This presentation is about anemia of chronic disease, nowadays also called as anemia of Inflammation. I have dealt with anemia in CKD and malignancy in detail.

1. Anemia of Chronic Disease
Or, Anemia of
Inflammation (AI)
Dr. Subhash Thakur
Clinical Oncologist
MD (PGIMER, Chandigarh)
4/19/2021 MBBS 3rd year Lecture CMC, Bharatpur, Nepal

2. Contents
• Anemia in CKD
• Causes
• Work up
• Treatment options
• Anemia in malignancies
• Causes
• Effects
• Management
• Introduction
• Etiology and
Pathophysiology
• Clinical Features
• Evaluation
• Management

3. Introduction
• Any major disease except than blood loss
• Rheumatoid Arthritis
• Hematological and Solid malignancies
• End Stage Renal Disease
• Chronic Infections

4. Causes
• Infections
• HIV
• Tb, sepsis
• Malaria etc
• Cancer
• Hematological
Malignancies
• Solid Tumors
• Autoimmune
• Rheumatoid arthritis
• SLE
• Vasculitis
• Sarcoidosis
• Inflammatory Bowel Diseases

5. Pathophysiology
• Not able to utilize stored iron and produce red cells and make Hb
• Inadequate erythrocyte production or increased red cell destruction
• Inhibition of intestinal absorption of iron
• Low serum Iron
• Low binding capacity (low transferrin)
• Usually are normocytic normochromic but can be microcytic and
hypochromic

7. Prevalence
• Infectious Diseases: Developing and under developed countries
• Malignancies and Inflammatory Diseases: Developed countries
• 3rd most prevalent anemia after IDA and thalassemia

8. Clinical Features
• Sign and Symptoms of underlying causes
• Anemia Symptoms: tiredness, fatigue, shortness of breath, light headedness,
confusion etc

9. Evaluation
• Decreased Fe2++
• Increased Ferritin
• Decreased TIBC

10. Management
• Effective treatment of the underlying disease
• Anemia that present in setting of infections, inflammation or
malignancies require sufficient diagnostic studies to more threatening
causes such as
occult hemorrhage,
iron, B12 or folate deficiency,
hemolysis and drug reaction.

11. Treatment
Treatment ACD ACD with true ID
Treatment of underlying disease Yes Yes
Transfusion Yes Yes
Iron supplementation No Yes
Erythropoietic agents Yes Yes, in patients who do not have
response to iron therapy

12. Anemia in Chronic Kidney Disease

13. Causes leading to Anemia
• Decreased erythropoietin production (most important)
• RBCs –Shorter half life
• Blood loss during dialysis
• Iron deficiency

14. Work Up
• Initiate when Creatinine Clearance is <60 ml/min or Hb<11 gm/dl
• Hb/Hematocrit
• MCV
• Iron Studies : Fe++, Fe+++
• TIBC (transferrin Saturation)
• Stool guaic

15. Treatment Options
• Iron
• ESA (Erythropoietin Stimulating agent)
• Blood transfusions
• Folic acid and Vitamin B12

16. ESAs
• Epoietin – alpha : SC/IV
• Darbepoietin

17. When to Start
• Address all correctable causes of anemia including iron deficiency and
inflammations prior to initiation of ESA therapy
• When Hb<10 gm/dl
• Target : 10 – 11.5 gm/dl
• Avoid High concentration > 13 gm/dl

18. Dose
• Epoietin alpha: 20 – 50 IU/kg body weight three times a week
• Darbepoietin: 0.45 microgram/kg, once weekly
• Caution : CVD thromboembolism, seizure

19. ESA Monitoring
• Hb concentration initially every 1-2 weeks followed by 2-4 weeks when
stable.
• Monitor BP
• Iron stores:
• Ferritin target: 200 – 500
• TIBC > 20 %

20. Common causes of inadequate responses to
ESA therapy
• IDA (most common)
• Infections or inflammations
• Others: Chronic blood loss, renal bone disease, vitamin B12/folate
deficiency, hemolysis, Vitamin C deficiency
• Iron Therapy: parenteral route is preferred

21. ACD in Malignancies
• Frequent complication
• Etiology: Cancer itself and treatment: Chemotherapy and radiation therapy

22. Associated with
• Fatigue
• Impaired physical function
• Reduced quality of life

23. Consequences of anemia on cancer
• Impaired response to cancer treatment
• Reduced overall survival

24. Management
• When should ESA treatment be considered?
Ans : Patients undergoing chemotherapy after correction of iron
deficiency and other underlying causes

25. Which patients should receive ESA?
• Patients with symptomatic anemia
• Patients receiving chemotherapy or radio-chemotherapy and develops anemia
• Hb<10 gm/dl
• Asymptomatic patients undergoing chemotherapy and Hb<8 gm/dl

26. Should patients who do not receive
Chemotherapy treatment be treated with ESA?
• No

27. What is the Hb target range for treatment with
ESA
• Hb – 12 gm/dl without RBC transfusion

28. At what dose should ESA be started
• Epoietin: 450 IU/wk/kg body weight (alpha, beta and zeta)
• Darbepoietin : 6.75 microgram/kg – 3 weekly
8.25 microgram/Kg ---- weekly
20000 IU weekly – Epoietin theta

29. Which patients should be considered for RBC
transfusion?
• Patients with Hb<7-8 gm/dl or severe anemia related symptoms even at
higher Hb

30. Management of ChT induced anemia in
patients with solid and hematological
malignancies
• Assess Hb, iron status (TSAT, SF) and CRP at baseline and before the
Chemotherapy Cycle.

31. Hb 10-11 gm/dl
1. ? ID (TSAT<20%, SF < 100 ng/ml) : IV Iron 1000 mg
2. Vitamin B12/folate deficiency: B12/folate: low serum B12/folate :
B12/folate
3. Other causes of anemia: treat underlying cause

32. Hb: 8-10 gm/dl
• Vitamin B12 or folate deficientcy if yes, supplement
• SF, if < 100 ng/ml (Absolute ID)– IV iron, add ESA if Hb still < 10 gm/dl
• TSAT <20%, SF normal (Functional ID) – ESA + iron IV (1000 mg)
• TSAT normal, SF normal – ESA, add iv iron if Hb still<10 gm/dl

33. Hb<7-8 gm/dl
• Rapid Hb increase needed: RBC transfusion

34. Revision with MCQs

35. 1. Which of the following is NOT a cause of microcytic anemia
a. Thalassemia
b. Anemia of chronic disease
c. Iron deficiency anemia
d. Pancytopenia
e. Lead poisoning

36. 2. The lab reports for a patient with low mean cell volume
show high serum ferritin and low total iron binding capacity.
What is the most likely cause for this patient’s anemia?
a. Fe deficiency
b. Anemia secondary to inflammation
c. Thalassemia
d. Hemoglobinopathy

37. 3. Fe is absorbed in the
a. Stomach
b. Duodenum
c. Jejunum
d. Ileum

38. Q4. Where is most non heme iron found in the
body?
a. Bound to IF
b. Bound to transferrin
c. Free in plasma
d. Stored in liver

39. Q5. Select the following that enhance Fe
absorption (select all that apply)
a. Citric acid
b. Polyphenols (tea)
c. Phytate (bran)
d. Calcium
e. Ascorbic acid

40. Q6. What is the most important test for Fe
stores?
a. Serum iron
b. TIBC
c. Serum ferritin

41. Q7. Which of the following is not an etiology
of Fe deficiency anemia?
a. Chronic blood loss
b. Increased requirement
c. Infection
d. Malabsorption
e. Decreased intake

42. Q8. TIBC increases in iron deficiency anemia
because
a. Inflammatory response to deficiency
b. Compensation by other factors
c. Ability to absorb increases

43. Q9. Pica, a clinical presentation for Fe
deficiency anemia, is
a. Itchiness
b. ED
c. Desire to eat weird things
d. A small woodland creature

44. Q10. Which lab investigations would you order if you suspect
Fe deficiency anemia? (check all that apply)
a. CBC
b. Blood smear
c. Serum iron
d. Serum ferritin
e. TIBC
f. All of the above