Anemia of chronic disease
Anemia of chronic disease, also called anemia of inflammation, is a normocytic normochromic anemia driven by hepcidin-mediated iron sequestration and cytokine blunting of erythropoiesis in patients with chronic infection, autoimmune disease, malignancy, or kidney disease. The iron-study pattern of low serum iron, low total iron-binding capacity, and normal-to-high ferritin distinguishes it from iron deficiency, and management centers on treating the underlying disease rather than iron supplementation.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: anemia of chronic disease, more accurately called anemia of inflammation, is a normocytic normochromic anemia that develops in patients with chronic infection, autoimmune disease…
- Epidemiology
Second most common anemia encountered in clinical practice, behind iron deficiency anemia, and the most common anemia in hospitalized and chronically ill patients.
- Risk factors
Chronic infection: tuberculosis, osteomyelitis, chronic HIV infection, and other indolent or persistent infections.
- Pathophysiology
Cytokine trigger: interleukin-6 and other inflammatory mediators released during infection, autoimmune activity, or malignancy stimulate hepatic hepcidin synthesis.
- Clinical features
Usually mild and nonspecific: fatigue, pallor, and reduced exercise tolerance proportional to the degree of anemia, often overshadowed by symptoms of the underlying illness.
- Differential diagnosis
Iron deficiency anemia: the most important distinction; low ferritin, high (not low) TIBC, low transferrin saturation, and elevated sTfR, versus low TIBC and normal-to-high ferritin in anemia of chronic disease (iron deficiency anemia).
- Diagnosis
No single confirmatory test; diagnosis rests on a compatible iron-study pattern in a patient with a recognized chronic inflammatory, infectious, or malignant illness, once hemolysis and blood loss are excluded.
- Management
Treat the underlying condition first: anemia of chronic disease seldom requires direct treatment, and hemoglobin typically improves once the driving infection, autoimmune disease, malignancy, or kidney disease is controlled.
- Complications
Reduced functional capacity and quality of life: fatigue and exercise intolerance from chronic anemia compound the burden of the underlying illness.
- Prognosis
Generally favorable and reversible: hemoglobin typically normalizes or substantially improves once the underlying condition is effectively treated.
- Prevention
No dedicated screening program exists for anemia of chronic disease itself; prevention is achieved indirectly through early recognition and treatment of the driving chronic disease.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Chronic kidney disease
Chronic kidney disease is abnormal kidney structure or function present for more than 3 months, staged by the Kidney Disease: Improving Global Outcomes (KDIGO) system using estimated glomerular filtration rate and albuminuria, and managed with blood pressure control, renin-angiotensin blockade, an SGLT2 inhibitor, and correction of its metabolic complications.
- Myelodysplastic syndromes
Myelodysplastic syndromes are clonal stem cell disorders producing ineffective hematopoiesis: a dysplastic, usually hypercellular bone marrow with peripheral cytopenias and a variable risk of transformation to acute myeloid leukemia. Diagnosis requires bone marrow biopsy showing dysplasia after excluding reversible mimics, risk is stratified with the IPSS-R, and treatment ranges from supportive transfusions and lenalidomide in lower-risk disease to hypomethylating agents and allogeneic transplant, the only cure, in higher-risk disease.
- Sideroblastic anemias
Sideroblastic anemias are disorders of defective mitochondrial heme synthesis in which iron accumulates around the erythroblast nucleus, producing ring sideroblasts on marrow Prussian blue stain and, unlike iron deficiency, iron overload rather than iron depletion. Causes are hereditary, clonal (myelodysplastic syndrome with ring sideroblasts), or reversible acquired (alcohol, lead, isoniazid/B6 deficiency, copper deficiency, zinc excess, chloramphenicol), and management centers on identifying and reversing the cause, a pyridoxine trial, and treating iron overload.
- Beta-thalassemia
Beta-thalassemia is an inherited hemoglobinopathy caused by point mutations that reduce or abolish beta-globin chain synthesis, producing a spectrum from asymptomatic trait to transfusion-dependent thalassemia major (Cooley anemia) with ineffective erythropoiesis, marrow expansion, and hepatosplenomegaly. Diagnosis rests on hemoglobin electrophoresis showing elevated HbA2 and HbF, and management of major disease centers on chronic transfusion paired with iron chelation, since transfusional iron overload is the leading cause of death.
- Rheumatoid arthritis
Rheumatoid arthritis is a chronic systemic autoimmune disease causing symmetric small-joint polyarthritis of the hands and feet that spares the distal interphalangeal joints, with morning stiffness over an hour. Diagnosis combines the ACR/EULAR classification criteria with rheumatoid factor, anti-CCP antibody, and radiographs. Treat-to-target management anchors on methotrexate, escalating to a biologic or targeted synthetic disease-modifying antirheumatic drug when remission is not reached.
- Aplastic anemia
Aplastic anemia is an acquired or inherited hematopoietic stem cell disorder that produces pancytopenia with a hypocellular, fatty bone marrow and no dysplasia, blasts, or fibrosis. Diagnosis rests on marrow biopsy showing less than 25% cellularity with severity graded by the Camitta criteria, and treatment is allogeneic stem cell transplantation for young fit patients with a matched donor or antithymocyte globulin plus cyclosporine and eltrombopag for everyone else.