What is the most likely diagnosis?

D. The peripheral blood smear reveals abnormal red blood cells with irregular and asym-metric protrusions with knobby ends of different sizes called acanthocytes (spur cells). In addition to liver disease, acanthocytes can be seen in abetalipoproteinemia, McLeod syndrome, neuroacanthocy-tosis syndromes, anorexia nervosa, myelodysplastic syndrome, and postsplenectomy. Spur cell anemia presents as a hemolytic anemia seen in cases of advanced liver disease, especially alcoholic liver disease and alcoholic cirrhosis. Echinocytes (burr cells), on the other hand, are red blood cells with regular and symmetrical short protrusions of similar sizes. Echinocytes are most commonly artifactual, but can also be seen in severe renal disease. Peripheral blood smears contrasting acanthocytes with echino-cytes are shown below (Hepatol Res. 2010;40(2):161).