Hgb level was 12.4 ± 2.0 gm/dl (range 7.3 to 16.5), and 34 patients were anemic. After controlling for age (p < 0.0019), ascites (p < 0.0389), BMI (p < 0.0093), 02 Sat (p < 0.0093) and MELD (p < 0.0205) anemia significantly reduced exercise tolerance expressed as distance walked on 6MWT (p < 0.0006).

Anemia was also associated with severe fatigue on the FFSS (p < 0.06) after controlling for ascites (p < 0.0217), 02 saturation (p < 0.0402) and encephalopathy grade (p < 0.0193).


  • Severe fatigue as assessed by FFSS and 6MWT is common in cirrhotic patients, and high fatigue scores are associated with poor quality of life.
  • Factors associated with increased fatigue include anemia, ascites, low resting oxygen saturation, MELD score > 20, and symptomatic hepatic encephalopathy
  • Demonstration that human recombinant erythropoietin therapy improves the anemia of cirrhotic patients will have important therapeutic implications.

N Kontorinis and others. Anemia Is a Major Determinant of Fatigue in Patients with Cirrhosis. Abstract 1274 (poster). Digestive Disease Week 2004. May 15-20. New Orleans, LA.


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