Transcript ANEMIA OF CHRONIC DISEASE (ACD)

Fify Henrika
Clininal Pathology Department of FKUI
Module Hematoloy & Onkology
September 2, 2014
IRON
PROTOPORPHYRIN
a. IRON DEFICIENCY
b. CHRONIC
INFLAMMATION/
MALIGNANCY
SIDEROBLASTIC
ANEMIA
HAEM
+
GLOBIN
THALASSEMIA
(Α OR Β)
HAEMOGLOBIN
ANEMIA OF CHRONIC DISEASE (ACD)
ONE OF THE MOST COMMON ANEMIA OCCUR IN
PATIENTS:
 CHRONIC INFLAMMATORY
 CHRONIC INFECTION
 TRAUMA
 MALIGNANCY
RENAL, HEPATIC AND EDOCRINOLOGICAL
DISEASES ARE NOT CONSISTENTLY ASSOCIATED
WITH ABNORMALITIES OF IRON METABOLISM
SEEN IN ACD
PATHOGENESIS
ANEMIA IS ASSOSIATED WITH DECREASED IRON RELEASE
FROM MACROPHAGE TO PLASMA
REDUCED RBC LIFESPAN
IN ADEQUATE IT ERYTHROPOIETIN RESPONSE TO ANEMIA,
CAUSE BY CYTOKINE EFFECTS SUCH IL-1, TNF ON
ERYTHROPOIESIS
HEPCIDIN RELEASED BY THE LIVER IN RESPONSE TO
INFLAMMATION
Inhibits
macrophage
release of iron
Inhibits iron
absorption
CAUSES OF THE ANEMIA OF CHRONIC DISEASES
(ACD)
CHRONIC INFLAMMATORY DISEASES
INFECTIONS (E.G. PULMONARY ABSCESS,
TUBERCULOSIS, OSTEOMYELITIS, PNEUMONIA,
BACTERIAL ENDOCARDITIS)
NON-INFECTIONS (E.G. RHEUMATOID ARTHRITIS,
SYSTEMIC LUPUS ERYTHEMATOSUS AND OTHER
CONNECTIVE TISSUE DISEASE, SARCOIDOSIS, CROHN’S
DISEASE
MALIGNANT DISEASES
CARCINOMA, LYMPHOMA, SARCOMA
Hoffbrand AV, Moss PAH, Pettit JE. Essential haematology .5th ed. Oxford : Blackwell Publishing; 2006.p.39.
INVESTIGATION OF A HYPOCHROMIC
MICROCYTIC ANAEMIA
MCV  / MCH 
BLOOD FILM
SERUM IRON
SERUM IRON 
MARROW FOR
IRON
SIDEROBLASTIC
ANAEMIA
SERUM IRON N /
HAEMOGLOBIN
STUDIES : Hb F/ HbA2
THALASSAEMIA,
ABNORMAL
HAEMOGLOBIN
SERUM IRON 
FERRITIN LEVEL
FERRITIN 
IRON
DEFICIENCY
FERRITIN N / 
ANAEMIA OF
CHRONIC DISORDER
Lewis SM, Bain BJ, Bates I. Dacie and Lewis practical haematology. 9th ed. London : Churchill Livingstone; 2001.p.582.
LABORATORY FINDINGS (1)
HYPOFERREMIA
 NORMOCHROMIC NORMOCYTIC ANEMIA, RARELY
HYPOCHROMIC MICROCYTIC ANEMIA
 SERUM IRON ↓, TIBC ↓, SATURATION INDEX <15%
 BM IRON STORES NORMAL OR ↑, SERUM FERRITIN
NORMAL OR ↑
 REDUCED BM SIDEROBLASTIC IRON BECAUSE
REDUCED SUPPLY OF IRON TO THE MARROW
ERYTHROCYTE
LABORATORY FINDINGS (2)
Accumulation of iron-containing granules in normoblasts
(Pearls’ reaction)
LABORATORY FINDINGS (3)
Abnormal plasma protein  acute phase response
IL-1 + OTHER MEDIATORS OF INFLAMMATION
(Protein synthesis)
MACROPHAGE
↑ COMPLEMENT
↑ FERRITIN
↑ PHAGOCYTIC
ACTIVITY
↑ IL-1
HEPATOCYTE
↑ ACUTE-PHASE
REACTANS
↓ ALBUMIN
↓ TRANSFERRIN (TIBC)
↑ CRP
Erythrocyte sedimentation rate (ESR) increased
The role of lactoferrin in causing hypoferremia
LABORATORY DIAGNOSIS OF
HYPOCHROMIC ANAEMIA
IRON DEFICIENCY
CHRONIC
INFLAMMATORY OR
MALIGNANCY
Reduced in relation to
severity of anaemia
Normal or mild
reduction
Reduced
Reduced
TIBC
Raised
Reduced
Serum transferrin
receptor
Raised
Normal/low
Serum ferritin
Reduced
Normal or raised
Bone marrow
iron stores
Absent
Present
Erythroblast iron
Absent
Absent
MCV
MCH
Serum iron
Hoffbrand AV, Moss PAH, Pettit JE. Essential haematology .5th ed. Oxford : Blackwell Publishing; 2006.p.39.
TREATMENT
IRON THERAPY AND HEMATINIC AGENT ARE
UNNECESSARY
RESOLVE THE UNDERLYING INFLAMMATORY OR
INFECTIOUS PROCESS SUCCESSFULLY TREATED
ANEMIA WILL IMPROVE WITH EFFECTIVE
CHEMOTHERAPY FOR MALIGNANT DISEASE
THE ANEMIA RESPONSE TO ERYTHROPOIETIN IN
ACD