Anemia of chronic disease

A decrease in erythrocyte production can be multifactorial. A deficiency in nutrients (such as iron, vitamin B12, and folic acid) is a common cause that often is easily treatable. In addition, patients with cancer and CKD are at risk for developing a hypoproductive anemia. Furthermore, patients with chronic immune-related diseases (such as rheumatoid arthritis and systemic lupus erythematosus) can develop anemia as a complication of their disease. Anemia related to these chronic inflammatory conditions is typically termed anemia of chronic disease. 

Patients with CKD suffer from a decrease in erythropoietin production because erythropoietin is produced mainly in the kidneys.4,5 Finally, in patients with anemia of chronic disease, there is a blunted erythropoietin production as well as a diminished response to erythropoietin.9 Anemia of chronic disease also affects iron homeostasis, causing iron sequestration into storage sites and decreasing the amount available to the rest of the body.9... 

Chronic autoimmune disorders or infections, such as human immunodeficiency virus (HIV) infection or rheumatoid arthritis (anemia of chronic disease)... 

High WBC/platelets may be from anemia of chronic disease, malignancy, or chronic kidney disease. 

FIGURE 63-3. The anemia evaluation process. MCV, mean corpuscular volume Pb, lead TIBC, total iron binding capacity ACD, anemia of chronic disease. 

Anemia of chronic disease is a term given those with underlying conditions that contribute to or cause anemia in a patient. These chronic diseases can include cancer, chronic... 

Besides anemia associated with cancer and CKD, anemia of chronic disease can result from inflammatory processes and occurs commonly in autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. In treating these types of anemia of chronic disease, the most important principle is treating the underlying disease. These patients also may have iron deficiency and should be treated in the manner already discussed. Erythropoietin therapy such as epoetin-alfa therapy at a dose of 150 units/kg three times a week also may be used in these patients. 

This patient has the subjective symptoms of weight loss, decreased appetite, shortness of breath, and cough. Abnormal laboratory values include elevated temperature, decreased hemoglobin and hematocrit, and decreased CD4 count. Chest x-ray shows diffuse interstitial infiltrates bilaterally. Physical exam reveals thrush. The assessment is possible AIDS with CD4 count of 150 cells/mm3, thrush, a respiratory illness (possibly Pneumocystis jiroveci pneumonia), and anemia of chronic disease. He also has a history of hepatitis B, hypertension, and GERD (on famotidine), poor adherence to his anti hypertensive medications, and likely has an irregular daily regimen due to his occupation as a truck driver. 

Anemia of chronic disease is a hypoproliferative anemia associated with chronic infectious or inflammatory processes, tissue injury, or conditions that release proinflammatory cytokines. The pathogenesis is based on shortened RBC survival, impaired marrow response, and disturbance of iron metabolism. For information on anemia of chronic kidney disease, see Chap. 76. 

Bone marrow failure Anemia of chronic disease Renal failure Endocrine disorders Myelodysplastic anemias... 

Anemia of chronic disease Anemia of the elderly Malignant bone marrow disorders Peripheral... 

Diagnosis of anemia of chronic disease is usually one of exclusion, with consideration of coexisting iron and folate deficiencies. Serum iron is usually decreased but, unlike iron-deficiency anemia, serum ferritin is normal or increased and TIBC is decreased. The bone marrow reveals an abundance of iron the peripheral smear reveals normocytic anemia. 

Laboratory findings of anemia of critical illness disease are similar to those of anemia of chronic disease. 

Treatment of anemia of chronic disease is less specific than that of other anemias and should focus on correcting reversible causes. Iron therapy is... 

Epoetin alfa can be considered, especially if cardiovascular status is compromised, but the response can be impaired in patients with anemia of chronic disease (off-label use). The initial dosage is 50 to 100 units/kg three times weekly. If Hb does not increase after 6 to 8 weeks, the dosage can be increased to 150 units/kg three times weekly. 

In anemia of chronic disease, reticulocytosis should occur a few days after starting epoetin alfa therapy. Iron, TIBC, transferring saturation, or ferritin... 

Anemia of chronic disease is the second most common form of anemia. Recombinant erythropoietin frequently corrects the anemia with few or no transfusions. Anemia may also develop during radiotherapy or chemotherapy. Recombinant erythropoietin has been shown to increase hematocrit and decrease transfusion requirements after the first month of therapy in anemic cancer patients undergoing chemotherapy. 

Anemia of chronic disease Disorders of hemoglobin synthesis... 

The RBC is either in the upper half of or above the reference interval in thalassemias but within the reference interval in most hemoglobinopathies without a coinherited thalassemia. In contrast the RBC is low in iron deficiency anemias and anemia of chronic disease and is proportionally related to the decrease in Hb concentration. The red cell distribution width (ROW), a measure of the variation in the size of the RBC (anisocytosis), tends to be above the reference interval in iron deficiency anemias and other microcytic anemias. The RDW in thalassemias is usually within the reference interval, reflecting the rmiformity of the red cell size. However, in Hb H disease and 5P-thalassemia the RDW is moderately increased. 

Arndt, U., Kaltwasser, J.P., Gottschalk, R., Hoelzer, D. and Moller, B. (2005) Correction of iron-deficient erythropoiesis in the treatment of anemia of chronic disease with recombinant human erythropoietin. Ann Hematol, 84, 159-66. 

Anemia of chronic disease (ACD) is a diagnosis of exclusion. It results from chronic inflammation, infection, or malignancy, and can occur as early as 1 to 2 months after the onset of these processes. The serum iron level is usually decreased, but in contrast to IDA, the serum ferritin concentration is normal or increased and TIBC is usually decreased. Treatment is aimed at correcting the underlying pathology. 

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