A 59 year-old man with a history of decompensated alcoholic cirrhosis (Child-Pugh Class C) and obesity was admitted to the hospital almost one month ago with severe symptomatic anemia. He underwent upper endoscopy, which showed non-bleeding esophageal varices. These were banded. His hospitalization has been complicated by acute kidney injury, progressive ascites, and hyponatremia. Most relevant from a hematological standpoint is worsening anemia, despite multiple transfusions of packed red cells. It is for this reason that you are asked to see him. He has had mild macrocytic anemia and thrombocytopenia in the past, presumed secondary to portal hypertension. Prior to this admission, he had received occasional red cell transfusions, but these were typically in the setting of acute gastrointestinal bleeding. When you see him, he denies any symptoms of bleeding. He is fatigued, but he denies shortness of breath or chest pain. He has a history of alcohol abuse disorder. There is no family history of chronic liver disease or hematological disorders. He lives at home with his wife, and is retired. He does not smoke, and he denies alcolol intake over the past 3 years. His home medications include rifaximin, Lasix, pantoprazole and folic acid. He has no known drug allergies.

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