Last reviewed: March 2020
Last updated: July  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • systemic symptoms of underlying condition
  • absent hx of bleeding
  • physical finding suggesting infection
  • physical finding suggesting neoplasm
  • physical finding suggesting autoimmune disorder

Other diagnostic factors

  • absent hx of high alcohol intake
  • absent hx of exposure to chemicals and radiation
  • absent hx of drugs known to be associated with risk of anaemia
  • absent hx of poor nutrition
  • decreased exercise tolerance
  • shortness of breath with exercise
  • fatigue
  • pallor

Risk factors

  • autoimmune disorders
  • malignancy
  • acute or chronic infection
  • critical illness, major trauma, or major surgery with delayed recovery

Diagnostic investigations

1st investigations to order

  • Hb
  • WBC and differential
  • platelet count
  • MCV
  • MCHC
  • peripheral blood smear
  • serum ferritin
  • serum iron
  • total iron binding capacity
  • transferrin saturation
  • absolute reticulocyte count
  • serum creatinine
  • LDH
More 1st investigations to order

Investigations to consider

  • CRP
  • erythrocyte sedimentation rate
  • serum B12
  • serum folate
  • thyroid function tests
  • LFTs
  • indirect and direct bilirubin
  • erythropoietin
  • quantitative haemoglobin A2 analysis
  • bone marrow biopsy
More investigations to consider

Emerging tests

  • soluble transferrin receptor
  • ratio of soluble transferrin receptor to log ferritin
More emerging tests

Treatment algorithm


Associate Professor

Hemophilia and Thrombosis Center

University of North Carolina

Chapel Hill



AM declares that she has no competing interests.

Dr Alice Ma would like to gratefully acknowledge Dr Damon Houghton, Dr Marco Giovannini, Dr Pasquale Niscola, Dr Karen D. Serrano, and Dr Robert D. Woodson, previous contributors to this topic. DH, MG, PN, KDS, and RDW declare that they have no competing interests.

Peer reviewersVIEW ALL

Professor of Clinical Medicine

Eastern Virginia Medical School




SRL declares that he has no competing interests.

Associate Professor of Medicine

Innsbruck Medical University




CP declares that he has no competing interests.

Hematology/Oncology Fellow

Department of Medical Oncology

University of Colorado Health Sciences Center




RC declares that he has no competing interests.

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