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Anemia of Inflammation and Chronic Disease

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Anemia of Inflammation and Chronic Disease Anemia of Inflammation and Chronic Disease National Hematologic Diseases Information Service What is anemia? What is anemia of Anemia is a condition in which a person inflammation and chronic has a lower than normal number of red disease (AI/ACD)? blood cells or the amount of hemoglobin in the red blood cells drops below normal, Anemia of inflammation and chronic which prevents the body’s cells from getting disease is a type of anemia that commonly enough oxygen. Hemoglobin is an iron-rich occurs with chronic, or long term, illnesses protein that gives blood its red color and lets or infections. Cancer and inflammatory red blood cells transport oxygen from the disorders, in which abnormal activation of lungs to the body’s tissues. Therefore, low the immune system occurs, can also cause numbers of red blood cells or low levels of AI/ACD. hemoglobin also cause low blood iron levels. AI/ACD is easily confused with iron- People with anemia may feel tired because deficiency anemia because in both forms their blood does not supply enough oxygen of anemia levels of iron circulating in the to the body’s organs and tissues. If anemia blood are low. Iron in the body is found both becomes severe and prolonged, the lack of circulating in the blood and stored in body oxygen in the blood can lead to shortness of tissues. Circulating iron is necessary for red breath or exercise intolerance—a condition blood cell production. Low blood iron levels in which a person becomes easily fatigued occur in iron-deficiency anemia because during or after physical activity—and levels of the iron stored in the body’s tissues eventually can cause the heart and other are depleted. In AI/ACD, however, iron organs to fail. stores are normal or high. Low blood iron levels occur in AI/ACD, despite normal iron stores, because inflammatory and chronic diseases interfere with the body’s ability to use stored iron and absorb iron from the diet. AI/ACD is the second most common form of anemia, after iron-deficiency anemia.1 1Agarwal N, Prchal JT. Anemia of chronic disease (anemia of inflammation). Acta Haematologica. 2009;122(2–3):103–108. Who gets AI/ACD? Infectious and inflammatory diseases. As part of the immune system response that While AI/ACD can affect people at any age, occurs with infectious and inflammatory older adults are especially at risk because diseases, cells of the immune system release they have the highest rates of chronic proteins called cytokines. Cytokines help disease. AI/ACD is also common among heal the body and defend it against infection. hospitalized patients, particularly those with However, they can also affect normal body chronic illnesses. functions. In AI/ACD, immune cytokines More than 130 million Americans live with interfere with the body’s ability to absorb and at least one chronic illness.2 Addressing use iron. Cytokines may also interfere with the causes of anemia in people with chronic the production and normal activity of EPO. disease can help improve their health and Infectious diseases that cause AI/ACD quality of life. include What causes AI/ACD? • tuberculosis, an infection in the lungs Anemia of inflammation and chronic disease • HIV/AIDS, an infection that destroys is caused by red blood cells not functioning the immune system normally, so they cannot absorb and use • endocarditis, an infection in the heart iron efficiently. In addition, the body cannot respond normally to erythropoietin (EPO), a • osteomyelitis, a bone infection hormone made by the kidneys that stimulates Sometimes, acute infections—those that bone marrow to produce red blood cells. develop quickly and may not last long—can Over time, this abnormal functioning causes also cause AI/ACD. a lower than normal number of red blood cells in the body. Inflammatory diseases that can lead to AI/ACD include Some of the chronic diseases that lead to AI/ACD include infectious and inflammatory • rheumatoid arthritis, which causes pain, diseases, kidney disease, and cancer. Certain swelling, stiffness, and loss of function treatments for chronic diseases may also in the joints impair red blood cell production and • lupus, which causes damage to various contribute to AI/ACD. body tissues, such as the joints, skin, kidneys, heart, lungs, blood vessels, and brain 2Chronic diseases and health promotion. Centers for Disease Control and Prevention website. www.cdc.gov/nccdphp/overview.htm. Updated August 13, 2012. Accessed July 24, 2013. 2 Anemia of Inflammation and Chronic Disease • diabetes, in which levels of blood Cancer. AI/ACD can occur with certain glucose, also called blood sugar, are types of cancer, including Hodgkin’s disease, above normal non-Hodgkin’s lymphoma, and breast cancer. Like infectious and inflammatory diseases, • heart failure, in which the heart cannot these types of cancer cause inflammatory pump enough blood to meet the body’s cytokines to be released in the body. Anemia needs can also be made worse by chemotherapy • inflammatory bowel disease (IBD), and radiation treatments that damage the diseases that cause inflammation and bone marrow, and by the cancer’s invasion of irritation in the intestines bone marrow. IBD, including Crohn’s disease, can also cause iron deficiency due to poor absorption What are the symptoms of of iron by the diseased intestine and bleeding A I /AC D? from the gastrointestinal (GI) tract. Anemia of inflammation and chronic disease Kidney disease. People with kidney disease typically develops slowly and, because can develop anemia for several different it is usually mild, may cause few or no reasons. Diseased kidneys often fail to symptoms. Symptoms of anemia may also be make enough EPO. In addition, kidney masked by the symptoms of the underlying disease results in abnormal absorption and disease. Sometimes, AI/ACD can cause or use of iron, which is typical of AI/ACD. contribute to Anemia worsens as kidney disease advances. • fatigue Therefore, most people with kidney failure have anemia. Kidney failure is described as • weakness end-stage kidney disease, sometimes called • pale skin ESRD, when treated with a kidney transplant or blood-filtering treatments called dialysis. • a fast heartbeat People with kidney failure can also develop • shortness of breath iron deficiency due to blood loss during • exercise intolerance hemodialysis, a type of dialysis that uses a special filter called a dialyzer to remove wastes from the blood. Low levels of iron and folic acid—another nutrient required for normal red blood cell production—may also contribute to anemia in people with kidney disease. 3 Anemia of Inflammation and Chronic Disease How is AI/ACD diagnosed? How is AI/ACD treated? To diagnose AI/ACD, a health care provider Anemia of inflammation and chronic disease orders a blood test called a complete blood often is not treated separately from the count (CBC). A blood test involves drawing condition with which it occurs. In general, a person’s blood at a health care provider’s health care providers focus on treating office or commercial facility and sending the underlying illness. If this treatment the sample to a lab for analysis. The CBC is successful, the anemia usually resolves. includes a measurement of a person’s For example, antibiotics prescribed for hematocrit, the percentage of the blood that infection and anti-inflammatory medications consists of red blood cells. The CBC also prescribed for rheumatoid arthritis or IBD measures the amount of hemoglobin in the can cause AI/ACD to disappear. However, blood and can show whether a person has a AI/ACD is increasingly being viewed as lower than normal number of red blood cells. a medical condition that merits direct treatment. In addition to measuring hematocrit and hemoglobin, the CBC includes two other For people with cancer or kidney disease measurements to show whether a person has who have low levels of EPO, a synthetic enough iron: form of EPO may be prescribed. A health care provider usually injects EPO • The ferritin level indicates the amount subcutaneously—under the skin—two or of iron stored in the body. A ferritin three times a week. A person may be taught score below 200 nanograms per liter is how to inject the EPO at home. People a sign that a person may have an iron on hemodialysis who cannot tolerate EPO deficiency. shots may receive EPO intravenously during • The transferrin saturation (TSAT) is hemodialysis. a score that indicates how much iron If iron deficiency has a role in causing is available, or circulating, to make AI/ACD, a person may need iron red blood cells. A TSAT score below supplements to raise hematocrit to a target 20 percent is another sign of iron level. Iron supplements can be taken by deficiency.3 pill, subcutaneously, or intravenously during A CBC result that shows low iron levels in hemodialysis. the blood yet normal measures of iron stores People with kidney disease and AI/ACD in the body is a hallmark of AI/ACD. may also be advised to take vitamin B12 and folic acid supplements. A person should talk with a health care provider before taking any supplements. Read more in Anemia in Kidney Disease and Dialysis at www.kidney.niddk.nih.gov. 3Besarab A, Coyne DW. Iron supplementation to treat anemia in patients with chronic kidney disease. Nature Reviews Nephrology. 2010;6(12):699–710. 4 Anemia of Inflammation and Chronic Disease Eating, Diet, and Nutrition People with anemia caused by iron, vitamin Points to Remember B12, or folic acid deficiencies are usually • Anemia is a condition in which a advised to include sources of these nutrients person has a lower than normal in their diets. number of red blood cells or the Dietary sources of iron include amount of hemoglobin in the red blood cells drops below normal, • beans which prevents the body’s cells • breakfast cereals from getting enough oxygen.
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