Anemia of Chronic Disease

How to Cite This Chapter: Crowther M, Podolak-Dawidziak M. Anemia of Chronic Disease. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. Accessed January 28, 2022.
Last Updated: September 3, 2021
Last Reviewed: September 3, 2021
Chapter Information

Also see Anemia: General Considerations.

Definition, Etiology, PathogenesisTop

Anemia of chronic disease (ACD) (also termed anemia of inflammation) is caused by decreased red blood cell (RBC) production due to an activated cellular immune response and by increased production of proinflammatory cytokines and hepcidin. It is the second most common anemia after iron deficiency anemia. Its incidence increases with age and it is frequently found in patients with acute or chronic inflammatory conditions.

Causes: Acute or chronic infections, malignancy, autoimmune diseases (most frequently rheumatoid arthritis, systemic lupus erythematosus, and vasculitis syndromes), occult inflammatory conditions, selected drug therapies (eg, interferon).

Clinical Features and Natural History Top

ACD usually manifests within a few months of the development of the underlying condition. Its severity increases with the severity of the causative disorder. Clinical manifestations include signs and symptoms of the underlying condition as well as general symptoms of anemia.


Diagnostic Tests

1. Complete blood count (CBC) (see Table 8.5-1, see Table 8.5-2), normal or low reticulocyte counts, normal red cell distribution width.

2. Parameters of iron metabolism: see Table 8.5-1, see Table 8.5-2.

3. Other tests: Abnormalities caused by the underlying condition, frequently increased levels of the markers of inflammation. Endogenous erythropoietin levels do not correspond to the severity of anemia. Serum transferrin receptor (sTfR) is a protein that can be assayed in the blood in some centers. It generally should be normal in patients with ACD and increased in patients with iron deficiency anemia.

Diagnostic Criteria

Normocytic and normochromic anemia after other causes of anemia (particularly coexisting iron deficiency) have been excluded.

Differential Diagnosis

Iron deficiency anemia (see Table 8.5-1), other types of anemia (see Table 8.1-1).

Treatment Top

1. Treatment of the underlying condition

2. Severe anemia: Transfusion of packed red blood cells (PRBCs).

3. Patients with anemia in the course of anticancer chemotherapy and selected other patients with low serum erythropoietin levels: Consider the use of an erythropoiesis-stimulating agent (ESA): subcutaneous human recombinant erythropoietin alpha 40,000 IU once weekly, subcutaneous human recombinant erythropoietin beta 30,000 IU once weekly, or subcutaneous darbepoetin 500 microg every 3 weeks. Doses are titrated to increase hemoglobin to the lowest level sufficient to avoid PRBC transfusion. Contraindications and adverse effects: see Chronic Kidney Disease.

4. Absolute or relative iron deficiency may be observed in some patients with ACD and should be treated with IV iron. Controversy exists regarding what ferritin and transferrin saturation level should be provided. However, a low serum ferritin level is an absolute indication for iron therapy (see Iron Deficiency Anemia).

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