ANEMIA OF CHRONICH DISEASE

By amirhossein heydarian
 DEFENITION
 The terms anemia of chronic disease or chronic disorders refer to mild to
moderately severe anemias ([Hb] 7-12 g/dl) associated with chronic
infections and inflammatory disorders and some malignancies.
 The newer name for this anemia is anemia of inflammation(AI)

 AI is characterized by:
 Inadequate erythrocyte production
 Low serum iron
 Low binding capacity (i.e low transferrin)
 The erythrocytes usually are normocytic and normochromic
 but can be mildly hypochromic and microcytic.
 EPIDEMIOLOGY

The high prevalence of infectious diseases worldwide and the

high prevalence of inflammatory and malignant disorders in the
industrialized countries suggest that AI is the second or third most
common form of anemia after iron-deficiency anemia (IDA) and
thalasemia .
ETIOLOGY
 Infections (acute and chronic)
 Viral infections, including HIV infection
 Bacterial including tuberculosis, osteomyelitis and sepsis
 Parasitic including malaria
 Fungal

 Cancer
 Hematologic including multiple myeloma and lymphoma
 Solid tumor including carcinoma
ETIOLOGY

 Autoimmune
 Rheumatoid arthritis and other rheumatologic disorders
 Systemic lupus erythematosus
 and connective-tissue diseases
 Vasculitis
 Sarcoidosis
 Inflammatory bowel disease
 systemic inflammatory response syndrome
ETIOLOGY

 Chronic rejection after solid-organ transplantation

 Chronic kidney disease and inflammation

 PATHOGENESIS

 Red cell destruction

 Inadequate erythropoietin secretion and resistance to erythropoietin
 Erythropoiesis as a result of iron unavailability
 Interleukin -6 ,Hepcidin ,and Hypoferremia
 Serum iron concentrations are dependent on iron released from
Macrophages and Hepatocytes
 Inhibition of Intestinal absorption of iron
 CLINICAL FEATURES

 The clinical manifestations of AI usually are obscured by the signs

and symptoms of the underlying disease.

 Moderate anemia (Hg<10) can exacerbate the symptoms of the

preexisting ischemic heart disease or respiratory disease.
 The erythrocytes in AI are normocytic and normochromic but
, with increasing severity and duration , can become
hypochromic and eventually microcytic.
 The absolute reticulocyte count is normal or slightly elevated.
 Hypoferremia and decreased serum transferrin
 Interleukin -6 ,Hepcidin ,and Hypoferremia
 Normal to increased serum ferritin
 Marrow iron stain
Hypoferremia and decreased serum
Transferrin
 Hypoferremia , decrease in the serum iron concentration , is a defining feature of
AI .

 Moderately decreased:
The decreased in transferrin concentration develops more slowly than the
decreas in the iron levels because of the longer half-life of transferrin (8-12 days )
compared to the half-life of iron ( approximately 90 minutes )
Increased serum ferritin

Serum ferritin concentrations , which reflects iron stores , are

increased in AI but decreased in Iron deficiency .
Marrow iron stain
 Marrow aspiration or biopsy is rarely required for diagnosis of AI .
In general , the marrow morphology and stainable iron are normal ,
unless the underlying disease alters the picture .

 The most important information that obtained from marrow

examination is the content of and distribution of iron.
DIFFERENTIAL DIAGNOSIS
 Most patients with chronic infections , inflammatory diseases , or
neoplastic disorders are anemic.
The diagnosis of AI should be made only if the anemia is mild to moderate
,the serum and iron binding capacity are low , and the serum ferritin is
elevated .

 Drug-induced marrow suppression or drug-induced hemolysis

 Chronic blood loss
 Renal impairment
 Endocrine disorders
 Anemia resulting from metastatic invasion of the bone marrow
 Thalassemia minor
 Dilution anemia
Algorithm for the Differential Diagnosis
THERAPY AND PROGNOSIS

 Anemia that presents in the setting of infection , inflammation , or

malignancy requires sufficient diagnostic studies to more
threatening causes , such as occult hemorrhage ; iron , B12 , and
folate deficency ; hemolysis and drug reaction .

 If the anemia can be designated as AI after such studies ,effective

treatment of the underlying disease resolves the anemia
Therapeutic Options for ACD