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{{Anemia of chronic disease}}
{{Anemia of chronic disease}}
{{CMG}}
{{CMG}}{{shyam}}{{AE}}{{OK}}
==Overview==
==Overview==
Mild [[Normocytic anemia|normocytic]] and [[Normochromic anemia|normochromic]] [[anemia]] with a [[hemoglobin]] concentration of 10 to 11 g/dL. Less than 25 percent of the cases have [[microcytic]] and [[hypochromic anemia]] with a [[mean corpuscular volume]] (MCV) less than 70 fL. Normal or low [[mean corpuscular hemoglobin]] (MHC) similar to the MCV, and normal to increased red cell distribution width (RDW). No significant changes in the [[mean corpuscular hemoglobin concentration]] (MCHC). 20 percent of cases have severe [[anemia]], with a [[hemoglobin]] concentration <8 g/dL. [[Absolute reticulocyte count]] is frequently low (<25,000/microL). There could be an elevation in [[cytokines]] (eg, [[IL-6]], [[interferon-gamma]]) and acute phase reactants (e.g. [[fibrinogen]], [[erythrocyte sedimentation rate]], [[C-reactive protein]], [[ferritin]], [[haptoglobin]], [[factor VIII]]).
.
==Laboratory Findings==
==Laboratory Findings==
Anemia of chronic disease is often a mild [[Anemia#Normocytic_anemia|normocytic anemia]], but can sometimes be more severe, and can sometimes be a [[microcytic anemia]]; thus, it often closely resembles iron-deficiency anemia. Indeed, many people with chronic disease can also be genuinely [[iron deficiency|iron deficient]], and the combination of the two causes of anemia can produce a more severe anemia. As with iron deficiency, anemia of chronic disease is a problem of red cell production. Therefore, both conditions show a low [[reticulocyte production index]], suggesting that [[reticulocyte]] production is impaired and not enough to compensate for the decreased red blood cell count.
'''General''' <ref name="pmid23953340">{{cite journal |vauthors=Gangat N, Wolanskyj AP |title=Anemia of chronic disease |journal=Semin. Hematol. |volume=50 |issue=3 |pages=232–8 |date=July 2013 |pmid=23953340 |doi=10.1053/j.seminhematol.2013.06.006 |url=}}</ref><ref name="pmid15758012">{{cite journal |vauthors=Weiss G, Goodnough LT |title=Anemia of chronic disease |journal=N. Engl. J. Med. |volume=352 |issue=10 |pages=1011–23 |date=March 2005 |pmid=15758012 |doi=10.1056/NEJMra041809 |url=}}</ref><ref name="pmid2392639">{{cite journal |vauthors=Vreugdenhil G, Löwenberg B, van Eijk HG, Swaak AJ |title=Anaemia of chronic disease in rheumatoid arthritis. Raised serum interleukin-6 (IL-6) levels and effects of IL-6 and anti-IL-6 on in vitro erythropoiesis |journal=Rheumatol. Int. |volume=10 |issue=3 |pages=127–30 |date=1990 |pmid=2392639 |doi= |url=}}</ref><ref name="pmid15774616">{{cite journal |vauthors=Macciò A, Madeddu C, Massa D, Mudu MC, Lusso MR, Gramignano G, Serpe R, Melis GB, Mantovani G |title=Hemoglobin levels correlate with interleukin-6 levels in patients with advanced untreated epithelial ovarian cancer: role of inflammation in cancer-related anemia |journal=Blood |volume=106 |issue=1 |pages=362–7 |date=July 2005 |pmid=15774616 |doi=10.1182/blood-2005-01-0160 |url=}}</ref>
 
* Mild [[Normocytic anemia|normocytic]] and [[normochromic anemia]] with a [[hemoglobin]] concentration of 10 to 11 g/dL
While no single test is always reliable to distinguish the two causes of disease, there are sometimes some suggestive data:
* [[Microcytic]] and [[hypochromic anemia]] with a [[mean corpuscular volume]] (MCV) less than 70 fL in less than 25 percent of the cases
 
* Normal or low [[mean corpuscular hemoglobin]] (MHC) similar to the MCV
* In anemia of chronic disease without iron deficiency, [[ferritin]] levels should be normal or high, reflecting the fact that iron is stored within cells, and ferritin is being produced as an [[acute phase reaction|acute phase reactant]] but the cells are not releasing their iron. In [[iron deficiency anemia]] ferritin should be low.
* Normal to increased red cell distribution width (RDW)
 
* No significant changes in the [[mean corpuscular hemoglobin concentration]] (MCHC)
* [[TIBC]] should be high in genuine iron deficiency, reflecting efforts by the body to produce more [[transferrin]] and bind up as much iron as possible; [[TIBC]] should be low or normal in anemia of chronic disease.
* Severe [[anemia]], with a [[hemoglobin]] concentration <8 g/dL in 20 percent of cases
 
* Low absolute [[reticulocyte count]] (<25,000/microL) in many cases
If the importance of [[hepcidin]] in this condition is borne out, tests to measure hepcidin or cellular expression of [[ferroportin]] may one day be useful, but neither are available as [[validate|validated]] clinical [[assays]].
* Elevation in [[cytokines]] (e.g. [[IL-6]], [[interferon-gamma]])
 
* Elevation in acute phase reactants (e.g., [[fibrinogen]], [[erythrocyte sedimentation rate]], [[C-reactive protein]], [[ferritin]], [[haptoglobin]], [[factor VIII]])
Examination of the bone marrow to look for the absence or presence of iron, or a trial of iron supplementation (pure iron deficiency anemia should improve markedly in response to iron, while anemia of chronic disease will not) can provide more definitive diagnoses.
'''Iron studies'''
* Low serum [[iron]] concentration and [[transferrin]] level (also measured as [[Total iron-binding capacity|total iron binding capacity]], TIBC)
* Normal or low-normal percent saturation of [[transferrin]] (TSAT)
* Normal or elevated serum [[ferritin]] concentration
'''Soluble transferrin receptor''' studies<ref name="pmid10817554">{{cite journal |vauthors=Suominen P, Möttönen T, Rajamäki A, Irjala K |title=Single values of serum transferrin receptor and transferrin receptor ferritin index can be used to detect true and functional iron deficiency in rheumatoid arthritis patients with anemia |journal=Arthritis Rheum. |volume=43 |issue=5 |pages=1016–20 |date=May 2000 |pmid=10817554 |doi=10.1002/1529-0131(200005)43:5<1016::AID-ANR9>3.0.CO;2-3 |url=}}</ref><ref name="pmid19795030">{{cite journal |vauthors=Koulaouzidis A, Said E, Cottier R, Saeed AA |title=Soluble transferrin receptors and iron deficiency, a step beyond ferritin. A systematic review |journal=J Gastrointestin Liver Dis |volume=18 |issue=3 |pages=345–52 |date=September 2009 |pmid=19795030 |doi= |url=}}</ref><ref name="pmid23086764">{{cite journal |vauthors=Infusino I, Braga F, Dolci A, Panteghini M |title=Soluble transferrin receptor (sTfR) and sTfR/log ferritin index for the diagnosis of iron-deficiency anemia. A meta-analysis |journal=Am. J. Clin. Pathol. |volume=138 |issue=5 |pages=642–9 |date=November 2012 |pmid=23086764 |doi=10.1309/AJCP16NTXZLZFAIB |url=}}</ref>
* sTfR is normal in patients with ACD.
* It helps to distinguish between [[Iron deficiency anemia]] and ACD
'''sTfR - ferritin index'''<ref name="pmid15758012">{{cite journal |vauthors=Weiss G, Goodnough LT |title=Anemia of chronic disease |journal=N. Engl. J. Med. |volume=352 |issue=10 |pages=1011–23 |date=March 2005 |pmid=15758012 |doi=10.1056/NEJMra041809 |url=}}</ref><ref name="pmid9028338">{{cite journal |vauthors=Punnonen K, Irjala K, Rajamäki A |title=Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency |journal=Blood |volume=89 |issue=3 |pages=1052–7 |date=February 1997 |pmid=9028338 |doi= |url=}}</ref>
* Calculation of the ratio of sTfR (expressed as mg/L) to [[ferritin]] (expressed as mcg/L), or the ratio of sTfR to the logarithm (to the base 10) of the [[ferritin]] concentration
* A sTfR/log [[ferritin]] ratio (TfR-[[ferritin]] index) <1 suggests the diagnosis of ACD, while a ratio >2 suggests the presence of IDA . Those with the combination of IDA and ACD will also have a TfR-[[ferritin]] index >2.
'''Peripheral blood smear'''
* [[Leukocytosis]] with a "[[left shift]]" (bands and immature forms) in the presence of [[infection]]
* Presence of [[leukemic]] or [[malignant]] cells, or [[leukopenia]]/[[lymphocytopenia]] in [[cancer]] or acute or chronic disorders involving the [[immune system]]  
'''Bone marrow studies''' <ref name="pmid14175842">{{cite journal |vauthors=ELLIS LD, JENSEN WN, WESTERMAN MP |title=MARROW IRON. AN EVALUATION OF DEPLETED STORES IN A  SERIES OF 1,332 NEEDLE BIOPSIES |journal=Ann. Intern. Med. |volume=61 |issue= |pages=44–9 |date=July 1964 |pmid=14175842 |doi= |url=}}</ref>
* Normal or increased amounts of storage [[iron]] in [[bone marrow]] [[macrophages]] 
* Decreased number of sideroblasts


==References==
==References==

Latest revision as of 00:33, 24 November 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Shyam Patel [2]Associate Editor(s)-in-Chief: Omer Kamal, M.D.[3]

Overview

Mild normocytic and normochromic anemia with a hemoglobin concentration of 10 to 11 g/dL. Less than 25 percent of the cases have microcytic and hypochromic anemia with a mean corpuscular volume (MCV) less than 70 fL. Normal or low mean corpuscular hemoglobin (MHC) similar to the MCV, and normal to increased red cell distribution width (RDW). No significant changes in the mean corpuscular hemoglobin concentration (MCHC). 20 percent of cases have severe anemia, with a hemoglobin concentration <8 g/dL. Absolute reticulocyte count is frequently low (<25,000/microL). There could be an elevation in cytokines (eg, IL-6, interferon-gamma) and acute phase reactants (e.g. fibrinogen, erythrocyte sedimentation rate, C-reactive protein, ferritin, haptoglobin, factor VIII). .

Laboratory Findings

General [1][2][3][4]

Iron studies

Soluble transferrin receptor studies[5][6][7]

sTfR - ferritin index[2][8]

  • Calculation of the ratio of sTfR (expressed as mg/L) to ferritin (expressed as mcg/L), or the ratio of sTfR to the logarithm (to the base 10) of the ferritin concentration
  • A sTfR/log ferritin ratio (TfR-ferritin index) <1 suggests the diagnosis of ACD, while a ratio >2 suggests the presence of IDA . Those with the combination of IDA and ACD will also have a TfR-ferritin index >2.

Peripheral blood smear

Bone marrow studies [9]

References

  1. ↑ Gangat N, Wolanskyj AP (July 2013). "Anemia of chronic disease". Semin. Hematol. 50 (3): 232–8. doi:10.1053/j.seminhematol.2013.06.006. PMID 23953340.
  2. ↑ 2.0 2.1 Weiss G, Goodnough LT (March 2005). "Anemia of chronic disease". N. Engl. J. Med. 352 (10): 1011–23. doi:10.1056/NEJMra041809. PMID 15758012.
  3. ↑ Vreugdenhil G, Löwenberg B, van Eijk HG, Swaak AJ (1990). "Anaemia of chronic disease in rheumatoid arthritis. Raised serum interleukin-6 (IL-6) levels and effects of IL-6 and anti-IL-6 on in vitro erythropoiesis". Rheumatol. Int. 10 (3): 127–30. PMID 2392639.
  4. ↑ Macciò A, Madeddu C, Massa D, Mudu MC, Lusso MR, Gramignano G, Serpe R, Melis GB, Mantovani G (July 2005). "Hemoglobin levels correlate with interleukin-6 levels in patients with advanced untreated epithelial ovarian cancer: role of inflammation in cancer-related anemia". Blood. 106 (1): 362–7. doi:10.1182/blood-2005-01-0160. PMID 15774616.
  5. ↑ Suominen P, Möttönen T, Rajamäki A, Irjala K (May 2000). "Single values of serum transferrin receptor and transferrin receptor ferritin index can be used to detect true and functional iron deficiency in rheumatoid arthritis patients with anemia". Arthritis Rheum. 43 (5): 1016–20. doi:10.1002/1529-0131(200005)43:5<1016::AID-ANR9>3.0.CO;2-3. PMID 10817554.
  6. ↑ Koulaouzidis A, Said E, Cottier R, Saeed AA (September 2009). "Soluble transferrin receptors and iron deficiency, a step beyond ferritin. A systematic review". J Gastrointestin Liver Dis. 18 (3): 345–52. PMID 19795030.
  7. ↑ Infusino I, Braga F, Dolci A, Panteghini M (November 2012). "Soluble transferrin receptor (sTfR) and sTfR/log ferritin index for the diagnosis of iron-deficiency anemia. A meta-analysis". Am. J. Clin. Pathol. 138 (5): 642–9. doi:10.1309/AJCP16NTXZLZFAIB. PMID 23086764.
  8. ↑ Punnonen K, Irjala K, Rajamäki A (February 1997). "Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency". Blood. 89 (3): 1052–7. PMID 9028338.
  9. ↑ ELLIS LD, JENSEN WN, WESTERMAN MP (July 1964). "MARROW IRON. AN EVALUATION OF DEPLETED STORES IN A SERIES OF 1,332 NEEDLE BIOPSIES". Ann. Intern. Med. 61: 44–9. PMID 14175842.


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