From the Guidelines
The treatment for anemia of chronic disease primarily focuses on addressing the underlying condition causing the anemia, such as chronic infection, inflammation, or malignancy, and may include iron supplementation and erythropoiesis-stimulating agents (ESAs) like epoetin alfa or darbepoetin alfa, as supported by the most recent guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) in 2023 1.
Key Considerations
- Anemia of chronic disease is a complex condition involving reduced iron availability for erythropoiesis, impaired erythropoietin production, and shortened red blood cell survival due to inflammatory cytokines.
- Iron supplementation, particularly intravenous iron preparations like iron sucrose or ferric carboxymaltose, may be considered if iron deficiency coexists with anemia of chronic disease.
- ESAs such as epoetin alfa or darbepoetin alfa may be prescribed when hemoglobin levels fall below 10 g/dL, especially in patients with chronic kidney disease or those receiving chemotherapy.
- Blood transfusions are typically reserved for severe anemia or when patients are symptomatic.
Treatment Approach
- Regular monitoring of hemoglobin levels, iron studies, and inflammatory markers is crucial to assess treatment response and adjust therapy accordingly.
- The effectiveness of these treatments can vary due to the complex mechanisms involved in anemia of chronic disease.
- Recent studies and guidelines, such as those from KDIGO in 2023 1, emphasize the importance of balancing the risks and benefits of treatment, including the use of ESAs and intravenous iron.
Important Studies
- The 2023 KDIGO conference on novel anemia therapies in chronic kidney disease provides updated conclusions on the management of anemia in CKD patients 1.
- Previous studies, such as the TREAT trial published in 2009, have shown that complete anemia correction with ESAs may be more harmful than beneficial in certain patient populations 1.
From the Research
What is Anemia of Chronic Disease
Anemia of chronic disease is a condition that accompanies a specific underlying disease, characterized by a decrease in hemoglobin, hematocrit, and erythrocyte counts due to a complex process, usually initiated by cellular immunity mechanisms and pro-inflammatory cytokines and hepcidin 2. This type of anemia is the second most common after iron deficiency anemia and its severity generally correlates with the severity of the underlying disease.
Causes and Pathogenesis
The anemia of chronic disease is associated with infectious, inflammatory, and neoplastic diseases, and is caused by the release of cytokines that mediate inflammatory and immune response 3. Abnormal iron metabolism with iron trapping in reticuloendothelial cells is primarily the cause of this condition, making iron unavailable for erythropoiesis although iron tissue reserves are elevated. Disorder in erythropoietin secretion and shortening of red cell life span also play a role in the pathogenesis of anemia of chronic disease.
Diagnosis
The differential diagnosis of anemia of chronic diseases is primarily based on the exclusion of other types of anemia, in particular iron deficiency 2. The main features of anemia of chronic diseases include:
- Mild to moderate lowering of hemoglobin level
- Decreased percentage of reticulocyte count
- Low iron and transferrin concentration, but increased ferritin Diagnosis also involves assessing the severity of the underlying disease and may include measurement of other hematopoietic factors such as folic acid, vitamin B12, hepcidin, creatinine, and erythropoietin.
Treatment
The basic form of treatment for anemia of chronic diseases remains supplementation with:
- Iron
- Folic acid
- Vitamin B12 as well as a diet rich in these hematopoietic factors 2. The route of administration (oral, intramuscular, or intravenous) requires careful consideration of the benefits and possible side effects, and assessment of the patient's clinical status. In some cases, erythropoiesis-stimulating agents may be used, particularly in severe anemias that lead to impaired quality of life and have an impact on mortality and survival rate 3. Iron therapy is essential when using erythropoietin to maximize erythropoiesis by avoiding absolute and functional iron deficiency 4.
Key Considerations for Treatment
Some key points to consider in the treatment of anemia of chronic disease include:
- Monitoring of iron stores and adjustment of iron supplementation as needed 4
- Use of erythropoiesis-stimulating agents in severe anemias 5
- Careful consideration of the route of administration and potential side effects of treatments 2
- Importance of treating the underlying disease in managing anemia of chronic disease 3