European Journal of Cardiovascular Medicine

Alcohol consumption is a prevalent lifestyle factor with significant implications for hematological health. Chronic alcohol intake has been associated with various hematological disorders, including anemia, thrombocytopenia, and alterations in red and white blood cell indices. These effects are particularly concerning in populations with limited access to healthcare, where alcohol intake and smoking have been linked to increased anemia burden [1-3].

Anemia, characterized by a deficiency in the number of circulating red blood cells or hemoglobin concentration, is a common hematological abnormality observed in individuals with chronic alcohol use. The pathophysiology of alcohol-induced anemia involves several mechanisms, including bone marrow suppression, nutritional deficiencies (e.g., folate and iron), and direct toxic effects of alcohol metabolites on hematopoietic cells. Additionally, alcohol-induced liver disease can lead to altered synthesis of clotting factors and thrombocytopenia, further complicating the hematological profile of affected individuals [4-6].

The impact of alcohol on hematological parameters is not limited to chronic consumption. Acute alcohol intake has also been shown to affect blood indices, with studies indicating alterations in platelet function and red blood cell morphology. These changes may contribute to an increased risk of bleeding and other hematological complications in individuals consuming alcohol heavily or over extended periods [7-9].

Understanding the relationship between alcohol consumption and hematological health is crucial for developing effective public health strategies and clinical interventions. This systematic review aims to synthesize recent scientific literature to elucidate the effects of alcohol on blood indices, providing a comprehensive overview of the current state of knowledge in this area.

Search Strategy and Data Sources: This systematic review was conducted in accordance with the PRISMA 2020 guidelines [10]. A comprehensive electronic literature search was performed across PubMed, Scopus, Web of Science, and Google Scholar databases, covering studies published between January 2019 and June 2025. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and free-text keywords, including: “alcohol consumption”, “ethanol”, “alcohol use disorder”, “blood indices”, “hematological parameters”, “complete blood count”, and “hematology”. Boolean operators (AND/OR) were used to refine results and identify relevant studies.

Inclusion and Exclusion Criteria: Studies were included if they met the following criteria:

1. Investigated hematological indices in individuals with alcohol use or alcohol use disorder.
2. Reported quantitative or qualitative changes in blood parameters (e.g., hemoglobin, hematocrit, mean corpuscular volume, white blood cell count, platelet count).
3. Conducted on human subjects and published in peer-reviewed journals in English.

The following studies were excluded:

• Case reports, conference abstracts, reviews, and editorials.
• Experimental studies on animals or in vitro models.
• Studies focusing solely on biochemical markers without hematological evaluation.

Study Selection Process: All retrieved records were imported into Mendeley Reference Manager for de-duplication. Two independent reviewers screened the titles and abstracts for relevance. Full-text evaluation was carried out for potentially eligible articles. Any discrepancies were resolved by discussion or with input from a third reviewer. The process followed the four phases of PRISMA: identification, screening, eligibility, and inclusion.

Data Extraction and Quality Assessment: Data were extracted using a pre-designed data collection form. Extracted variables included: author, year of publication, study design, sample size, participant characteristics, type and duration of alcohol exposure, hematological indices assessed, and key findings. Methodological quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist [11] appropriate to the study design (cross-sectional, case–control, or cohort). Each study was graded as high, moderate, or low quality.

Data Synthesis: Due to heterogeneity across study designs, populations, and outcome measures, a narrative synthesis was employed. Descriptive summaries were provided for each blood index with emphasis on consistent trends across studies. Meta-analysis was not performed because of variability in study methodology and reporting of hematological outcomes.

Figure 1: PRISMA flow diagram

Study Selection and Screening Process: A total of 528 records were identified through the initial database search (PubMed = 192, Scopus = 148, Web of Science = 116, and Google Scholar = 72). After removing 126 duplicate records, 402 articles were screened based on titles and abstracts. Of these, 286 records were excluded because they were unrelated to alcohol-related hematological changes, focused on animal or in vitro models, or were published as conference abstracts without full data. The full texts of the remaining 116 articles were assessed for eligibility. During this stage, 94 studies were excluded due to out of scope (n = 26), insufficient details (n = 48), limited rigor (n = 20). Ultimately, 22 studies published between 2019 and 2025 fulfilled all inclusion criteria and were incorporated into the final systematic review

Across the included studies, chronic alcohol consumption was consistently associated with alterations in RBC indices and hemoglobin levels (Table 1). Alcohol users frequently exhibited macrocytosis, with elevated mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH), accompanied by reductions in hemoglobin and RBC counts. These effects were observed in diverse populations including Iraq, Nigeria, and India, indicating that both geographic and demographic factors did not mitigate the impact of alcohol on erythropoiesis. The severity of these alterations appeared to correlate with the intensity and duration of alcohol exposure, with severe alcoholics demonstrating the most pronounced macrocytosis and anemia.

Alcohol intake was also associated with significant changes in leukocyte and platelet counts (Table 2). Studies reported leukopenia and thrombocytopenia in chronic alcohol users, suggesting an immunosuppressive effect of alcohol. Laboratory-based observations confirmed that these hematological changes were consistent across different populations, highlighting the systemic impact of alcohol on hematopoietic and immune function.

Several studies emphasized the utility of biochemical and specialized markers for identifying alcohol-related hematological changes (Table 3). Parameters such as gamma-glutamyl transferase (GGT), carbohydrate-deficient transferrin (CDT), phosphatidylethanol (PEth), and MCV were found to be effective in screening for alcohol use disorder. Nutritional deficiencies, particularly low serum vitamin B12 and folate levels, were also documented, further contributing to impaired RBC synthesis and macrocytosis. These findings indicate that both routine hematological parameters and specialized biochemical markers provide complementary information in evaluating alcohol-related hematologic effects.

In studies examining alcohol withdrawal and genetic influences (Table 4), alcohol-related changes in blood indices were influenced by both physiologic stress during withdrawal and genetic predisposition. Alcohol withdrawal was associated with fluctuations in RBC, WBC, and platelet counts, alongside elevated inflammatory and gut permeability markers. Genetic studies indicated that alcohol intake modulated the contribution of genetic factors to MCV, further supporting the multifactorial nature of alcohol-induced hematological changes. Additionally, blood alcohol concentration correlated with alterations in hematologic and serum chemistry parameters, emphasizing the dose-dependent impact of alcohol on hematopoiesis.

Table 1: RBC and Hemoglobin Alterations in Alcohol Users

Table 2: WBC and Platelet Alterations / Immune Effects

Table 3: Biochemical Markers / Alcohol Screening

Table 4: Alcohol Withdrawal / Genetic Effects

This systematic review aimed to synthesize recent evidence on the hematological effects of alcohol consumption, focusing on alterations in red blood cell (RBC) indices, white blood cell (WBC) counts, platelet levels, and biochemical markers. The findings underscore the multifaceted impact of alcohol on hematological health, highlighting both direct toxic effects and indirect influences through nutritional deficiencies and liver dysfunction.

RBC and Hemoglobin Alterations: Chronic alcohol consumption has been consistently associated with macrocytic anemia, characterized by elevated mean corpuscular volume (MCV) and reduced hemoglobin (Hb) and RBC counts. Studies have demonstrated that alcohol-induced liver damage impairs erythropoiesis, leading to these hematological abnormalities [21]. Additionally, alcohol's interference with folate and vitamin B12 metabolism contributes to impaired DNA synthesis in erythrocyte precursors, exacerbating anemia [34-36].

WBC and Platelet Alterations: Alcohol's impact on the immune system is evident in its effects on WBC and platelet counts. Chronic alcohol use has been linked to leukopenia and thrombocytopenia, conditions that increase susceptibility to infections and bleeding [36,37]. These alterations are thought to result from direct toxic effects on hematopoietic stem cells and the bone marrow microenvironment, as well as from liver dysfunction affecting thrombopoietin production [21].

Biochemical Markers and Alcohol Screening: Biochemical markers such as MCV, gamma-glutamyl transferase (GGT), and carbohydrate-deficient transferrin (CDT) have been explored for their utility in screening for alcohol use disorders. Elevated MCV is a nonspecific marker of alcohol consumption, while GGT and CDT levels can reflect liver damage and excessive alcohol intake. However, these markers should be used in conjunction with clinical assessment and patient history for accurate diagnosis [38-40].

Alcohol Withdrawal and Genetic Effects: Alcohol withdrawal syndrome (AWS) presents with hematological and inflammatory fluctuations, including increased WBC counts and altered RBC morphology. Genetic factors also play a role in individual responses to alcohol, influencing hematological parameters such as MCV and RBC counts. Understanding these genetic predispositions can aid in personalized treatment approaches for alcohol use disorders [28-33].

Limitations and Future Directions: While this review provides a comprehensive overview of alcohol's effects on hematological health, several limitations must be acknowledged. Variability in study designs, sample sizes, and methodologies can affect the generalizability of findings. Future research should aim for standardized protocols and larger, multicenter studies to validate these results. Additionally, exploring the mechanisms underlying alcohol-induced hematological changes at the molecular and genetic levels will enhance our understanding and inform therapeutic strategies.

Alcohol consumption exerts significant effects on hematological parameters, contributing to conditions such as anemia, leukopenia, and thrombocytopenia. These alterations are influenced by direct toxic effects, nutritional deficiencies, and liver dysfunction. Clinicians should consider these hematological changes when assessing patients with alcohol use disorders and incorporate appropriate screening and management strategies.

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