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Anemia of chronic disease

Last reviewed: 28 Oct 2023
Last updated: 17 Nov 2023



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
More key diagnostic factors

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
Other diagnostic factors

Risk factors

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

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
More 1st investigations to order

Investigations to consider

  • 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
More investigations to consider

Treatment algorithm


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

Haematology/Oncology Fellow


The Ohio State University James Comprehensive Cancer Center




MH declares that she has no competing interests.


Dr Eric Kraut and Dr Marium Husain would like to gratefully acknowledge 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. 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




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

Hematology/Oncology Fellow

Department of Medical Oncology

University of Colorado Health Sciences Center




RC declares that he has no competing interests.

Brady Stein, MD

Associate Professor of Medicine

Northwestern University




BS declares that he has no competing interests.

  • 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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