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Anaemia of Chronic Disease (Acd)
Essentials
- Exclude "specific" anaemias (iron deficiency, vitamin deficiency, haemolysis, acute haemorrhage, myelodysplastic syndrome and malignanat haematological diseases). This can be done with basic investigations of anaemia Assessment of Anaemia in Adults.
- Assess whether the severity of the anaemia can be explained by the severity of the primary disease.
- Avoid unnecessary iron therapy in secondary anaemia, but aim at finding those patients who would benefit from iron, i.e. who have combined anaemia.
Basis
- A heterogeneous group of anaemic conditions
- Pathogenesis: in anaemia associated with a chronic disease, erythropoiesis is attenuated and the utilization of iron is inhibited by mediators of inflammation and by hepcidin that regulates iron transport. Hepcidin, in a manner of speaking, "closes the ports for iron" preventing iron absorption and its release from macrophages. Usually, anaemia of chronic disease appears 1-2 months after onset of the primary disease and reflects its inflammatory activity.
- Common in some patient groups (e.g. in severe rheumatoid arthritis and renal insufficiency Treatment of Chronic Renal Failure).
- Is not caused by a deficiency of vitamins or mineral elements.
- The coexistence of anaemia of chronic disease and some other type of anaemia is not uncommon.
Underlying diseases
- Anaemia associated with a chronic disease (synonyms: anaemia of inflammation, secondary anaemia)
- Chronic infections
- Other chronic inflammatory diseases (autoimmune disease, severe traumas and burns)
- Malignant tumours (without infiltrates to bone marrow)
- "Organ-specific" causes
- Chronic renal failure Treatment of Chronic Renal Failure
- Cirrhosis and other liver diseases
- Endocrinopathies (hypothyroidism, hyperthyroidism, adrenal failure, androgen deficiency, hypopituitarism, hyperparathyroidism, anorexia nervosa)
Diagnostic assessment
- Identify the underlying disease. Include erythrocyte sedimentation rate, CRP and blood white cell count determinations in the routine laboratory examination of anaemia (the others are: haemoglobin, haematocrit, MCV and reticulocyte count).
- Consider whether the underlying disease can explain the degree of anaemia. In moderate and mild diseases the haemoglobin concentration is usually 100-110 g/l and in more severe diseases it may be 70-90 g/l or even lower.
- If the haemoglobin concentration is disproportionately low, search for specific causes of anaemia.
- Exclude increased red cell loss (bleeding or haemolysis, reticulocyte count increased).
- Exclude iron deficiency (decreased ferritin, increased plasma TfR concentration; check the reference range applied in your own laboratory), vitamin B12 deficiency and folate deficiency (MCV > 100 fl).
- In anaemia associated with a chronic disease, red cell morphology is usually normochromic and normocytic, but becomes hypochromic and microcytic as the condition is prolonged. At this stage, the condition resembles iron deficiency anaemia.
- Note that plasma ferritin that reflects the amount of iron storages in the tissues also acts in the same way as acute-phase proteins. Therefore, a person with inflammatory disease may have iron deficiency even if plasma ferritin concentration would be as much as 100-200 µg/l.
- Bone marrow examination is useful in all obscure cases.
- A patient with anaemia of chronic disease often also has other concurrent factors that contribute to the anaemia, like iron deficiency and renal insufficiency.
- An iron therapy trial is a practical approach if iron deficiency is combined with the anaemia of chronic disease. Iron stores are restored in 2-3 months and the true level of anaemia of chronic disease is revealed. Also in this case, the assessment of the cause of iron deficiency must be kept in mind.
- Treat the underlying disease.
- It is important for successful treatment to exclude the action of complicating factors such as haemorrhage, iron deficiency, vitamin deficiency, haemolysis, renal insufficiency and bone marrow effects of drugs.
- Avoid routine administration of iron, but iron medication may be considered for a persistent inflammatory anaemia, in which case parenteral preparations are the primary choice. The best response is obtained in patients with obvious iron deficiency and low activity of inflammation.
- Certain groups of renal or cancer patients are treated with erythropoietin (epoetin, darbepoetin alfa) according to the treatment regime chosen by a specialist.
- Red cell transfusions are given in special cases.