Laboratory Orders for Anemia of Chronic Inflammation with Persistent Microscopic Hematuria
Order CRP and ESR immediately to confirm active inflammation, obtain a peripheral blood smear to screen for dysplastic cells or malignancy, and repeat urinalysis with microscopy in 2–4 weeks to assess for persistent hematuria and evaluate for glomerular disease. 1
Immediate Inflammatory Marker Assessment
Measure C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) now to document the degree of systemic inflammation driving your patient's anemia of chronic disease, because ferritin 1442 ng/mL with low TIBC 205 µg/dL and normal iron saturation confirms iron sequestration rather than true iron deficiency. 1
CRP and ESR are essential because they determine whether the markedly elevated ferritin reflects active inflammation (ferritin > 100 µg/L with elevated CRP/ESR indicates anemia of chronic disease) or whether an alternative diagnosis such as malignancy or hepatic disease is present. 1
Peripheral Blood Smear Review
Order a peripheral blood smear immediately to examine for dysplastic red cells, blasts, schistocytes, or other abnormal morphologies that would suggest myelodysplastic syndrome, hematologic malignancy, or bone marrow infiltration—all of which can present with normocytic anemia and markedly elevated ferritin. 2
The smear is critical because your patient's pattern (normocytic anemia, ferritin > 1000 ng/mL, low TIBC) raises concern for underlying malignancy, chronic kidney disease, or bone marrow failure, and dysplastic features would mandate bone marrow examination. 2
Hematuria Evaluation Protocol
Repeat urinalysis with microscopy in 2–4 weeks to confirm persistence of the 11–30 RBC/hpf finding, because transient hematuria from menstruation, vigorous exercise, or urinary tract infection must be excluded before pursuing invasive renal imaging. 1
If hematuria persists on repeat testing, order urine microscopy specifically to identify RBC casts or dysmorphic RBCs, which indicate glomerular disease (e.g., IgA nephropathy, lupus nephritis, post-infectious glomerulonephritis) rather than structural urologic pathology. 1
Obtain renal ultrasound if hematuria persists, to evaluate for structural abnormalities such as renal calculi, cysts, or masses that could explain both the hematuria and contribute to anemia through chronic blood loss. 1
Additional Workup to Identify the Underlying Inflammatory Condition
Measure serum creatinine and estimate glomerular filtration rate (eGFR) because chronic kidney disease (GFR < 30 mL/min/1.73 m²) frequently produces normocytic anemia with elevated ferritin and low TIBC, and the concurrent hematuria may signal glomerular disease. 1
Order a reticulocyte count to confirm that the anemia is hypoproliferative (reticulocyte index < 1.0–2.0), which is typical of anemia of chronic disease and helps exclude hemolysis or acute blood loss as contributing factors. 2
Consider age-appropriate malignancy screening (e.g., chest X-ray, abdominal/pelvic CT, tumor markers) because ferritin > 1000 ng/mL in the setting of normocytic anemia and ongoing pain raises suspicion for occult solid tumor or hematologic malignancy such as lymphoma or myeloma. 1
Pain Assessment and Symptom-Directed Testing
If your patient's pain is musculoskeletal or systemic, order rheumatologic serologies (ANA, rheumatoid factor, anti-CCP) to screen for autoimmune inflammatory conditions such as rheumatoid arthritis or systemic lupus erythematosus, which commonly cause anemia of chronic disease and can present with hematuria from lupus nephritis. 1
If abdominal pain is present, obtain liver function tests and hepatitis serologies, because chronic liver disease elevates ferritin and can produce normocytic anemia through multiple mechanisms including portal hypertension and splenic sequestration. 1
Critical Pitfalls to Avoid
Do not start empiric iron supplementation when ferritin is 1442 ng/mL, because hepcidin-mediated sequestration prevents iron utilization and supplementation may worsen iron overload without improving hemoglobin. 1
Do not attribute hematuria to menstruation or dismiss it as insignificant in a patient with anemia and systemic inflammation; persistent microscopic hematuria mandates evaluation for glomerular disease or urologic malignancy. 1
Do not delay malignancy work-up while awaiting response to treatment of the anemia; the combination of normocytic anemia, ferritin > 1000 ng/mL, and persistent pain requires parallel investigation for occult cancer. 1
Do not assume the anemia will self-correct once inflammation is treated; monitor hemoglobin every 4–6 weeks and consider erythropoiesis-stimulating agents only if hemoglobin falls below 10 g/dL and remains symptomatic despite optimal management of the underlying condition. 1