Investigations
1st investigations to order
Hb
Test
The degree of anaemia in ACD is typically mild to moderate (Hb 80 g/L [8 g/dL] to 110 g/L [11 g/dL])
Severe anaemia may indicate an alternative or co-existing cause (e.g., blood loss, iron deficiency anaemia, or a primary haematological disorder).
Result
women <120 g/L (<12 g/dL); men <130 g/L (<13 g/dL)
WBC and differential
Test
Associated infection or other stimuli in anaemia of chronic disease may cause the WBC count, absolute neutrophil count, and/or absolute monocyte count to increase.
Result
count may be elevated
platelet count
Test
Platelets may be mildly to moderately increased due to the underlying infection or inflammation.
Result
may be increased
mean corpuscular volume (MCV)
Test
Anaemia in ACD disease is normocytic or microcytic.
Result
normal or reduced
mean corpuscular haemoglobin concentration (MCHC)
Test
Anaemia in ACD is normochromic or hypochromic.
Result
normal or reduced
peripheral blood smear
Test
Spherocytes, red blood cell (RBC) fragments, macro-ovalocytes, helmet cells, pencil-shaped forms, and nucleated RBCs suggest other diagnoses.
WBCs and platelets are typically normal morphologically or compatible with infection (increased bands, toxic granulation, Dohle's bodies).
Other morphological abnormalities of any cell line should prompt a search for alternative haematological disorders.
Result
RBCs can be microcytic, hypochromic; WBCs and platelets are generally normal in appearance
serum ferritin
Test
Moderately helpful in distinguishing anaemia of chronic disease (ACD) and iron deficiency (ferritin rises in the former and falls in the latter).
Less helpful when the two conditions co-exist.
Ferritin level in ACD, with absent iron deficiency, is typically >225 picomol/L (>100 nanograms/mL) and often significantly higher, thus reflecting its dual roles in iron storage and as an acute-phase reactant.[22]
Result
increased
serum iron
Test
Less useful than transferrin saturation.
Result
reduced
total iron-binding capacity
Test
Typically <45 micromol/L (<250 micrograms/dL)
If it is increased (>70 micromol/L [>400 micrograms/dL]), it is suggestive of iron deficiency anaemia, and further iron studies may be required.
Result
normal or reduced
transferrin saturation
Test
The transferrin saturation is typically 5% to 15% in anaemia of chronic disease.
Result
reduced
absolute reticulocyte count
Test
Indicative of underproduction by the marrow (typical in anaemia of chronic disease).
Result
low for the degree of anaemia
serum creatinine
Test
May be useful for ruling out anaemia associated with renal insufficiency, although anaemia of chronic disease may complicate anaemia that is primarily due to renal disease.
Result
variable
Investigations to consider
C-reactive protein (CRP)
Test
Helps to confirm the presence of inflammation and supports the diagnosis of anaemia of chronic disease if the cause of anaemia is uncertain.
Result
elevated
erythrocyte sedimentation rate
Test
Helps to confirm the presence of inflammation and supports the diagnosis of anaemia of chronic disease (ACD) if the cause of anaemia is uncertain.
Widely used, after diagnosis, as a marker of disease activity in certain diseases that are associated with ACD (e.g., rheumatoid arthritis, polymyalgia rheumatica).
Result
elevated
serum B12
Test
Useful for ruling out B12 deficiency.
Result
normal
serum folate
Test
Useful for ruling out folate deficiency.
Result
normal
thyroid function tests
Test
Useful as a test to exclude hypo- or hyperthyroidism that can lead to anaemia.
Result
normal
LFTs
Test
Useful for ruling out liver disease as a cause of the anaemia.
Result
normal
indirect and direct bilirubin
Test
Useful for ruling out haemolysis as the cause of the anaemia.
Result
normal
LDH
Test
Useful for ruling out haemolysis or another bone marrow disorder (elevated LDH).
Result
normal generally, although may at times be increased by the condition causing anaemia of chronic disease
erythropoietin
haemoglobin electrophoresis
Test
May be used to exclude beta-thalassemia trait (microcytosis, significant poikilocytosis, MCHC relatively normal).
Result
normal
bone marrow biopsy
Test
Usually performed if there is suspicion of a primary haematological disorder (e.g., myelodysplasia or a haematological malignancy).
May also be performed, when necessary, to determine if iron deficiency is present.
Result
iron present in reticuloendothelial tissue but not in normoblasts; no evidence of tumour, dysplasia, or other abnormalities
soluble transferrin receptor
Test
Useful for distinguishing iron deficiency (elevated levels) from anaemia of chronic disease (normal levels).
Result
normal
ratio of soluble transferrin receptor to log ferritin
Test
Useful for distinguishing iron deficiency or co-existing iron deficiency and anaemia of chronic disease (ACD) value >2) from ACD (value <1).[17]
Result
low (<1)
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