Pathophysiology
Acute-phase and cytokines proteins play a crucial role in the pathogeneses of anemia of chronic disease (ACD). The iron metabolism alterations through the ferritin and hepcidin molecule are mainly responsible for the resultant anemia. There could also be a concomitant iron deficiency which would affect the therapeutic and diagnosis protocol. Hanif, & Anwer. (2020), mention that incidences of ACD have been known to increase with age, and it affects up to 77% of the elderly. No single clear cause of anemia has been found, thus showing it as a multifactorial etiology.
ACD is found in patients whose present illness elicits active inflammatory/immune responses, contributing to reduced iron uptake. The condition was observed by Nalado et al. (2020) as a moderate to mild anemia among patients diagnosed with other chronic disease conditions, which may not be inflammatory. The ACD is also typical in several diseases such as chronic infections, malignancies, and auto-immune diseases, which indicates the diversity in this condition’s pathogenic pathways. The common symptoms include paleness of the skin, fatigue and feeling weak, sweating, shortness of breath, headaches, rapid heartbeat, feeling faint and dizzy.
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Diagnostic Testing and Rationale
The wide-ranging settings in which ACD is seen make diagnosis challenging. Therefore, confounding conditions, nutritional deficiencies, hemoglobinopathies, hemolysis or bleeding, recurrent phlebotomy, medications, born marrow infiltration, or infection may impact the hematological picture . Nalado et al. (2020) indicates that u sually, anemia is mild to moderate, normocytic and normochromic though anemia may be microcytic as it progresses) and the low count of reticulocyte, which all show this condition’s hypo proliferative nature. Inflammation can be inferred for other blood count features such as thrombocytosis or monocots, neutrophilia, and via measurement, if there are no markers for non-specific inflammatory, like erythrocyte sedimentation rate (ESR) or C‐reactive protein (CRP).
The doctors must carry out a blood test to examine the availability of low hemoglobin levels. Hanif & Anwer (2020) point out that for adult women, the average hemoglobin level should be 12.3-15.3 g/dL, and adult men should have a group of 14-17.5 g/Dl. The finger-stick test is also ideal for measuring Hemoglobin. A blood test will reveal the overall capacity of iron-binding, a count of reticulocytes low. Repo et al (2021) also shows a higher level of sedimentation being released within the blood from inflammatory proteins.
A bone marrow biopsy can also be done. Tomasz, Ewa, & Jolanta (2020) say that one can do the test in an outpatient setting with light sedation or local anesthesia. The examination will reveal an increase in iron stores from the collected bone marrow. It will also show a low serum level of iron which indicates ACD.
Evidence-based treatment modalities
S hort-term RCTs have shown a reduction in iron test status by using intravenous iron treatments administered to patients in need of iron therapy. Also, best practice calls for the need to ensure that CHR is within ferritin and TSAT guidance. Nalado et al. (2020) show that the clinical practice recommendations advocate administering iron to serum ferritin of 500 ng/ml. When prescribing iron therapy, it is crucial to balance the potential benefits of minimizing or avoiding blood transfusion. Treatment on underlying malignant or inflammatory processes associated with ACD will continually improve the level of anemia. For example, Salad et al. (2020) say that it can be through the use of corticosteroids in polymyalgia rheumatic, the use of TNF‐α inhibitors for IBD- inflammatory bowel disease treatment, or rheumatoid arthritis, and use of the antiretroviral drug for human immunodeficiency virus (HIV) infection. Gupta, et al. (2020) have proposed the use of preoperative intravenous IV Irion treatment to treat iron deficiency and preoperative anemia.
Inform Practice
Implication through the up-to-date, evidence-based treatment guidelines enables me to correlate the possible clinical pathways of underlying diseases with the patient's Ferro kinetic state. Through the knowledge from scientifically proven data, I can rule out iron deficiency with other causes of anemia that can lead to misdiagnosis. Also, the acute phase and cytokines protein play a crucial role in anemia of chronic disease pathogenesis.
Patient Education
I will ensure that I offer individualized therapy that accounts for the benefits and risks of Hb concentration decline. I will also inform the patients of the implications of ESA that are needed to maintain Hb concentration. If need be, I will notify the patient of the necessity of a blood transfusion. I will also inform the patient of the implication of lab reports on blood count that include red cell indices, Hb concentration, platelet count, and white blood cells count, among other vital pieces that will determine the appropriate approach to treatment.
Most Important Information
The most important message is the need to investigate anemia. Hanif & Anwer (2020) say that the following tests have to be included in the initial evaluation: blood counting, serum ferritin, TSATM folate, serum vitamin b12 levels, TSAT, and Absolute reticulocyte count .
Challenging Information
Various opinions have come up on the most preliminary aspects to measure. Some prefer the use of patients' serum folate level, yet it has no scientific grading. Other nephrologists have chosen the use of folate supplementation without having to measure the serum folate. This difference in opinions is, therefore, confusing. The is also the question of whether in not to consider blood transfusion as an ideal treatment. As per the conditions of acute infections, ESA's responsiveness decreases and may also get lost completely. Therefore, increasing the ESA according to Warner, et al, (2929) does not generally cause an improvement in anemia, yet at the same time, it might necessitate a blood transfusion. Therefore, there is a need to balance the benefits of transfusions in treating weaknesses and consider its risks from sensitization, especially when the patient needs a renal transplant. Tomasz et al. (2020) indicate that transfusion is only preserved for patients with life-threatening or severe anemia within the ACD context and not sustainable for patients with forms of chronic anemia.
Patient Safety Issue
The recommendation calls for great caution when using ESA therapy, especially among CKD patients who have active malignancy. Tomasz, Ewa, & Jolanta (2020) add that these are patients with a history of malignancy or stroke. Also, there is a need to take extra caution when opting for blood transfusion as am iron therapy to avoid exposing the patient to unknown long-term risks. The recommendation indicates that one can consider transfusion of a CKD patient with less acute anemia within the arbitrary threshold Hb, but at the same time determined by symptoms causing anemia.
References
Gupta, S., Panchal, P., Gilotra, K., Wilfred, A. M., Hou, W., Siegal, D.,... & Belley-Cote, E. P. (2020). Intravenous iron therapy for patients with preoperative iron deficiency or anaemia undergoing cardiac surgery reduces blood transfusions: a systematic review and meta-analysis. Interactive CardioVascular and Thoracic Surgery , 31 (2), 141-151..
Hanif, N., & Anwer, F. (2020). Chronic Iron Deficiency. StatPearls [Internet] .
Repo, M., Hannula, M., Taavela, J., Hyttinen, J., Isola, J., Hiltunen, P.,... & Lindfors, K. (2021). Iron Transporter Protein Expressions in Children with Celiac Disease. Nutrients , 13 (3), 776.
Salado, A. M., Olorunfemi, G., Dix-Peek, T., Dickens, C., Khambule, L., Snyman, T.,... & Naicker, S. (2020). Hepcidin and GDF-15 are potential biomarkers of iron deficiency anemia in chronic kidney disease patients in South Africa. BMC nephrology , 21 (1), 1-10.
Tomasz, G., Ewa, W., & Jolanta, M. (2020). Biomarkers of iron metabolism in chronic kidney disease. International Urology and Nephrology , 1-10.
Warner, M. A., Shore-Lesserson, L., Shander, A., Patel, S. Y., Perelman, S. I., & Guinn, N. R. (2020). Perioperative anemia: prevention, diagnosis, and management throughout the spectrum of perioperative care. Anesthesia & Analgesia , 130 (5), 1364-1380.
