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ANEMIA - PART II Anemia of Chronic Inflammation

ANEMIA - PART II Anemia of Chronic Inflammation. BY: Zorawar Noor 4/21/2014. Objectives. Understand the pathogenesis of anemia of chronic inflammation (ACI) Review 4 Simple Laboratory Steps to diagnose anemia (from Part I) Learn the characteristics lab findings of ACI

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ANEMIA - PART II Anemia of Chronic Inflammation

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  1. ANEMIA - PART IIAnemia of Chronic Inflammation BY: Zorawar Noor 4/21/2014

  2. Objectives • Understand the pathogenesis of anemia of chronic inflammation (ACI) • Review 4 Simple Laboratory Steps to diagnose anemia (from Part I) • Learn the characteristics lab findings of ACI • Learn how to find coexisting iron deficiency

  3. When to Suspect Anemia of Chronic Inflammation? • In inflammatory, infectious, and malignant conditions (RA, SLE, osteomyelitis…) • In cases with normocytic and normochromic anemia (usually mild and asymptomatic)

  4. Pathogenesis • Inflammatory cytokine release (IL-6) triggers: • Hepcidin • Hepcidin decreases iron absorption in GI tract, and makes macrophages hold onto iron • Bone marrow is hypoproliferative despite having slightly increased EPO levels • EPO levels are not as high as they should be • Unlike in iron deficiency anemia, where peripheral RBCs gain a longer circulating half-life, there is shorter RBC life span.

  5. 4 Steps to Classify Anemia (Review from Part I) • Step 1 – Characterize by MCV • Microcytic, normocytic, macrocytic • Step 2 - Identify Morphologies on Peripheral Smear • E.g. hypochromia, bite cells, etc. • Step 3 – Calculate Reticulocyte Index • Reticulocyte Index (RI) = ReticCount * 0.5(Hct/45) • Step 4 – Use iron studies, bone marrow biopsy, etc. See presentation “Anemia, Part I” for more explanation of each step

  6. Diagnosis • History: collagen vascular diseases, malignancies, osteomyelitis, etc. • Step 1) MCV initially normal • Step 2) if chronic, can see mirocytosis and hypochromia • Step 3) Low Retic Count • Step 4) normal or low iron, low TIBC, high ferritin

  7. Iron Studies in ACI

  8. MKSAP Case 2 • A 22-year old woman undergoes a new patient evaluation. She was recently diagnosed with SLE. Her menstrual pattern is normal, and her medical history is otherwise noncontributory, her only medications are hydroxychloroquine and a multivitamin. • On Physical exam: T37.2C, BP 126/78, P88, RR17, and the patient has a malar rash, thinning hair, but no joint abnormalities, oral lesions, pericardial or pleural rubs, or heart murmurs. • Laboratory studies: Hgb 8.2, WBC 3900, Ferritin 556, Iron 18, Retic Count 2%, TIBC 180, Transferrin sat 10%, and creatinine 1.0.

  9. …MKSAP Case 2

  10. …MKSAP Case 2 • Which of the following is the most likely diagnosis? • (A) inflammatory anemia • (B) iron deficiency • (C) microangiopathic hemolytic anemia • (D) Warm Ab-associated hemolysis

  11. Answer Explanation • History of SLE • Step 1) MCV is low late in inflammatory anemia • Step 2) Hypochromia is noticeable, also late finding • Step 3) low RI is consistent with Inflammatory Anemia • Step 4) Ferritin is high from inflammation, TIBC is low ( think of iron being stored away from pathogens needing it for their own use through hepcidin)

  12. Finding Coexisting Iron Deficiency • Transferrin will often be reduced, not increased like it is in iron deficiency anemia (IDA) • Unlike usual Inflammatory anemia, • Soluble transferrin receptor (sTfR)-ferritin index • Ration of the sTfR to logarithm of ferritin • If index <1.0 suggests pure inflammatory anemia • If index >2.0, could be IDA or combination • Bone Marrow biopsy (macrophages with iron in ACD)

  13. Summary • Just approach it one step at a time! • Remember the pathogenesis of ACI, cytokines cause hypo-proliferation and low-iron because it stays in macrophages • Always watch out for coexisting iron deficiency • Treat the underlying cause.

  14. References • Harrison’s Principles of Internal Medicine • Adamson JW. Chapter 103. Iron Deficiency and Other Hypoproliferative Anemias. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9117223. Accessed December 7, 2011 • Wians, F.H. and Urban JE. “Discriminating between Anemia of Chronic disease Using Traditional Indices of Iron Status v. Transferring Receptor Concentration”. 2001. American Journal of Clinical Pathology. Volume 115. • UptoDate

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