ANEMIA OF CHRONIC DISEASE (ACD) This is another option for an Overview slides using transitions. Fify Henrika Clininal Pathology Department of FKUI Module Hematoloy & Onkology September 2, 2014

IRON PROTOPORPHYRIN + IRON DEFICIENCY SIDEROBLASTIC ANEMIA HAEM GLOBIN HAEMOGLOBIN SIDEROBLASTIC ANEMIA IRON DEFICIENCY CHRONIC INFLAMMATION/ MALIGNANCY + THALASSEMIA (Α OR Β)

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

Inhibits iron absorption 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  SERUM IRON  SERUM IRON N / FERRITIN LEVEL MARROW FOR IRON HAEMOGLOBIN STUDIES : Hb F/ HbA2 FERRITIN  FERRITIN N /  THALASSAEMIA, ABNORMAL HAEMOGLOBIN SIDEROBLASTIC ANAEMIA IRON DEFICIENCY 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 Erythrocyte sedimentation rate (ESR) increased IL-1 + OTHER MEDIATORS OF INFLAMMATION (Protein synthesis) MACROPHAGE HEPATOCYTE ↑ COMPLEMENT ↑ FERRITIN ↑ PHAGOCYTIC ACTIVITY ↑ IL-1 ↑ ACUTE-PHASE REACTANS ↓ ALBUMIN ↓ TRANSFERRIN (TIBC) ↑ CRP

The role of lactoferrin in causing hypoferremia This is another option for an Overview slides using transitions.

LABORATORY DIAGNOSIS OF HYPOCHROMIC ANAEMIA IRON DEFICIENCY CHRONIC INFLAMMATORY OR MALIGNANCY MCV MCH Reduced in relation to severity of anaemia Normal or mild reduction Serum iron Reduced TIBC Raised Serum transferrin receptor Normal/low Serum ferritin Normal or raised Bone marrow iron stores Absent Present Erythroblast 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

THANK YOU