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Anemia Guide


Anemia due to chronic diseases

Anemia due to chronic diseases

General Overview
As the name suggests, anemia of chronic disease refers to anemia that develops as a result of a chronic diseases such as cancer, serious infections or inflammation, and autoimmune conditions (A condition where your body's immune system mistakenly kills the healthy cells of your body). Anemia of chronic illness is the second most common cause of anemia. Anemia of chronic illness often co-exists with iron deficiency anemia (IDA).
Introduction
Your blood consists of liquid called plasma and three main types of blood cells:

White blood cells, which help your body to fight infections, platelets, which help in the clotting process when you suffer a cut, or injury, red blood cells (RBC), which help carry oxygen from your lungs, with the help of a protein called hemoglobin, to all the cells and organs of your body. This supply of oxygenated blood to all the cells of the body is crucial for normal functioning. Oxygenated blood helps give your body its energy and your skin a healthy glow.

Your bone marrow contains special cells called stem cells, which are responsible for producing blood cells  RBC, WBC, and platelets. Your bone marrow needs to continually produce new blood cells of all 3 types to replace old ones that die. RBCs live for about 120 days, platelets about 7 days and most WBC a day or less before they are used and absorbed by your body. The blood cells produced in the bone marrow enter your bloodstream, to replace old cells. Normally this process is regulated, such that blood cells that die are constantly replaced by new ones.

Iron is an essential element in the function of all cells. The key role of iron in your body is to carry oxygen, as part of hemoglobin to the various cells and organs of the body. The body's source of iron is from the food we eat. Iron is absorbed from the intestines, attaches to a protein in the blood and is stored in the bone marrow, where it is used to produce hemoglobin.

Most often a problem in iron absorption is the cause of anemia due to chronic disease.
Signs and Symptoms
Symptoms associated with anemia due to chronic disease are similar to those seen with anemia in general. If you have low to moderate anemia, you will experience increased tiredness, shortness of breath, rapid heart beat, cold hands and feet, light headedness, dizzy spells, and sore tongue. In advanced stages you may notice cracks at the corners of your mouth, and spoon shaped finger nails.
Causes
There are three possible mechanisms that have been identified as responsible for causing anemia during chronic diseases:
Shortened RBC lifecycle: The RBCs in your body live for about 120 days before they are absorbed by your body. It has been observed that in anemia associated with chronic diseases, the RBCs have a shorter lifespan – This means that you will have fewer RBCs in your blood to carry oxygen to the various cells of your body. This is seen quite often in patients with cancer and infectious diseases.
Impaired Erythropoiesis: Erythropoiesis refers to the process of RBC formation inside your bone marrow (a red spongy material inside the cavity of some of your large bones, like your hip bone). For RBC to be formed your bone marrow requires a substance called erythropoietin, it has been determined that there is decreased availability of erythropoietin, because of which there is decreased/impaired production of RBC.
Impaired Iron absorption: Iron that is absorbed from the food you eat is stored in the cells of you body and released during RBC production. It is believed that in anemia of chronic disease, there is a problem in the iron transfer protein – Transferrin which causes the reticulocytes (young RBCs that grow into mature RBCs) to not receive iron leading to the reduced formation of new RBC, leading to anemia.

Risk Factors
If you have long standing infections, diseases, or inflammation you may be at risk of developing anemia. Some of the common conditions that can lead to anemia associated with chronic disease include:

Kidney failure: In chronic renal failure and patients who are on dialysis, anemia is seen almost always. There are many reasons for anemia in kidney failure; the main reason however is due to the failure of the kidneys to secrete the substance erythropoietin, which we have seen is necessary for RBC production. Blood loss and dialysis can also cause anemia due to kidney failure. Also because your kidneys are not functioning normally, there is accumulation of toxins in your body which can also suppress the functioning of your bone marrow leading to reduced production of RBC and subsequently anemia.

Cancer
: Anemia in cancer may be due to the cancer; products released by the cancer tumors, or may be a result of the treatment:

  • Blood loss as a result of external or internal bleeding from the tumor.
  • Proteins produced by the cancer, that can replace or suppress the bone marrow leading to reduced RBC production
  • Development of antibodies by the body that mistakenly kill the healthy cells of the body including the RBC.
  • Abnormalities in the production of erythropoietin leading to reduced production of new RBC.
Rheumatoid arthritis: Anemia due to rheumatoid arthritis is fairly common though it is usually mild to moderate in nature. Anemia in rheumatoid arthritis is primarily due to increased production of certain inflammatory products which causes a decreased erythropoietin response in the bone marrow.

Crohn's disease: This is a condition in which the lining of your stomach and intestines become inflamed causing ulcers, severe pain, bleeding and diarrhea. You will also notice blood in your stool. Severe crohn's disease can cause serious and continuous bleeding.

Diagnosis and Screening
In order to diagnose your anemia, your doctor may take your medical history, do a physical exam, and order diagnostic tests and procedures

Complete blood count (CBC)
This is one of the first tests your doctor will order. The CBC helps determine a number of things about your condition:
Hemoglobin level: The normal range of hemoglobin is 14-18 gm/dl for males and 12-16gm/dl for females. A low hemoglobin level may indicate IDA
Hematocrit: The hematocrit level measures how much of your blood is made up of RBC. The normal range for hematocrit levels for the general population is 32-43 percent. A low hematocrit level is another sign of anemia.
The CBC also checks the number and size of your RBCs. In anemia due to iron deficiency the number of RBC is usually low and the RBCs are also smaller in size
If the CBC results confirm that you have anemia, your doctor may order additional tests to determine the cause, severity, and correct treatment for your condition. One such test your doctor might order is the reticulocyte count. Reticulocytes are young RBC. This test measures the number of new RBC in your blood. The reticulocyte test is used to determine whether your bone marrow is producing RBC at the proper rate.

Tests That Measure Iron Levels in the Body
Your doctor may also order several tests to check the level of iron in the blood and the body:
Serum iron test: This test measures the amount of iron in your blood. Low levels of iron in your blood can indicate anemia.
Serum ferritin test: Ferritin is a protein that helps store iron in your body. The serum ferritin test provides your doctor with an idea of how much of the body's stored iron has been used up. A depletion in the body's iron stores may indicate anemia
Transferrin level or total iron-binding capacity test (TIBC): Transferrin is a protein that carries iron in your blood. The TIBC test measures how much of the transferrin in your blood is not carrying iron. [NIH.Gov, 2008; Adamson JW, 2005]

Tests that diagnose internal bleeding
Internal bleeding may be seen in some conditions such as Crohn's disease. If your doctor suspects internal bleeding in your stomach or intestines, several tests may be ordered to determine the source of the bleeding:
Fecal occult blood test: This test checks your stool for signs of blood. If blood is found in the stool, further tests may be used to find the source of the bleeding:
Colonoscopy: In this test, a thin, flexible tube attached to a video camera is used to examine the rectum and colon to identify the source of bleeding.
Upper GI endoscopy: In this test, a thin, flexible tube attached to a video camera is used to examine the stomach and upper intestines for signs of bleeding.
Treatment
Treatment of anemia due to chronic diseases is focused on treating or managing the underlying cause of anemia and providing supplements to treat the anemia.

Severity and cause of your anemia determines the therapy that your doctor will advise. In most cases your doctor may prescribe iron supplements to treat your anemia. Your doctor may also prescribe vitamin C to help the body absorb iron from the food you eat. You doctor may also advice a diet rich in iron, folic acid and vitamin C. Vegetarians may be advised to include citrus fruits like oranges, grapes vegetables such as spinach and other dark green leafy vegetables. In severe and life threatening anemia, you may require hospitalization, blood transfusions, and iron injections.
Self Care and Lifestyle Change
You must ensure that you visit your doctor regularly for checkups, take supplements as prescribed by your doctor.

References
 

  • Adamson JW. Iron deficiency and other hyperproliferative anemias. In: Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL, eds. Harrison’s principles of Internal Medicine. 16th ed. Mcgraw-Hill Professional; 2005.
  • Zarchansky R, Houston DS. Anemia of chronic disease – A harmful disorder or an adaptive, beneficial response? CMAJ. 2008;179(4):333-37.