Anemia of Chronic Disease

Anaemia of chronic disease (inflammation) is mild to moderate anaemia in chronic infection, inflammation, malignancy and kidney disease.

• Second commonest anaemia after iron deficiency.
• Mechanism: IL 6 mediated hepcidin increase blocks iron export (ferroportin) causing functional iron restriction, shortened red cell survival, blunted erythropoietin response and marrow suppression.
• Associated: rheumatoid arthritis, lupus, inflammatory bowel disease, tuberculosis, HIV, osteomyelitis, cancer, heart failure, CKD, critical illness.
• Often coexists with absolute iron deficiency.

• Mild fatigue, pallor; symptoms mainly of the underlying disease.
• Haemoglobin typically 8 to 11 g/dL, rarely under 8.

• Normocytic (or mildly microcytic) normochromic anaemia, low reticulocyte index.
• Low serum iron, low transferrin saturation, low or normal TIBC, normal to raised ferritin (over 100 µg/L), raised CRP and ESR.
• Soluble transferrin receptor normal (raised in iron deficiency), sTfR/log ferritin index below 1 in ACD.
• Combined iron deficiency suggested by ferritin 30 to 100 µg/L with raised CRP and low transferrin saturation.
• Exclude haemolysis, B12/folate deficiency, renal failure, marrow disease, haemoglobinopathy.

• Treat the underlying disease; anaemia often resolves.
• Iron for coexisting deficiency: IV iron (ferric carboxymaltose 500 to 1000 mg, iron sucrose 200 mg) preferred, since oral iron is poorly absorbed with elevated hepcidin.
• ESA for CKD (epoetin alfa 50 to 100 units/kg three times weekly, darbepoetin 0.45 micrograms/kg weekly, targeting haemoglobin 10 to 11.5 g/dL), chemotherapy induced anaemia (haemoglobin under 10), with iron repletion; roxadustat in CKD.
• Transfusion only for symptomatic severe anaemia (haemoglobin under 7 g/dL).
• Heart failure with iron deficiency: ferric carboxymaltose to ferritin under 100 or 100 to 299 with saturation below 20%.
• Avoid ESA in curable malignancy or active cancer when not on chemotherapy.
• Monitor haemoglobin, ferritin, transferrin saturation.