Anemia of chronic disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 29 Apr 2025

Last updated: 11 Oct 2024

Anemia of chronic disease (ACD) is characterized by anemia and evidence of immune system activation.

Anemia is mainly due to decreased red blood cell production; may be aggravated by shortened red blood cell survival.

Commonly found in acute and chronic infections; autoimmune disorders; chronic diseases; malignancy; after major trauma, surgery, or critical illness; and among older adults.

Physical examination findings are those of the underlying disorder.

Therapeutic approach is primarily treatment of the underlying disorder, although treatment of the anemia itself is sometimes appropriate.

Definition

ACD is a common syndrome in which the anemia is due to an inflammation-mediated reduction in red blood cell (RBC) production and sometimes in RBC survival.[1][2]

Laboratory studies, which collectively identify the syndrome, typically show normocytic normochromic or microcytic hypochromic anemia, relatively low absolute reticulocyte count, low serum iron, low total iron-binding capacity, low to normal percent transferrin saturation, and elevated ferritin.

History and exam

Key diagnostic factors

systemic symptoms of underlying condition
absent history of bleeding
physical finding suggesting infection
physical finding suggesting neoplasm
physical finding suggesting autoimmune disorder

Full details

Other diagnostic factors

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

Full details

Risk factors

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

Full details

Diagnostic tests

1st tests to order

Hb
WBC and differential
platelet count
mean corpuscular volume (MCV)
mean corpuscular hemoglobin concentration (MCHC)
peripheral blood smear
serum ferritin
serum iron
total iron-binding capacity
transferrin saturation
absolute reticulocyte count
serum creatinine

Full details

Tests to avoid

flow cytometry

Full details

Tests to consider

C-reactive protein (CRP)
erythrocyte sedimentation rate
serum B12
serum folate
thyroid function tests
LFTs
indirect and direct bilirubin
LDH
erythropoietin
hemoglobin electrophoresis
bone marrow biopsy
soluble transferrin receptor
ratio of soluble transferrin receptor to log ferritin

Full details

Treatment algorithm

ACUTE

mild to moderate anemia (hemoglobin [Hb] 8 to 11 g/dL)

severe (Hb <8 g/dL) or life-threatening (Hb <6.5 g/dL) anemia

Contributors

Authors

Marina Beltrami Moreira, MD

Assistant Professor

The Ohio State University Wexner Medical Center

The Ohio State University College of Medicine

Columbus

Disclosures

MBM has a pending research grant from the Pfizer-NCCN grant program.

Acknowledgements

Dr Marina Beltrami Moreira would like to gratefully acknowledge Dr Eric Kraut, Dr Marium Husain, Dr Alice Ma, Dr Damon Houghton, Dr Marco Giovannini, Dr Pasquale Niscola, Dr Karen D. Serrano, Dr Robert D. Woodson, and Dr Kiranveer Kaur, previous contributors to this topic. EK, MH, AM, DH, MG, PN, KDS, RDW, and KK declare that they have no competing interests.

Peer reviewers

Sean R. Lynch, MD

Professor of Clinical Medicine

Eastern Virginia Medical School

Norfolk

Disclosures

SRL declares that he has no competing interests.

Christopher Pechlaner, MD

Associate Professor of Medicine

Innsbruck Medical University

Innsbruck

Austria

Disclosures

CP declares that he has no competing interests.

Robert Chen, MD

Hematology/Oncology Fellow

Department of Medical Oncology

University of Colorado Health Sciences Center

Denver

Disclosures

RC declares that he has no competing interests.

Brady Stein, MD

Associate Professor of Medicine

Northwestern University

Evanston

Disclosures

BS declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

KDIGO Anemia Work Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2(4):279-335.Full text

Bohlius J, Bohlke K, Castelli R, et al. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update. J Clin Oncol. 2019 Apr 10;37(15):1336-51.Full text Abstract

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: hematopoietic growth factors [internet publication].Full text

Aapro M, Beguin Y, Bokemeyer C, et al. Management of anaemia and iron deficiency in patients with cancer: ESMO clinical practice guidelines. Ann Oncol. 2018 Oct 1;29(suppl 4):iv271.

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Iron deficiency anemia
- Iron deficiency anemia coexisting with ACD
- Anemia associated with chronic renal disease (erythropoietin deficiency)
More Differentials
Guidelines
- NCCN clinical practice guidelines in oncology: hematopoietic growth factors
- Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update
More Guidelines
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Anemia of chronic disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to avoid

Tests to consider

Treatment algorithm

mild to moderate anemia (hemoglobin [Hb] 8 to 11 g/dL)

severe (Hb <8 g/dL) or life-threatening (Hb <6.5 g/dL) anemia

Contributors

Authors

Marina Beltrami Moreira, MD

Disclosures

Acknowledgements

Peer reviewers

Sean R. Lynch, MD

Disclosures

Christopher Pechlaner, MD

Disclosures

Robert Chen, MD

Disclosures

Brady Stein, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice