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Background and objective: Anemia is a frequent complication of liver cirrhosis and has been associated with worsening outcomes and other sequelae of hepatic dysfunction. Its pathophysiology is multifactorial, with gastrointestinal bleeding, splenomegaly-related hypersplenism, and nutritional deficiencies among the principal contributors to clinically significant anemia. Transjugular intrahepatic portosystemic shunt (TIPS) implantation has been reported to ameliorate anemia (PMID: 35301618); however, the mechanisms underlying this effect remain incompletely understood.

Method: We enrolled 344 patients with liver cirrhosis who underwent TIPS implantation between 2010 and 2024. Hemoglobin levels were compared before and 30 and 120 days after TIPS. To explore potential mechanistic changes, erythropoietin levels, reticulocyte counts, spleen length, and haptoglobin were assessed at baseline and after TIPS in a predefined subcohort.

Result: TIPS implantation was associated with a significant improvement in anemia severity, with the greatest benefit observed in patients with baseline hemoglobin <8 g/dL. Importantly, evidence of hematopoietic recovery was seen irrespective of pre-procedural hemoglobin, reflected by increased erythropoietin levels and higher reticulocyte counts. In patients with higher baseline hemoglobin (>10 g/dL), the overall effect on hemoglobin was less pronounced. This pattern may, at least in part, reflect shunt-associated hemolysis, as suggested by concomitant changes in hemolysis-related parameters. Reduced hypersplenism following TIPS placement may contribute to these hematologic changes.

Summary: TIPS placement was associated with improvement in anemia among patients with cirrhosis, with the most pronounced benefit observed in those with severe baseline anemia. The concomitant increases in erythropoietin levels and reticulocyte counts suggest enhanced hematopoietic activity and recovery following TIPS. However, hemolysis-related alterations may attenuate the overall rise in hemoglobin, particularly in patients with higher baseline hemoglobin concentrations.