Chronic Anemia
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Anemia is defined as an absolute reduction in the quantity of the oxygen-carrying pigment hemoglobin (Hgb) in the circulating blood. Anemia is further broadly subcategorized into acute and chronic. (See Etiology.)
Anemia usually is grouped into 3 etiologic categories: decreased red blood cell (RBC) production, increased RBC destruction, and blood loss.
Anemia is a manifestation of an underlying disease process and is not a diagnosis in itself. A wide array of diseases, including inflammations, infections, and malignancies, may at some point be associated with anemia. Common conditions associated with anemia include the following:
Gastritis
Gastric or duodenal ulcer
Liver or renal disease
Hypothyroidism
Sickle cell disease
Hypermenorrhea
Previous history of anemia or blood transfusions
Thrombocytopenia or blood coagulation disorders
Cancer or other chronic illness (eg, rheumatic disease)
Poor diet, especially iron deficiency
A disease may lead to anemia through a combination of mechanisms. For example, a gastrointestinal malignancy may cause anemia through blood loss, as well as lead to anemia of chronic disease. (See Etiology.)
Go to Anemia and Pediatric Chronic Anemia for complete information on these topics.
For patient education information, see Anemia.
Possible causes of this condition include iron deficiency, thalassemia, sideroblasts, and lead poisoning.
Anemia of chronic disease commonly is manifested by normocytic normochromic indices; however, microcytic hypochromic indices also can be associated with anemia of chronic disease.
Possible causes of macrocytic anemia include vitamin B-12 deficiency, folate deficiency, liver disease, and hypothyroidism.
Normocytic anemia is further divided into 2 broad categories: anemia with primary bone marrow involvement and anemia secondary to underlying disease.
Anemias with primary bone involvement include aplastic anemia and myelophthisic anemia.
The etiology of myelophthisic anemia involves interruption of normal hematopoiesis due to the accumulation of malignant or reactive cells or cell products. It is characterized by the appearance of immature myeloid cells and nucleated RBCs in the peripheral blood. The 3 major classes of disorders that can produce myelophthisic anemia are intrinsic bone marrow malignancies (eg, leukemia, lymphoma, myeloma), metastatic tumors (eg, neuroblastoma, melanoma), cancers that are more prone to bone marrow metastasis (eg, prostate, breast, lung, stomach, renal carcinomas), and granulomatous disease (eg, tuberculosis, sarcoidosis).
Agnogenic myeloid metaplasia, which is characterized by anemia with primary bone marrow involvement, involves gradual bone marrow fibrosis, extramedullary hematopoiesis, and splenomegaly with no known underlying systemic disorder.
Most cases of anemia in the world are secondary to an underlying disease. The marrow does not respond appropriately to microcytic anemia, leading to decreased production of RBCs. This type of anemia includes that associated with liver cirrhosis, uremia, chronic inflammation, and hypoendocrine conditions (eg, thyroid, adrenal, pituitary disorders).
This type of anemia includes sickle cell anemia, thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome, aortic valve prosthesis, disseminated intravascular coagulation (DIC), cold agglutinin disease, and paroxysmal cold hemoglobinuria (PCH).
The incidence of anemia mirrors the incidence of the underlying cause. Some published studies report the incidence of anemia to be 2-15% in the United States and Great Britain.
Anemia is far more common in underdeveloped countries than in the United States. The true incidence of anemia is difficult to define because of multiple factors (eg, patient population, geographic location, normal range reference, ability to adequately screen for the disease).
Among 292 children in a low-income community in the Dominican Republic, 69.9% were found to be anemic using the World Health Organization (WHO)–recommended hemoglobin cut point of <11.0 g/dl, and 34.6% were classified as anemic using a cut point of <10.0 g/dl. The prevalence of microcytosis in anemic children ranged from 23.5% to 80.2%, depending on the hemoglobin and age-based mean corpuscular volume cut points used. [1]
African Americans have a higher incidence of sickle cell anemia and glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. G-6-PD is essential for RBC protection from oxidative insults and for approximately 10% of RBC energy production.
Mediterranean populations show a higher incidence of beta thalassemia.
Sex distribution varies based on the underlying cause. Overall, females have approximately twice the incidence of males of anemia.
Anemia is prevalent in all age groups. Some younger patients may have a better ability to compensate for anemia, which may delay initial diagnosis.
Prognosis is dependent on several factors. The underlying medical condition usually dictates the prognosis, but comorbid conditions, the chronicity of the disease, and the patient’s diet, age, and access to medical care are contributing factors.
The majority of complications in chronic anemia arise from chronic or persistent tissue hypoxia.
Pediatric patients, elderly patients, and patients who are immunocompromised are at the highest risk for complications, since they have less physiologic reserve.
Failure to comply with follow-up and treatment regimens predisposes patients with chronic anemia to complications.
McLennan JD, Steele M. Extent of microcytic anemia among children in a low-income, peri-urban community in the Dominican Republic using different cut-points. J Trop Pediatr. 2015 Apr. 61 (2):86-91. [Medline].
[Guideline] American College of Obstetricians and Gynecologists (ACOG). Anemia in pregnancy. 2008 Jul. [Full Text].
Zittermann A, Jungvogel A, Prokop S, Kuhn J, Dreier J, Fuchs U, et al. Vitamin D deficiency is an independent predictor of anemia in end-stage heart failure. Clin Res Cardiol. 2011 Apr 7. [Medline].
Omar N, Salama K, Adolf S, El-Saeed GS, Abdel Ghaffar N, Ezzat N. Major risk of blood transfusion in hemolytic anemia patients. Blood Coagul Fibrinolysis. 2011 Apr 19. [Medline].
Gao C, Li L, Chen B, Song H, Cheng J, Zhang X, et al. Clinical outcomes of transfusion-associated iron overload in patients with refractory chronic anemia. Patient Prefer Adherence. 2014. 8:513-7. [Medline].
Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee
Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology
Disclosure: Nothing to disclose.
Eric Wilke, MD Medical Director, Traditions Emergency Medicine, College Station Medical Center
Eric Wilke, MD is a member of the following medical societies: American College of Emergency Physicians, Texas Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians
Disclosure: Nothing to disclose.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Roy Alson, MD, PhD, FACEP Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Associate Medical Director, North Carolina Baptist AirCare
Roy Alson, MD, PhD, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine, World Association for Disaster and Emergency Medicine
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Fredrick Melik Abrahamian, DO, FACEP,to the development and writing of the source article.
Chronic Anemia
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