Anemia of Inflammation

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Key points

  • Anemia of inflammation results from hepcidin-induced hypoferremia combined with cytokine-mediated suppression of erythropoiesis and decreased lifespan of erythrocytes.

  • Treatment of the cause of inflammation improves the anemia.

  • Treatment with erythropoiesis-stimulating agents and/or intravenous iron is rarely necessary.

Clinical presentation

  • Mild to moderate anemia (hemoglobin rarely <8 g/dL)

  • Occurring in a setting of infection, inflammatory disease, or malignancy

  • Low serum iron

  • Systemic iron stores not depleted

Pathophysiology

  • Mildly shortened erythrocyte survival (increased destruction)

  • Hypoferremia, iron-restricted erythropoiesis from cytokine-stimulated hepcidin increase

  • Suppression of erythropoiesis by direct effects of cytokines on the marrow

  • Variable effects of inflammation on erythropoietin production, renal excretion of hepcidin

Treatment of AI

  • Treat the underlying disease

  • Treat anemia specifically only if severe or limits activities of daily living

  • Erythrocyte transfusion for acute symptoms

  • Erythropoiesis-stimulating agents (ESAs) with or without IV iron (off-label treatment)

  • Experimental therapies under development include new ESAs, anticytokine drugs, and agents targeting the hepcidin-ferroportin pathway

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