ANAEMIA OF CHRONIC DISORDERS

Question 1

What is Anaemia of chronic disorders (ACD)?

Answer 1

Anaemia of chronic disorders (ACD) is anaemia occurring in the setting of chronic illnesses or disorders.
It occurs mostly in patients with chronic inflammatory disorders and malignant diseases.

Question 2

AETIOLOGY

Answer 2

• Chronic inflammatory diseases

Infections (e.g. pulmonary abscess, tuberculosis, osteomyelitis, pneumonia, bacterial endocarditis)

Non-infectious (e.g. rheumatoid arthritis, systemic lupus erythematosus and other connective tissue diseases, sarcoidosis, inflammatory bowel disease, liver disease)

• Malignant diseases
  Carcinoma, lymphoma, sarcoma

Question 3

What are the underlying factors causing ACD?

Answer 3

The underlying factors are:
Role of hepcidin
Reduced red cell lifespan
Inadequate erythropoietin response to anaemia

Question 4

Write short notes on the pathogenesis of ACD
(discussing the role of hepcidin and cytokine release)

Answer 4

In chronic inflammatory conditions, there is release of cytokines e.g. IL-1, TNF etc.

With cytokine release, there is increased synthesis of hepcidin

Hepcidin inhibits release of iron from macrophages. It also inhibits iron absorption from the GIT

It achieves the above by causing degradation of ferroportin mRNA.

Thus iron is present in the reticuloendothelial stores but is not available for use.

Reduced red cell survival and inadequate erythropoietin response are all caused by release of cytokines.

Question 4

INVESTIGATIONS

Answer 4

FBC:
PCV: ↓
WBC: May be normal, ↓ or ↑ (depending on underlying disease)
Platelets: May be normal, ↓ or ↑ (depending on underlying disease)
Red cell indices: Usually normal, but may show a mild reduction
Blood film: Usually reveals normocytic, normochromic red cells. There may be mild hypochromia.
Bone marrow aspiration: Perls’ stain reveals stainable iron (haemosiderin) within the macrophages but NO iron within developing erythroblasts.
Serum iron: ↓
TIBC: ↓
Serum ferritin: normal or ↑

Question 5

CLINICAL FEATURES

Answer 5

Symptoms:
Easy fatiguability
Breathlessness (dyspnoea)
Headaches
Dizziness

Signs:
Pallor
Tachycardia
Third heart sound
Hemic murmur
NOTE: The anaemia is usually mild and non-progressive

Question 5

Comparing IDA and ACD

Answer 5

IDA
PCV: Low
Red cell indices: Low
Serum Iron: Low
TIBC: High
Serum ferritin: Low
Bone marrow in iron stores: Absent
Erythroblast iron: Absent

ACD

PCV: Low (usually mild anaemia)
Red cell indices: normal or Low
Serum Iron: Low
TIBC: Low
Serum ferritin: normal or High
Bone marrow in iron stores: Present
Erythroblast iron: Absent

Question 6

TREATMENT

Answer 6

Treat the underlying cause.
Erythropoietin may be helpful e.g. in the setting of chronic kidney disease.
Anaemia hardly responds to iron therapy.