Management of Anemia of Chronic Disease with Malnutrition
The initial approach to managing anemia of chronic disease with malnutrition should include comprehensive nutritional support, iron supplementation (preferably intravenous in active disease), and correction of specific micronutrient deficiencies while addressing the underlying inflammatory condition. 1
Diagnostic Approach
- Screen for anemia using complete blood count, serum ferritin, and C-reactive protein to distinguish between iron deficiency anemia and anemia of chronic disease 1
- In the presence of inflammation, serum ferritin up to 100 μg/L may still be consistent with iron deficiency; transferrin saturation <20% with ferritin >100 μg/L suggests anemia of chronic disease 1
- If serum ferritin is between 30-100 μg/L with inflammation present, a combination of iron deficiency and anemia of chronic disease is likely 1
- Check for other micronutrient deficiencies that may contribute to anemia, particularly folate, vitamin B12, zinc, and vitamin D 1
Nutritional Management
- Perform nutritional screening and assessment for all patients with chronic inflammatory conditions and anemia 1
- Provide adequate caloric intake matching energy requirements (similar to healthy population) 1
- Increase protein intake to 1.2-1.5 g/kg/day in patients with active inflammatory disease 1
- For malnourished patients, implement nutritional supplementation with appropriate follow-up every 1-3 months 1
Iron Supplementation Strategy
For patients with mild anemia and inactive disease: Start with oral iron as first-line treatment 1
For patients with active inflammatory disease: Use intravenous iron as first-line treatment 1
- Also indicated for patients with previous intolerance to oral iron, hemoglobin <100 g/L, or those requiring erythropoiesis-stimulating agents 1
- Calculate iron needs based on baseline hemoglobin and body weight:
- For Hb 100-120 g/L (women) or 100-130 g/L (men): 1000 mg if <70 kg; 1500 mg if ≥70 kg
- For Hb 70-100 g/L: 1500 mg if <70 kg; 2000 mg if ≥70 kg 1
Micronutrient Supplementation
- Provide multivitamin supplements to ensure balanced nutritional intake, particularly when providing nutritional support 1
- Specific replacement regimens are typically required for iron, zinc, and vitamin D deficiencies, as a multivitamin alone may not correct these 1
- Monitor micronutrient status regularly (annually for stable patients, more frequently for those with active disease) 1
- Educate patients about the importance of micronutrient supplementation to improve compliance 1
Monitoring and Follow-up
- For patients in remission or with mild disease: Check hemoglobin, iron indices every 6-12 months 1
- For patients with active disease: Monitor at least every 3 months 1
- After successful treatment with IV iron, initiate re-treatment when serum ferritin drops below 100 μg/L or hemoglobin falls below gender-specific thresholds (120 g/L for women, 130 g/L for men) 1
Special Considerations
- Recognize that many serum markers of micronutrient status are affected by inflammation (ferritin increases; folate, selenium, and zinc decrease) 1
- Consider that deficits may be present even in apparently well-nourished individuals 1
- Poor compliance with supplements is common, particularly in adolescents, requiring patient education about their importance 1
- In patients with severe malnutrition receiving nutritional support, be vigilant about the risk of refeeding syndrome 1
By addressing both the anemia and malnutrition simultaneously while treating the underlying inflammatory condition, outcomes related to morbidity, mortality, and quality of life can be significantly improved.