Management of Mild Normocytic Anemia with Normal Iron Studies
This patient does not require investigation or treatment at this time, as the hemoglobin of 122 g/L falls within or near the normal range for most populations, and all red cell indices and iron studies are normal. 1
Defining Anemia in This Case
Anemia is defined as hemoglobin below the lower limit of normal for the relevant population and laboratory, which varies by sex and should align with WHO thresholds: <130 g/L in men, <120 g/L in non-pregnant women. 1
A hemoglobin of 122 g/L (12.2 g/dL) is either normal or represents only borderline mild anemia depending on the patient's sex—it would be normal for a non-pregnant woman but mildly low for a man. 1, 2
The hematocrit of 0.35 (35%) is proportionate to the hemoglobin and does not suggest additional pathology. 1
Interpretation of Normal Indices
Normal MCV and MCH effectively exclude iron deficiency anemia, which characteristically presents with microcytosis (MCV <80 fL) and hypochromia (low MCH). 1, 2
Normal iron studies definitively rule out iron deficiency, as serum ferritin is the single most useful marker for iron deficiency, and transferrin saturation provides confirmatory evidence. 1
The combination of normal MCV, normal MCH, and normal iron studies makes this a normocytic anemia without iron deficiency, if anemia is present at all. 2
Clinical Approach
If the Patient is Female and Non-Pregnant:
- No investigation or treatment is needed, as hemoglobin of 122 g/L exceeds the WHO threshold of 120 g/L for non-pregnant women. 1, 2
If the Patient is Male:
Mild normocytic anemia (Hb 122 g/L vs. threshold 130 g/L) with normal iron studies warrants consideration of underlying causes such as anemia of chronic disease, early chronic kidney disease, or other systemic conditions. 2
Obtain additional workup including reticulocyte count, renal function (creatinine, eGFR), inflammatory markers (CRP), vitamin B12, and folate levels to identify potential causes of normocytic anemia. 2
A low or normal reticulocyte count indicates impaired erythropoiesis (chronic disease, renal insufficiency, bone marrow suppression), while an elevated reticulocyte count suggests hemolysis or acute blood loss. 2
Common Pitfalls to Avoid
Do not initiate empiric iron supplementation when iron studies are normal, as this provides no benefit and may cause unnecessary side effects or mask other diagnoses. 1
Do not assume all mild anemia requires aggressive investigation—the threshold for investigation is stronger when anemia is more severe or when there are concerning symptoms (fatigue, bleeding, weight loss). 1
Do not overlook that "normal" hemoglobin values vary by population and laboratory, so always compare against the specific reference range used. 1
Monitoring Recommendations
If this represents true mild anemia in a male patient, monitor hemoglobin at 3-month intervals to ensure stability and reassess if decline occurs. 1
Further investigation is only necessary if hemoglobin cannot be maintained or continues to decline, or if new symptoms develop. 1
For asymptomatic patients with stable mild normocytic anemia and normal iron studies, watchful waiting is appropriate while addressing any identified underlying conditions. 2