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Anemia of Chronic Disease
The document discusses anemia of chronic disease (ACD) and its relationship with various conditions such as chronic kidney disease and malignancies. It outlines causes, clinical features, evaluation methods, and treatment options including the use of erythropoietin-stimulating agents and iron supplementation. Anemia affects patient outcomes, particularly in those undergoing chemotherapy, necessitating careful management and monitoring.
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Anemia of Chronic Disease
- 1. Anemia of ChronicDisease Or, Anemia of Inflammation (AI) Dr. Subhash Thakur Clinical Oncologist MD (PGIMER, Chandigarh) 4/19/2021 MBBS 3rd year Lecture CMC, Bharatpur, Nepal
- 2. Contents • Anemia inCKD • Causes • Work up • Treatment options • Anemia in malignancies • Causes • Effects • Management • Introduction • Etiology and Pathophysiology • Clinical Features • Evaluation • Management
- 3. Introduction • Any majordisease except than blood loss • Rheumatoid Arthritis • Hematological and Solid malignancies • End Stage Renal Disease • Chronic Infections
- 4. Causes • Infections • HIV •Tb, sepsis • Malaria etc • Cancer • Hematological Malignancies • Solid Tumors • Autoimmune • Rheumatoid arthritis • SLE • Vasculitis • Sarcoidosis • Inflammatory Bowel Diseases
- 5. Pathophysiology • Not ableto utilize stored iron and produce red cells and make Hb • Inadequate erythrocyte production or increased red cell destruction • Inhibition of intestinal absorption of iron • Low serum Iron • Low binding capacity (low transferrin) • Usually are normocytic normochromic but can be microcytic and hypochromic
- 7. Prevalence • Infectious Diseases:Developing and under developed countries • Malignancies and Inflammatory Diseases: Developed countries • 3rd most prevalent anemia after IDA and thalassemia
- 8. Clinical Features • Signand Symptoms of underlying causes • Anemia Symptoms: tiredness, fatigue, shortness of breath, light headedness, confusion etc
- 9. Evaluation • Decreased Fe2++ •Increased Ferritin • Decreased TIBC
- 10. Management • Effective treatmentof the underlying disease • Anemia that present in setting of infections, inflammation or malignancies require sufficient diagnostic studies to more threatening causes such as occult hemorrhage, iron, B12 or folate deficiency, hemolysis and drug reaction.
- 11. Treatment Treatment ACD ACDwith true ID Treatment of underlying disease Yes Yes Transfusion Yes Yes Iron supplementation No Yes Erythropoietic agents Yes Yes, in patients who do not have response to iron therapy
- 12. Anemia in ChronicKidney Disease
- 13. Causes leading toAnemia • Decreased erythropoietin production (most important) • RBCs –Shorter half life • Blood loss during dialysis • Iron deficiency
- 14. Work Up • Initiatewhen Creatinine Clearance is <60 ml/min or Hb<11 gm/dl • Hb/Hematocrit • MCV • Iron Studies : Fe++, Fe+++ • TIBC (transferrin Saturation) • Stool guaic
- 15. Treatment Options • Iron •ESA (Erythropoietin Stimulating agent) • Blood transfusions • Folic acid and Vitamin B12
- 16. ESAs • Epoietin –alpha : SC/IV • Darbepoietin
- 17. When to Start •Address all correctable causes of anemia including iron deficiency and inflammations prior to initiation of ESA therapy • When Hb<10 gm/dl • Target : 10 – 11.5 gm/dl • Avoid High concentration > 13 gm/dl
- 18. Dose • Epoietin alpha:20 – 50 IU/kg body weight three times a week • Darbepoietin: 0.45 microgram/kg, once weekly • Caution : CVD thromboembolism, seizure
- 19. ESA Monitoring • Hbconcentration initially every 1-2 weeks followed by 2-4 weeks when stable. • Monitor BP • Iron stores: • Ferritin target: 200 – 500 • TIBC > 20 %
- 20. Common causes ofinadequate responses to ESA therapy • IDA (most common) • Infections or inflammations • Others: Chronic blood loss, renal bone disease, vitamin B12/folate deficiency, hemolysis, Vitamin C deficiency • Iron Therapy: parenteral route is preferred
- 21. ACD in Malignancies •Frequent complication • Etiology: Cancer itself and treatment: Chemotherapy and radiation therapy
- 22. Associated with • Fatigue •Impaired physical function • Reduced quality of life
- 23. Consequences of anemiaon cancer • Impaired response to cancer treatment • Reduced overall survival
- 24. Management • When shouldESA treatment be considered? Ans : Patients undergoing chemotherapy after correction of iron deficiency and other underlying causes
- 25. Which patients shouldreceive ESA? • Patients with symptomatic anemia • Patients receiving chemotherapy or radio-chemotherapy and develops anemia • Hb<10 gm/dl • Asymptomatic patients undergoing chemotherapy and Hb<8 gm/dl
- 26. Should patients whodo not receive Chemotherapy treatment be treated with ESA? • No
- 27. What is theHb target range for treatment with ESA • Hb – 12 gm/dl without RBC transfusion
- 28. At what doseshould ESA be started • Epoietin: 450 IU/wk/kg body weight (alpha, beta and zeta) • Darbepoietin : 6.75 microgram/kg – 3 weekly 8.25 microgram/Kg ---- weekly 20000 IU weekly – Epoietin theta
- 29. Which patients shouldbe considered for RBC transfusion? • Patients with Hb<7-8 gm/dl or severe anemia related symptoms even at higher Hb
- 30. Management of ChTinduced anemia in patients with solid and hematological malignancies • Assess Hb, iron status (TSAT, SF) and CRP at baseline and before the Chemotherapy Cycle.
- 31. Hb 10-11 gm/dl 1.? ID (TSAT<20%, SF < 100 ng/ml) : IV Iron 1000 mg 2. Vitamin B12/folate deficiency: B12/folate: low serum B12/folate : B12/folate 3. Other causes of anemia: treat underlying cause
- 32. Hb: 8-10 gm/dl •Vitamin B12 or folate deficientcy if yes, supplement • SF, if < 100 ng/ml (Absolute ID)– IV iron, add ESA if Hb still < 10 gm/dl • TSAT <20%, SF normal (Functional ID) – ESA + iron IV (1000 mg) • TSAT normal, SF normal – ESA, add iv iron if Hb still<10 gm/dl
- 33. Hb<7-8 gm/dl • RapidHb increase needed: RBC transfusion
- 34.
- 35. 1. Which ofthe following is NOT a cause of microcytic anemia a. Thalassemia b. Anemia of chronic disease c. Iron deficiency anemia d. Pancytopenia e. Lead poisoning
- 36. 2. The labreports for a patient with low mean cell volume show high serum ferritin and low total iron binding capacity. What is the most likely cause for this patient’s anemia? a. Fe deficiency b. Anemia secondary to inflammation c. Thalassemia d. Hemoglobinopathy
- 37. 3. Fe isabsorbed in the a. Stomach b. Duodenum c. Jejunum d. Ileum
- 38. Q4. Where ismost non heme iron found in the body? a. Bound to IF b. Bound to transferrin c. Free in plasma d. Stored in liver
- 39. Q5. Select thefollowing that enhance Fe absorption (select all that apply) a. Citric acid b. Polyphenols (tea) c. Phytate (bran) d. Calcium e. Ascorbic acid
- 40. Q6. What isthe most important test for Fe stores? a. Serum iron b. TIBC c. Serum ferritin
- 41. Q7. Which ofthe following is not an etiology of Fe deficiency anemia? a. Chronic blood loss b. Increased requirement c. Infection d. Malabsorption e. Decreased intake
- 42. Q8. TIBC increasesin iron deficiency anemia because a. Inflammatory response to deficiency b. Compensation by other factors c. Ability to absorb increases
- 43. Q9. Pica, aclinical presentation for Fe deficiency anemia, is a. Itchiness b. ED c. Desire to eat weird things d. A small woodland creature
- 44. Q10. Which labinvestigations would you order if you suspect Fe deficiency anemia? (check all that apply) a. CBC b. Blood smear c. Serum iron d. Serum ferritin e. TIBC f. All of the above