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Iron Disorders
Iron Overload
Hemochromatosis
Iron Deficiency Anemia
Anemia of Chronic
Disease
When the body senses a potential threat, iron gets shuttled to ferritin to be
contained so that the harmful invader cannot get to the iron. Just enough iron is
made available to make red blood cells but no surplus is left to nourish harmful
pathogens. Depending on the underlying cause of disease, a person with ACD
will experience a modest decline in hemoglobin. This will take place over time
following the onset of inflammation due to the presence of the infection or
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disease. Hemoglobin values will generally reach a low normal range of 9.510.5
g/dL and remain there within this moderately low range until the underlying
condition is cured. If disease that results in blood loss is present, the person will
develop iron deficiency anemia (IDA). ACD and IDA can be distinguished with a
serum ferritin test.
Taking iron pills for anemia of chronic disease could be harmful, even fatal.
The exact mechanism of ACD is not fully understood. Dr. Eugene Weinberg,
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post supplementation, except in individuals who had low iron stores at the
beginning of the study. Since iron stores were greater after iron supplementation,
Drs. Roughead and Hunts study demonstrated that adaptation in absorption did
not completely prevent differences in body iron stores.
The adaptation to reduce iron absorption even in volunteers with low iron stores
may indicate a localized control system to prevent excessive iron exposure of
intestinal cells. The study is consistent with two systems at work, one that
regulates how much iron we must absorb for normal function, and the iron
withholding defense system, which protects us from nurturing harmful pathogens
with excesses of iron we dont presently need.
In adults, anemia of chronic disease is likely due to some common ailment such
as urinary tract infection, a head or chest cold, mononucleosis, tonsillitis or strep,
stomach or intestinal flu, and bacterial infections such as H. pylori. ACD can also
occur when an autoimmune disease is present. Most of these conditions are
treatable and when the patient is cured, the anemia will be corrected. If the
anemia persists once an illness is cured, the doctor will want to investigate
further for a secondary underlying cause of anemia that may be more serious
such as kidney disease, tumor, or cancer.
Anemia of chronic disease can be an indicator that a serious life-threatening
condition is in the initial stages of development. However, when disease
advances beyond this mild form of anemia, where treatment of the underlying
condition cannot affect a cure, levels such as serum ferritin and transferrin iron
saturation percentage change. For this reason, persons who have experienced
anemia of chronic disease, where suspected underlying conditions have been
addressed but the anemia persists, further investigation is needed. Blood loss,
kidney function, bone marrow function, cancer, abnormal absorption or chronic
hemolysis could be pursued as causes.
Anemia of chronic disease can also be present even when tissues have
excessive levels of iron. Tissue iron is different from functional iron in
hemoglobin. Persons with hereditary hemochromatosis can have excessively
high tissue iron but develop anemia because of iron damage to the kidney,
anterior pituitary, or bone marrow. The damaged kidney produces less
erythropoietin, a hormone vital to red blood cell production (erythropoiesis). An
inflamed or damaged anterior pituitary can result in hypothyroidism, which
causes diminished erythropoiesis and mild anemia. The bone marrow is the site
of red blood cell formation.
Differentiating between anemia of chronic disease and iron-deficiency anemia
Patients with anemia of chronic disease do not generally have hemoglobin
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values below 9.5 g/dL, although levels can go much lower. Iron-deficiency
anemia is often suspected in patients with anemia of chronic disease because
the two conditions have many similarities. In both conditions, the serum iron level
is low. Small or microcytic cells can be present in either disorder, though this type
of cell is more indicative of true iron deficiency. Transferrin, a protein that
transports iron, is elevated in iron-deficiency anemia, indicating that the body
needs more iron. The total iron-binding capacity (TIBC), an indirect
measurement of transferrin, is low in anemia of chronic disease because there is
ample iron, but it is not easily available. TIBC tends to be increased when iron
stores are diminished and decreased when they are elevated. In iron-deficiency
anemia, the TIBC is higher than 400450 mcg/dL because stores are low. In
anemia of chronic disease, the TIBC is usually below normal because the iron
stores are elevated.
In nearly two-thirds of the patients, the serum ferritin is one test that can be used
to distinguish between anemia of chronic disease and iron-deficiency anemia.
Ferritin is an acute-phase reactant, which means that it can be elevated in the
presence of inflammation and this factor must be taken into consideration when
examining the findings. Serum ferritin can be raised to normal levels even in the
presence of iron deficiency. For this reason, difficulties arise in distinguishing iron
deficiency in a patient with inflammation or infection from the anemia of chronic
disease. Tests for inflammation like CRP are not helpful in this case. For some
cases in which both iron deficiency and anemia of chronic disease are possible,
bone marrow aspiration with iron staining is the traditional means of determining
that a person is iron deficient. However the serum transferrin receptor test can
be used to help differentiate between iron-deficiency anemia and anemia of
chronic disease. The serum transferrin receptor is much less affected by
inflammation than serum ferritin; results will be high in iron-deficiency anemia
and usually low to low-normal in anemia of chronic disease. The ratio of the
serum transferrin receptor to the logarithim of the serum ferritin concentration is
better able to distinguish anemia of chronic disease from iron deficiency than is
either test alone.
The greatest risk for harm is mistaking anemia of chronic disease for
iron-deficiency anemia and allowing the patient to take iron pills. This risk can be
reduced or eliminated by differenetiating between to the two iron disorders with
serum ferrtin test and by informing the patient about the differences in these two
iron disorders.
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Treatment
There is no treatment for anemia of chronic disease except to address the
underlying condition. Iron supplementation is inappropriate in these patients
because the added iron can become free to nourish bacteria and cancer cells.
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