What are the causes of normocytic (normal cell size) normochromic (normal hemoglobin content) anemia?

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Last updated: April 6, 2025 • View editorial policy

From the Guidelines

Normocytic normochromic anemia is typically caused by decreased red blood cell production, increased destruction, or blood loss, and treatment should focus on addressing the underlying cause, such as chronic diseases, acute blood loss, or bone marrow disorders. The diagnosis of normocytic normochromic anemia involves a complete blood count showing low hemoglobin with normal mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) 1. Some common causes of normocytic normochromic anemia include:

  • Chronic diseases, such as kidney disease, liver disease, or cancer
  • Acute blood loss
  • Hemolysis
  • Bone marrow disorders
  • Certain medications Treatment depends on the underlying cause and may include:
  • Addressing the primary condition
  • Iron supplementation if needed
  • Erythropoietin therapy for kidney disease, as recommended by the National Kidney Foundation guidelines 2
  • Blood transfusions for severe cases
  • Discontinuation of offending medications It is essential to assess the iron status of the patient and provide adequate iron stores before initiating erythropoietin therapy, as iron supplementation is often necessary to ensure an adequate response to erythropoietin in patients with chronic kidney disease 2. The prognosis varies based on the underlying cause, with some cases resolving completely with treatment while others may require ongoing management 1. Patients typically experience fatigue, weakness, shortness of breath, and pallor due to reduced oxygen-carrying capacity of the blood. A comprehensive review of the follow-up and treatment of each subtype of anemia related to causes independent of myelosuppressive cancer therapy is crucial for optimal patient outcomes 1.

From the Research

Definition and Causes of Normocytic Normochromic Anemia

  • Normocytic normochromic anemia is characterized by a mean corpuscular volume of 80 to 100 mcm3 3
  • Its causes include anemia of inflammation, hemolytic anemia, anemia of chronic kidney disease, acute blood loss anemia, and aplastic anemia 3
  • In chronic renal failure, normochromic normocytic anemia develops when the glomerular filtration rate drops below 20-30 ml/min 4

Pathophysiology of Normocytic Normochromic Anemia

  • The reasons for normochromic normocytic anemia in chronic renal failure include a moderately reduced red cell life span, blood loss, and an inadequate increase in erythropoiesis relative to the fall in hemoglobin 4
  • The life-span of red blood cells may be shortened by their reduced resistance to mechanical, osmotic or oxidative stress, as well as by extracorpuscular factors 4
  • Erythropoietin deficiency is a key cause of normochromic normocytic anemia in patients with chronic kidney disease 4, 5

Diagnosis and Management of Normocytic Normochromic Anemia

  • Hemolytic anemia can be diagnosed based on signs and symptoms of hemolysis, such as jaundice, hepatosplenomegaly, unconjugated hyperbilirubinemia, increased reticulocyte count, and decreased haptoglobin levels 3
  • Use of erythropoiesis-stimulating agents in patients with anemia due to chronic kidney disease should be individualized, but these agents should not be initiated in asymptomatic patients until the hemoglobin level is less than 10 g/dL 3
  • New therapeutic strategies, such as drugs manipulating the hypoxia-inducible transcription factor (HIF) system, are being developed to stimulate erythropoiesis in patients with chronic kidney disease 5, 6

Prognosis and Treatment Outcomes

  • The prognosis of patients with normocytic normochromic anemia of unknown cause is excellent, with a marginal increase in hemoglobin level over time 7
  • Treatment with erythropoiesis-stimulating agents and iron therapy can increase hemoglobin levels and improve patient quality of life, but a more cautious approach is advised due to concerns about cardiovascular and thrombosis risk 6

References

Guideline

cancer- and chemotherapy-induced anemia.

Journal of the National Comprehensive Cancer Network : JNCCN, 2012

Research

Anemia: Normocytic Anemia.

FP essentials, 2023

Research

Pathophysiology of renal anemia.

Clinical nephrology, 2000

Research

A clinical approach to "idiopathic" normocytic-normochromic anemia.

Journal of the American Geriatrics Society, 1996

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.