ANEMIA of CHRONIC

DISEASE
Causes of Anemia of Chronic Disease
Cancer
 Hematologic
 Solid Tumor
Infection
 Viral Infection including HIV
 Bacterial
 Parasitic
 Fungal
Autoimmune
 Rheumatoid Arthritis
 SLE and connective-tissue disease
 Vasculitis
 Sarcoidosis
 Inflammatory bowel disease

Chronic rejection after solid-organ transplantation

Chronic kidney disease and inflammation

TREATMENT
Rationale for treatment
Based on two principles.
First
anemia can be generally deleterious in itself, requiring a
compensatory increase in cardiac output in order to
maintain systemic oxygen delivery

Second
anemia is associated with a poorer prognosis in a
variety of conditions.
Thus, moderate anemia warrants correction, especially in patients older
than 65 years of age, those with additional risk factors ( such as coronary
artery disease, pulmonary disease, or chronic kidney disease), or
combination of these factors.
Treatment Options
I. TRANSFUSION
 Transfusions are particularly helpful in the context of
either severe anemia (in which the hemoglobin is less
than 8,00 g per deciliter) or life-threatening anemia(in
which the hemoglobin is less than 6,5 g per deciliter)

 It is important to note that existing guidelines for the

management of anemia of chronic disease do not
recommend long-term blood transfusion therapy in their
management algorithms because of the risk associated
with long term transfusion, such as iron overload and
sensitization to HLA antigents that may occur in patients
before renal transplantation.
II. IRON THERAPY

Iron is an essential nutrient for profilating microorganisms, and

the sequestration of iron from microorganisms or tumor cells
into the reticuloendothelial system is believed to be a
potentially effective defense strategy to inhibit the growth of
pathogens.

Iron therapy for patients with anemia of chronic disease is

controversial.
• On the basis of current data, patients with anemia of
chronic disease and absolute iron deficiency should
receive supplemental iron therapy.

• Iron supplementation should also be considered for

patients who are unresponsive to therapy with
erythropoietic agents because of functional iron
deficiency.

• However, iron therapy is currently not recommended

for patients with anemia of chronic disease who have
a high or normal ferritin level (above 100 ng per
millimeter).
III. ERYTHROPOIETIC AGENTS

Erythropoietic agents for patients with anemia of chronic

disease are currently approved for use by patients with
- cancer who are undergoing chemotherapy
- chronic kidney disease
- HIV infection

Three erythropoietic agents are currently available:

- epoetin alfa
- epoetin beta
- darbepoetin alfa
• Erythropoietin receptors are found on several malignant cell
lines, including mammary, ovarian,uterine, prostate,
hepatocellular and renal carcinoma as well as on myeloid cell
lines.
• Reportedly, those who responded well to epoetin therapy had
a significantly higher level of expression of CD 28 on T cells and
lower levels of interleukin-10, interleukin-12, interferon ¥ and
TNF  than did those with a poor response.
IV. MONITORING THERAPY

• For monitoring the response to erythropoietic agents,

hemoglobin levels should be determined after 4 weeks of
therapy and at intervals of two to four weeks thereafter.

• If the HB level increases by less than 1 g per deciliter, the iron

status should be reevaluated and iron suplementation
considered.

• If iron restricted erythropoiesis is not present, a 50 % escalation

in the dose of the erythropoietic agent is indicated.

• If no response is achieved after 8 weeks of optimal dosage in

the absence of iron deficiency, a patient is considered
nonresponsive to erythropoietic agents.
Conclusions

• End points that correlate with improvements in

morbidity and mortality in well-designed,
prospective studies must be identified in order
to determine the optimal therapeutic regimen
for patients with anemia of chronic disease