Anaemia of Chronic Disease

Anaemia from inflammation with excess cytokine production — a functional iron deficiency (stores normal/high, but unavailable for erythropoiesis).

Commonest anaemia in older adults — up to 70% of hospitalised elderly. Also common in obesity.

Chronic infection (TB, endocarditis), inflammatory disease (RA, SLE, IBD), malignancy, chronic organ disease (CKD, HF, COPD, liver disease), obesity, "inflammaging".

Cytokines (IL-6, TNF) are the trigger.

Functional iron deficiency via HEPCIDIN — the central mechanism. Hepcidin (liver peptide, acute-phase reactant) is over-produced by IL-6; it blocks ferroportin on enterocytes/macrophages/hepatocytes, blocking gut iron absorption and trapping iron in macrophage/ferritin stores.

Decreased EPO production/response — cytokines damage EPO-producing renal cells and down-regulate EPO receptors.

Shortened RBC lifespan and suppressed erythropoiesis — cytokine-mediated apoptosis of precursors and mature cells.

Normocytic, normochromic anaemia.

Iron pattern: low-normal iron/transferrin/saturation, but normal-to-ELEVATED ferritin.

Ferritin <30 ng/mL → IDA; >100 ng/mL → probable ACD; 30–100 → equivocal, use soluble transferrin receptor (sTfR) — HIGH in IDA, NORMAL in ACD, unaffected by inflammation.

Reticulocytes LOW; CRP/ESR elevated.

Treat the underlying disease — cornerstone but often difficult in frail elderly.

Iron NOT recommended unless true concomitant deficiency — avoid if ferritin >100 ng/mL (futile; iron just locked in RE system).

ESAs — FDA-approved only for cancer chemotherapy or HIV myelosuppression; check iron first (ESAs often precipitate absolute iron deficiency); target Hb 11–12 g/dL; monitor 2–4 weekly.