ll

1. Anemia and Anemia of
chronic disease
Dr. Noha Eisa
Lecturer of Clinical Hematology
Faculty of Medicine
Mansoura University
Sep-2018

2. Agenda:
 Case Scenarios:
 Anemia Classification:
 Anemia of chronic disease:
 Renal anemia.
 Discussion & Questions:

3. Case scenario I

4. A 56 Y old male presented with pallor ,easy
fatigability started 6m ago with Loss of wt.
and appetite, Prolonged constipation for 2y
CBC showed:
 TLC: 5.6
 Hb: 8.7 gm/dl
 MCV: 66 fl
 MCH: 27 pg
 PLT: 520

5. Other investigations:
 Blood film: showed microcytosis with
RC:7%
 S ferritin:8 ng/l
 Serum iron: 20 mcg/dL
 Transferrin Saturation: 9.6%
 LFTS: Normal
 Serum creatinine: Normal.

6. What is the type of anemia?
Mention the differential diagnosis of this type
of anemia?
What further studies, are indicated?
What is the most likely diagnosis?

7. Case scenario II

8. History of Present Illness
A 43 y old female patient presented to our
OPC with history of pallor and easy
fatigability 3m ago associated with bone aches.
 She had been doing well and one year prior
to the current visit, she was noted to have
normal hematocrit, iron studies and a
normal abdominal ultrasound.

9. Additional History
Past Medical History:
irrelevant
Past Surgical History:
appendectomy
Family History:
No other known genetic disorders in her
family
Allergies: No Known Drug Allergies
Medications: received tonics and iron
therapy,PPI

10. Physical Exam
 General: well appearing female in no acute
distress.
 Complexion: pallor
 Vital Signs: T: 98 BP: 105/65 HR: 70 RR: 12
The remainder of the physical exam was
normal

11. Laboratory Findings:
 Hemoglobin: 9 g/dL
 Hematocrit: 29.4%
 MCV: 80.2 fL
 MCH:28pg
 RDW: 15.3%
 Iron: 43 mcg/dL
 TIBC: 301 mcg/dL
 Transferrin Saturation: 15%
 Ferritin: 110 ng/mL
 Sedimentation Rate: 70 mm/hr

12.  What is the type of anemia?
 Mention the differential diagnosis of this type
of anemia?
 What further studies, are indicated?
 What is the most likely diagnosis?

13. Agenda:
 Case Scenarios:
 Anemia Classification:
 Anemia of chronic disease:
 Discussion:

14. Anemia:
Reduction in the concentration of circulating HB
or oxygen carrying capacity of blood below the
level for healthy person of the same age & sex in
the same in environment.
Anaemia is defined by the WHO as:
Hb < 12 g/dL in women.
Hb < 13 g/dL in men.

15. Normal adult red cell values:

16. Classification of anemia :
Until recently classification was based on the red
blood size (MCV).
Now depend on the automated reticulocyte count,
to assess RBC regeneration, :
Hypo-regenerative.
Regenerative anaemia.

17. Reticulocyte:
Reticulocyte (%) = [Number of Reticulocytes / Number of
total Red Blood Cells] X 100.
Corrected reticulocyte count = [(reticulocyte percent ×
patient’s hematocrit)/normal Hct ] .
If < 2  Marrow is not responding to the degree of
anemia.

18. I. Etiological classification:

19. II: Morphological classification of anaemia
Microcytic (<80fl) Normocytic (80-100) Macrocytic(>100 fl)
 Iron deficiency A RC:N RC: low meg Non meg
 Thalassemia  Haemolytic
anamia.
 Recent
blood loss.
 A.A  Vit
B12.
 Folic
acid
 Liver
disease
 Sideroblastic A  Chronic
renal
failure
 Hemolytic
anaemia
 Anemia of chronic
disease
 Anaemia of
chronic
disease
 MDS
 Anaemia of lead
poisoning
 Hypothyroi
dism
 Hypothyr
oidism
 Myelopthe
sic anaemia

20. The most frequent type of anaemia
is……….., closely followed by
……………..
The most frequent anemia in hospitalized
patients is ………………...

21. Agenda:
 Case Scenarios:
 Anemia Classification:
 Anemia of chronic disease:
 Discussion:

22. Anaemia of Chronic Disease (ACD)
 Most frequent anaemia among hospitalised patients.
 Mild to moderate, normo-/normochromic 75% while
25% are microcytic anemia.
 Develops in patients with cellular immune activation
 Degree of anaemia correlated to immune activation.

23. Inflammatory Diseases Associated
with the Development of ACD
I. Infections (acute and chronic)
A. Viral infections including HIV
B. Bacterial
C. Parasitic
D. Fungal
E. Helminth
II. Malignancies
A. Haematologic
B. Solid tumor
III. Autoimmune
A. Rheumatoid arthritis
B. SLE and connective tissue diseases
C. Vasculitis
D. Inflammatory bowel disease
IV. Chronic kidney disease and inflammation

24. Pathophysiology

25. Iron homeostasis:
 The bulk of iron in adult humans is found as erythrocyte heme. In
adult humans, erythrocytes have a life-span of 120 days.
 Senescent red blood cells or damaged red blood cells are phagocytosed
by macrophages, degraded in lysosomes and the constituent
components of the red cell, including iron, are recycled.
 The majority of iron that enters plasma daily comes not from dietary
iron but from the recycling of red blood cell iron by macrophages.
 Quantitatively, net iron absorption by the gut reflects about 5.0% of
the iron that enters plasma; the remainder is recycled iron.

26. • Body Iron Pool:
 Total body iron=3.5 g (2-5gm) distributed as follow
Hemoglobin 60- 70 %
Storage iron (Ferritin + Hemosiderin) 25 – 30 %
Myoglobin iron 3.5%
 Iron enzymes ( cytochromes, catalase, Peroxidase,
flavoprotein)
 Transport iron (iron in Plasma carried by
transferring)
0.08 %

27. Under steady-state conditions, the absorption of iron matches
the loss of iron through epithelial sloughing (1–2 mg/day).
In cases of iron need, intestinal iron absorption can increase 5
to 10 fold and there can be increases in the rate of
macrophage iron recycling.
Iron need is usually “signaled” by decreased transferrin
saturation, which is usually about 30%. When transferrin
saturation is > 70%, iron entering plasma is stored in
parenchymal cells such as hepatocytes, pancreatic acinar
cells, cardiomyocytes and adrenal tissue.

28. Regulation of iron acquisition and distribution:
 There are several Mechanisms to coordinate the rate of iron
acquisition be balanced by the rate of iron utilization
(erythropoiesis, and iron storage).
 Coordination requires communication between tissues that
utilize iron (developing erythrocytes) and store iron
(hepatocytes) with those cells (duodenal absorptive cells and
macrophages) that export iron into plasma.

29. Fig(3): Mammalian iron physiology. Vertebrate iron homeostasis
requires coordination between the tissues that export iron into
plasma (duodenal mucosa, macrophages), the tissues that utilize iron
such as red blood cell precursors and the tissues that store iron such
as hepatocytes, pancreatic cells and cardiac cells.

30.  This communication is mediated by the small peptide
hormone (Hepcidin)& Iron-regulatory proteins (IRPs).
 Iron-regulatory proteins (IRPs) and Hepcidin exert iron
homeostatic control at the cell and systemic levels,
respectively.

31.  Disruption of iron control mechanisms leads to genetic iron
disorders and may also contribute to the pathophysiology of
common pathologic conditions including inflammation,
neurodegeneration, metabolic disorders, and cancer.
 How IRP-based and systemic regulatory pathways
interconnect and work together in general iron homeostasis is
only partially understood and is a subject of intensive
investigation.

32. Hepcidin
Master Regulator of Iron Homeostasis

33. Hepcidin
Hepcidin is discovered made in the liver in response to iron
accumulation. Hepcidin is a 25 amino acid amphipathic
peptide containing six cysteines, which results in a high
degree of disulfide bonds.
Hepcidin is a member of the defensin family. There are two
features that distinguish hepcidin from other defensins;
1. Hepcidin is the only defensin that is made by the
hepatocyte, all other defensins are made by epithelial cells
2. The sequence of hepcidin is highly conserved in all
vertebrates, while other defensins show great sequence
variation from species to species.

34. At the systemic level, the liver peptide Hepcidin regulates iron
homeostasis by binding and degrading the sole cellular iron
exporter FPN, which is highly expressed at the basolateral surface
of duodenal enterocytes and on the cell membrane of
macrophages.
In this way, Hepcidin restricts the amount of iron delivered to its
plasma carrier transferrin.

35. Intestinal Iron Absorption
Enterocyte
Fe3+
Fe2+
Luminal Baso-lateral
Fe2+ Fe2+
DcytB Hephaestin
DMT1 Ferroportin
Tf Fe3+
Fe +
Heme-
oxygenase
Fe2+ Hepcidin
-
HCP-1
Heme
Slide courtesy of G. Weiss, MD
Hentze MW, et al. Cell. 2010;142:24-28.

36. Regulation of Hepcidin:

37. Clinically, plasma hepcidin concentration is modulated by
several “regulators.”
Hepcidin is a common effector of 4 known regulators of iron
homeostasis.
,
1. Erythropoietic demand,
2. Iron stores
3. Hypoxia, and
4. Inflammation
all act by modulating hepatocyte production of hepcidin.
ASH,2014
Increase:
 iron stores
 Inflammation
Decrease:
 Hypoxia
 Increased
erythropoietic activity
 Testosterone

38. Figure 1. Hepcidin is a common effector of 4 known regulators of iron homeostasis.
Iron stores, erythropoietic demand, hypoxia, and inflammation all act by modulating
hepatocyte production of hepcidin.
Increased iron stores and inflammation both appear to increase hepcidin expression,
primarily through signal transduction via the SMAD and JAK/STAT pathways, respectively.
Increased/ineffective erythropoietic drive and hypoxia appear to decrease hepcidin
expression, although the mechanisms of their control of hepcidin expression remain to be
fully elucidated.

39. Fe3+
Fe2+
Luminal Baso-lateral
Enterocyte
Fe2+ Fe2+
DcytB
Heph
DMT1
Tf Fe3+
Fe +
HO-1
Fe2+
HCP-1?
Heme
Fpn1
Fe2+
Heph
Tf Fe3+
Fpn1
Macrophage
Fe2+
HO-1
-
Tf-Fe+3
Inflammation (IL-6, LPS)+Hepcidin
Hepcidin
Tf-Fe+3
-
-
+
Liver
Slide courtesy of Dr. G. Weiss. Hentze MW, et al. Cell. 2010;142:24-28
Control of Body Iron Homeostasis
by Hepcidin

40. Pathophysiology—Cornerstones
 Iron retention within the reticulo-endothelial system.
 Impairment of erythrocyte progenitor formation.
 Inadequate formation and function of
erythropoietin.
 Reduced red cell survival.

41. Pathophysiology—Cornerstones
 Iron retention within the reticulo-endothelial
system.
 Impairment of erythrocyte progenitor formation.
 Inadequate formation and function of
erythropoietin.
 Reduced red cell survival.

42. Hepcidin
Stimulated also by Bacterial lipopolysaccharide (LPS), and IL-6 by
an iron independent pathway—acute phase protein (blocked by TNF-
a)
These lead to Hepcidin over-expression.
Hepcidin inhibits duodenal iron absorption and macrophage iron
release

43. Fe+2
Fe+2
Hepcidin
+
-
Hepcidin Duodenum
Liver
b
+
-
+
+
Ferritin
FP-1
Fe+2
Hepcidi
n
-
Tf/TfR
Macrophage
Fe+2 +
c
IL-6
IFN-γ
TNF-
α
IL-1
IL-10
Monocyte
CD3+
LPS
a
ACD is an immunity
driven disease
A collaborative work of acute phase
proteins (Hepcidin) and cytokines
Slide courtesy of Dr. G. Weiss.Weiss G. Biochim Biophys Acta. 2009;1790:682-693.

44. Pathophysiology—Cornerstones
 Iron retention within the reticulo-endothelial system.
 Impairment of erythrocyte progenitor formation.
 Inadequate formation and function of
erythropoietin.
 Reduced red cell survival.

45. Cytokine Effects on Erythroid Progenitor Cell
Proliferation
Putative molecular mechanisms:
• TNF-α -inhibitory effect via stroma
cells
• IL-1 acts primarily via IFN-g induction
• IFN-γ induces apotposis of CFU-e
• IFN-γ: caspase mediated apoptosis
involving ceramide
• IFN-γ induces NO; inhibits heme
synthesis
• Cytokines (IFN-γ) inhibit Epo and
SCF formation and functionality
• Iron restriction due to
cytokines/hepcidin
-
-
Fe+2
-
Bone marrow
Kidneys
Epo
IL-
6
IFN-abg
TNF-a
IL-
1
IL-10
Monocyte
CD3+
LPS
Slide courtesy of Dr. G. Weiss.
Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.

46. Pathophysiology—Cornerstones
 Iron retention within the reticulo-endothelial system.
 Impairment of erythrocyte progenitor formation.
 Inadequate formation and function of
erythropoietin.
 Reduced red cell survival.

47. Cytokine Effects on Epo Production
Putative molecular mechanisms:
• TNF-α/IL-1 induce NF-kB/GATA-2
with suppression of Epo gene
promotor
• Cytokine mediated radical formation
negatively affects Epo-producing cells
in the kidney
• Interaction with Epo/EpoR signal
transduction
(JAK2/STAT5/MAPK/PKC)
• Reduction of EpoR expression on
CFU-e
• Impaired Epo function because of
reduced iron availabiltiy
• Impaired Epo function due to
impaired erythroid progenitor
proliferation
-
-
Fe+2
Bone marrow
Kidneys
Epo
-
IFN-γ
TNF-α
IL-1
IL-10
Monocyte
CD3+
LPS
IL-6
?
Slide courtesy of Dr. G. Weiss.
Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.

48. Pathophysiology—Cornerstones
 Iron retention within the reticulo-endothelial system.
 Impairment of erythrocyte progenitor formation.
 Inadequate formation and function of
erythropoietin.
 Reduced red cell survival.

49. Reduced red cell survival.
Jonathan O. Cullis, British Journal of Haematology,2011. 154, 289–300
 Early studies suggested that red cell survival is shortened in
ACD.
 More recent research confirmed that red cell survival is
modestly shortened in patients with rheumatoid arthritis and
anaemic hospital inpatients.

51. Positive Effects of ACD?
 Withholding iron from infectious pathogens in
order to limit their growth1
Iron acquisition linked to pathogenicity in microbes, fungi?
 Reducing the supply of oxygen to rapid
proliferating tissues.
 Strengthening of immune response:
Weinberg ED. Biochim Biophys Acta. 2009;1790:600-605.

52. DIAGNOSIS
Lalitha Nayak, Lawrence B. Gardner, and Jane A. Little.ANEMIA OF CHRONIC DISEASES ,Hoffman 7thedition,2018
 The diagnosis of ACD is primarily one of exclusion and is
often difficult.
 Various laboratory tests have been suggested, but few have
proven value, because ACD occurs in too large a variety of
acute and chronic illnesses.
 The best way to diagnose ACD, at least provisionally, is to
document an anemia of underproduction with low serum iron
and low transferrin saturation levels and normal to elevated
serum ferritin level.

53. Other causes of anemia, such as hemolysis, nutritional
deficiency, or sequestration, should be ruled out, and
A component of iron deficiency should be strongly considered
in a patient with systemic inflammation and a low or “normal”
serum ferritin.
Bone marrow examination is usually not essential for the
diagnosis but may be necessary to rule out other diagnoses,
including malignancy (e.g., myelodysplastic syndrome).
Lalitha Nayak, Lawrence B. Gardner, and Jane A. Little ANEMIA OF CHRONIC DISEASES ,Hoffman 7thedition,2018

54. Blood Film Morphology:
Madu,A and Ughasoro,MAnaemia of Chronic Disease: An In-Depth Review. Med Princ Pract 2017;26:1–9
 Shows a normochromic and normocytic picture; this changes
with time to become hypochromic and microcytic.
 The haemoglobin concentration is usually 8–9.5 g/dL (mild to
moderate anaemia), and rarely drops to below 6 g/dL.
 In cases of suspected ACD with severe anaemia, other causes
of red cell loss or destruction should be vigorously
investigated.

55.  The reticulocyte count is usually reduced in ACD as well as in
IDA.
 The blood film may provide information on the underlying
cause of ACD:
1. Thrombocytosis in cases of chronic haemorrhage,
2. Toxic granules in neutrophils in severe sepsis,
3. Hyper segmented neutrophils in mixed nutritional
deficiency or folate/B 12 deficiency.

56. Others:
 Serum transferrin receptor (sTFR) and sTFR/ferritin ratio:
A possible tool for differentiating between ACD and IDA.
A ratio <1 makes ACD likely, whereas ratios >2 suggest
that iron stores are deficient, with or without ACD.

57.  Hepcidin assays:
1. IDA: Low
2. ACD: Raised
3. ACD/IDA: Normal
 Growth differentiation factor 15: raised in 2 and 3 others
Normal.

58. Use of laboratory investigations in the
differential diagnosis
of ACD.
Jonathan O. Cullis, British Journal of Haematology,2011. 154, 289–300

59. Differential Diagnosis Between ACD
and ACD Plus IDA
Anaemia
Biochemical or clinical
evidence of inflammation
Transferrin saturation <16%
Ferritin <30 mg/L
ACD/IDA
Ferritin >100 mg/L
ACD
Ferritin 30–100 mg/L
sTfR determination
sTfR/log ferritin >2 sTfR/log ferritin <1
Rule out other causes of anaemia
ACD/IDA
With permission from Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.

61. Agenda:
 Case Scenarios:
 Anemia Classification:
 Anemia of chronic disease:
 Renal anemia.
 Discussion & Questions:

62. Renal anemia
W. Coyne,D.et alKidney International Supplements (2017) 7, 157–163;
 Anemia is a common complication in patients with (CKD),
developing gradually and increasing in severity as kidney
disease progresses.
 Anemia is associated with poor outcomes, including higher
mortality in patients with end-stage renal disease (ESRD) and
in those with non–dialysis-dependent CKD.

63. Renal anemia
Pathogenic Factors of Renal Anemia:
 EPO deficiency
 Hemolysis
 Absolute iron deficiency
 Functional iron deficiency
 Folic acid deficiency
 Carnitine deficiency
Chronic inflammation
Aluminum intoxication
Hyperparathyroidism with
myelofibrosis
External blood loss
Bone-marrow suppression
induced by retained toxic
metabolites
Drugs

64. Erythropoietin deficiency
 The major cause of renal anemia.
 Previously, believed that the reason for inappropriately low
EPO levels in CKD was that the main cells in the body
producing erythropoietin were damaged by the same process
that was causing the renal failure.
 Recently, however, it became clear that with an appropriate
stimulus (eg, hypoxia, or a mimic of hypoxia caused by
pharmacological stabilization of hypoxia-inducible factor
[HIF], patients with end-stage renal failure are still able to
increase their plasma concentrations of erythropoietin.
LOW EPO:
 May be partly related to loss of the
kidney cells synthesizing the hormone,
 But also partly due to a malfunction of
the oxygen-sensing stimulus.

65. Uremic inhibitors:
 It was recognized that uremic serum inhibited erythroid colony
growth.
 Several substances in uremic serum could inhibit
erythropoiesis, including spermine, spermidine, putrescine,
cadaverine, and parathyroid hormone.

66. Inflammation:

67. Iron deficiency:

68. Hyperparathyroidism:
 Severe hyperparathyroidism may exacerbate renal anemia:
 The development of fibrosis in the bone marrow (a condition
known as osteitis fibrosa cystica).
 Direct suppression of erythroid colony growth by parathyroid
hormone.

69. Agenda:
 Case Scenarios:
 Anemia Classification:
 Anemia of chronic disease:
 Discussion:

70. Case scenario I

71. A 56 Y old male presented with pallor ,easy
fatigability started 6m ago with Loss of wt. and
appetite, Prolonged constipation for 2y
CBC showed:
TLC: 5.6
Hb: 8.7 gm/dl
MCV: 66 fl
MCH: 27 pg
PLT: 520

72. Other investigation:
 Blood film: showed microcytosis with
RC:7%
 S ferritin:8 ng/l (15 and 300 μg/L)
 Serum iron: 20 mcg/dL
 Transferrin Saturation: 9.6%
 LFTS: Normal
 Serum creatinine: Normal.

73. What is the type of anemia?
Mention the differential diagnosis of this type
of anemia?
What further studies, are indicated?
What is the most likely diagnosis?
Colonoscopy: huge cauliflower mass in RT
colon.
Pelvi-abdominal U/S: Hepatic and renal focal
lesion.

74. Case scenario II

75. History of Present Illness
A 43 y old female patient presented to our OPC
with history of pallor and easy fatigability 3m
ago associated with bone aches.
 She had been doing well and one year prior
to the current visit, she was noted to have
normal hematocrit, iron studies and a
normal abdominal ultrasound.

76. Additional History
Past Medical History:
irrelevant
Past Surgical History:
appendectomy
Family History:
No other known genetic disorders in her
family
Allergies: No Known Drug Allergies
Medications: received tonics and iron
therapy,PPI

77. Physical Exam
General: well appearing female in no acute
distress
Complexion: pallor
Vital Signs: T: 98 BP: 105/65 HR: 70 RR: 12
The remainder of the physical exam was
normal

78. Laboratory
 Hemoglobin: 9 g/dL
 Hematocrit: 29.4%
 MCV: 80.2 fL
 MCH:28pg
 RDW: 15.3%
 Iron: 43 mcg/dL
 TIBC: 301 mcg/dL
 Transferrin Saturation: 15%
 Ferritin: 110 ng/mL
 Sedimentation Rate: 70 mm/hr

79.  What is the type of anemia?
 Mention the differential diagnosis of this type
of anemia?
 What further studies, are indicated?
 LFTS: Normal
 KFTS:N
 Serum calcium:N
 ANA, ds DNA:negative
 Thyroid profile: Normal
 LDH: 400 (100 – 190)
 3 months later with persistent anemia the patient
complained of night fever.
 Post-contrast pan CT: Normal study
 SPEP: Normal
 BMA and B: Normal study
 Breast sonomammography normal.

80. What is the most likely diagnosis?
Upper GIT endoscope
MALT lymphoma

81. Home message:
 Anemia is not a diagnosis.
 It is a manifestation of an underlying disorder. Thus,
even mild, asymptomatic anemia should be
investigated.
 ACD is both common and multifactorial, an
unequivocal diagnosis may be challenging.
 The diagnosis of ACD is primarily one of exclusion
and is often difficult.
 Anemia is a common complication in patients with
(CKD) and associated with poor outcomes.

83. Thank you
Thank you