Anemia of Chronic and Inflammatory Disease (ACD)
Dietitians, especially those who work in long-term care, often encounter low hemoglobin and
hematocrit levels among patients. But does every patient with low hemoglobin and hematocrit
require an iron supplement? Will all patients respond to iron supplements? Do some patients
have anemia of chronic disease that does not need treatment?
Anemia is defined by the World Health Organization as hemoglobin of <12 grams (g)/deciliter
(dL) in women and <13 g/dL in men. It is estimated that as many as 61% of elderly people have
anemia. About 20%–36% of these individuals have idiopathic anemia, meaning no cause of the
anemia is found. Anemia is a marker for increased morbidity, hospitalizations, mortality, and
health care costs in community-dwelling older adults, but similar data on long-term care
residents is scarce.
Anemia of chronic disease, also called anemia of chronic and inflammatory disease (ACD), is a
medical diagnosis. It often coexists with iron-deficiency anemia (IDA). A brief overview of the
condition is found at
http://www.merck.com/mmpe/sec11/ch130/ch130d.html.
When a patient has ACD, iron stores are adequate. This type of anemia is caused by an
underlying medical condition that causes changes in iron metabolism. It is believed that this
mechanism involves the immune system; cytokines and cells of the reticuloendothelial system
induce changes in iron homeostasis, which affects red blood cell production and life span, as
well as intracellular iron metabolism.
Diagnosis of anemia of ACD requires the presence of chronic infection and/or inflammation, and
laboratory testing of serum transferrin receptor and serum ferritin.
Conditions that are associated with ACD include:
 Infections, both acute and chronic, including human immunodeficiency virus (HIV), other viral
infections, and bacterial, fungal, and parasitic infections
 Cancer
 Autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and
inflammatory bowel disease
Anemia is associated with age-associated alterations in cytokine levels, as well as with chronic
kidney disease, but is diagnosed and treated differently than ACD.
Before initiating treatment, it is necessary to differentiate ACD from IDA by using medical
history, physical symptoms, and laboratory analysis. ACD usually is mild to moderate
(hemoglobin 8–9.5 g/dL). Ferritin is an indicator of iron stores, so if the ferritin level is normal to
high, a patient probably has ACD, not IDA.
The following table summarizes how to differentiate between ACD, IDA, and a combination of
the two.
Blood Test
ACD
IDA
ACD and IDA
Iron
Low
Low
Low
Low
High
Low normal or high
Low or normal
Low
Low
High or normal
Low
Low or normal
Normal
High
High or normal
Increased
Normal
Increased
Total iron binding
capacity (TIBC)
% transferrin
saturation
Ferritin
Soluble transferrin
receptor
Cytokine levels
Adapted with permission from AMDA Clinical Practice Guidelines.
Treatment of ACD is based on treatment of the underlying disease, which may in itself resolve
the anemia. In some cases, ACD will not resolve because of the nature of the underlying illness.
Iron supplements are not recommended for individuals with a normal or high ferritin level,
because iron stores are adequate. Long-term transfusion therapy is not recommended for patients
with cancer or chronic kidney disease, because of the risks associated with transfusion. In some
cases of ACD, erythropoietic agents are recommended to increase the production of red blood
cells. However, not every patient with ACD is a candidate for this therapy.
In the long-term care setting, workup for and treatment of anemia will depend on a patient’s
comorbid conditions, quality of life, life expectancy, and wishes. Not all patients are candidates
for a complete evaluation and treatment of anemia.
Implications for dietetics practitioners
Diagnosis of ACD is complicated. Iron supplementation is not helpful for patients with ACD,
because iron stores are adequate. Dietetics practitioners should not base the decision to
recommend iron supplements on a patient’s hemoglobin level alone. They also should consider
the underlying diagnosis and further iron studies to differentiate between IDA and ACD.
References and recommended readings
American Medical Directors Association. Anemia in the Long-Term Care Setting Clinical
Practice Guideline. Columbia, MD: American Medical Directors Association; 2007.
Anemia.org. Handouts: anemia & aging. Available at:
http://www.anemia.org/patients/information-handouts/aging. Accessed August 26, 2012.
Merck Manual for Health Care Professionals. Anemia of chronic disease (iron-reutilization
anemia). Available at: http://www.merck.com/mmpe/sec11/ch130/ch130d.html. Accessed
August 26, 2012.
Review Date 8/12
G-0676