Conditions · Hematology and oncology
Anaemia of chronic disease (anaemia of inflammation) !
Anaemia of chronic disease is a mild anaemia caused by long-lasting inflammation, infection or cancer that locks iron away from new red cells.
Updated 2026-11-01
Structures involved
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In the clinical exam
Why it happens
- Systemic effects of inflammation: fever, acute-phase proteins, leukocytosis, sepsis
- Local effects of tumours and cancer cachexia
- Body iron balance
- Erythropoiesis and erythropoietin
- Iron metabolism
What it is
A usually mild to moderate, normocytic or slightly microcytic anaemia that develops in chronic inflammatory, infectious or malignant disease. Iron is present in the body but trapped in storage, so the marrow cannot use it.
Who gets it
The second most common anaemia after iron deficiency and the most common in hospitalised and older patients. In Colombia and Latin America, chronic infections such as tuberculosis and HIV, autoimmune disease, cancer and chronic kidney disease are frequent causes, and it often coexists with iron deficiency.
Causes
- Chronic infections (tuberculosis, HIV, osteomyelitis, endocarditis, chronic hepatitis)
- Autoimmune and inflammatory diseases (rheumatoid arthritis, lupus, inflammatory bowel disease)
- Cancers, especially lymphomas and solid tumours
- Chronic kidney disease (also low erythropoietin)
- Heart failure and ageing-related inflammation
Risk factors
- Any long-standing inflammatory, infectious or malignant disease
- Older age
- Chronic kidney disease
Pathophysiology
Inflammatory cytokines, especially interleukin-6, make the liver produce hepcidin. Hepcidin breaks down ferroportin, the iron exporter, so iron stays inside macrophages and is not absorbed from the gut. Cytokines also blunt erythropoietin release and the marrow's response to it and shorten red-cell survival, giving an iron-restricted, hypoproliferative anaemia.
Symptoms and signs
- Often few symptoms beyond those of the underlying disease
- Fatigue and weakness
- Pallor
- Breathlessness on exertion
- Headache
Diagnosis
- Clinical
- Anaemia in a person with a known chronic inflammatory, infectious or malignant disease; a search for an occult disease when none is known.
- Tests
- Normocytic or mildly microcytic anaemia with low reticulocytes. Low serum iron and low or normal transferrin (TIBC) with low transferrin saturation, but normal or high ferritin (ferritin is an acute-phase reactant). Raised CRP and ESR. Soluble transferrin receptor is normal (high in iron deficiency) and helps detect combined deficiency. Bone marrow examination is rarely needed.
- Imaging
- Not needed for the anaemia itself; imaging is guided by the suspected underlying disease.
Differential diagnosis
- Iron deficiency anaemia (high TIBC, low ferritin)
- Thalassaemia trait (microcytosis with normal iron studies)
- Sideroblastic anaemia
- Anaemia of chronic kidney disease
- Myelodysplastic syndrome or marrow infiltration
Goal of treatment
Treat the underlying disease, which is the main way to correct the anaemia, and support haemoglobin only when symptoms or comorbidities require it.
Treatment
- Medical
- Control of the underlying infection, inflammation or cancer usually improves the anaemia.
- Medical
- Intravenous iron when true iron deficiency coexists (oral iron is poorly absorbed while hepcidin is high).
- Medical
- Erythropoiesis-stimulating agents in selected patients, mainly with chronic kidney disease or chemotherapy, with attention to thrombotic risk.
- Acute
- Red-cell transfusion for severe or symptomatic anaemia, such as with myocardial ischaemia.
Complications
- Reduced exercise capacity and quality of life
- Worsening of heart failure and angina
- Higher mortality in heart failure and chronic kidney disease
Prognosis
Depends on the underlying disease; the anaemia usually improves when the cause is controlled.
Test yourself
Think of the answer, then tap the question to see it.
Which hormone is central to the pathophysiology of anaemia of chronic disease?
Hepcidin, produced by the liver in response to interleukin-6, which blocks ferroportin and traps iron.
How do ferritin and TIBC differ between anaemia of chronic disease and iron deficiency?
In chronic disease ferritin is normal or high and TIBC low; in iron deficiency ferritin is low and TIBC high.
What is the usual red-cell size in anaemia of chronic disease?
Normocytic, sometimes mildly microcytic.
What is the main treatment of anaemia of chronic disease?
Treating the underlying disease; iron, erythropoiesis-stimulating agents or transfusion only in selected cases.
Related conditions
- Iron deficiency anaemia
- Rheumatoid arthritis
- Chronic kidney disease
- Tuberculosis
- HIV infection and AIDS
- Crohn disease
- Thalassemias (α and β)
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Anemia of chronic disease (MedlinePlus (U.S. National Library of Medicine), 2024).
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