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.
Anemia of chronic disease (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.
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
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
- autoimmune disorders
- acute or chronic infection
- critical illness, major trauma, or major surgery with delayed recovery
- chronic disease
1st investigations to order
- WBC and differential
- platelet count
- peripheral blood smear
- serum ferritin
- serum iron
- total iron binding capacity
- transferrin saturation
- absolute reticulocyte count
- serum creatinine
Investigations to consider
- erythrocyte sedimentation rate
- serum B12
- serum folate
- thyroid function tests
- indirect and direct bilirubin
- hemoglobin electrophoresis
- bone marrow biopsy
- soluble transferrin receptor
- ratio of soluble transferrin receptor to log ferritin
persistent 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
Eric H. Kraut, MD
Professor of Internal Medicine
The Ohio State University
EHK declares that he has no competing interests.
Marium Husain, MD, MPH
The Ohio State University James Comprehensive Cancer Center
MH declares that she has no competing interests.
Kiranveer Kaur, MD
Assistant Professor of Medicine
Division of Medical Oncology
The Ohio State University Wexner Medical Center
KK declares that she has no competing interests.
Dr Eric Kraut, Dr Marium Husain, and Dr Kiranveer Kaur would like to gratefully acknowledge Dr Alice Ma, Dr Damon Houghton, Dr Marco Giovannini, Dr Pasquale Niscola, Dr Karen D. Serrano, and Dr Robert D. Woodson, previous contributors to this topic. AM, DH, MG, PN, KDS, and RDW declare that they have no competing interests.
Sean R. Lynch, MD
Professor of Clinical Medicine
Eastern Virginia Medical School
SRL declares that he has no competing interests.
Christopher Pechlaner, MD
Associate Professor of Medicine
Innsbruck Medical University
CP declares that he has no competing interests.
Robert Chen, MD
Department of Medical Oncology
University of Colorado Health Sciences Center
RC declares that he has no competing interests.
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