Tests
1st tests to order
Hb
Test
The degree of anemia in ACD is typically mild to moderate (Hb 8 g/dL to 11 g/dL).
Severe anemia may indicate an alternative or coexisting cause (e.g., blood loss, iron deficiency anemia, or a primary hematologic disorder).
Result
women <12 g/dL; men <13 g/dL
WBC and differential
Test
Associated infection or other stimuli in anemia 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
Anemia in ACD is normocytic or microcytic.
Result
normal or reduced
mean corpuscular hemoglobin concentration (MCHC)
Test
Anemia 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 bodies).
Other morphologic abnormalities of any cell line should prompt a search for alternative hematologic disorders.
Result
RBCs can be microcytic, hypochromic; WBCs and platelets are generally normal in appearance
serum ferritin
Test
Moderately helpful in distinguishing anemia of chronic disease (ACD) and iron deficiency (ferritin rises in the former and falls in the latter).
Less helpful when the two conditions coexist.
Ferritin level in ACD, with absent iron deficiency, is typically >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 <250 micrograms/dL.
If it is increased (>400 micrograms/dL), it is suggestive of iron deficiency anemia, and further iron studies may be required.
Result
normal or reduced
transferrin saturation
Test
The transferrin saturation is typically 5% to 15% in anemia of chronic disease.
Result
reduced
absolute reticulocyte count
Test
Indicative of underproduction by the marrow (typical in anemia of chronic disease).
Result
low for the degree of anemia
serum creatinine
Test
May be useful for ruling out anemia associated with renal insufficiency, although anemia of chronic disease may complicate anemia that is primarily due to renal disease.
Result
variable
Investigations to avoid
flow cytometry
Recommendations
Do not perform peripheral blood flow cytometry to screen for hematologic malignancy in the setting of isolated anemia.[33]
Rationale
Peripheral blood flow cytometry is only merited when morphologically abnormal cells are identified on a peripheral blood smear or clinical and/or laboratory findings indicate a high probability of hematologic malignancy.[33]
Tests to consider
C-reactive protein (CRP)
Test
Helps to confirm the presence of inflammation and supports the diagnosis of anemia of chronic disease if the cause of anemia is uncertain.
Result
elevated
erythrocyte sedimentation rate
Test
Helps to confirm the presence of inflammation and supports the diagnosis of anemia of chronic disease (ACD) if the cause of anemia 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 anemia.
Result
normal
LFTs
Test
Useful for ruling out liver disease as a cause of the anemia.
Result
normal
indirect and direct bilirubin
Test
Useful for ruling out hemolysis as the cause of the anemia.
Result
normal
LDH
Test
Useful for ruling out hemolysis or another bone marrow disorder (elevated LDH).
Result
normal generally, although may at times be increased by the condition causing anemia of chronic disease
erythropoietin
hemoglobin 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 hematologic disorder (e.g., myelodysplasia or a hematologic 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 tumor, dysplasia, or other abnormalities
soluble transferrin receptor
Test
Useful for distinguishing iron deficiency (elevated levels) from anemia of chronic disease (normal levels).
Result
normal
ratio of soluble transferrin receptor to log ferritin
Test
Useful for distinguishing iron deficiency or coexisting iron deficiency and anemia of chronic disease (ACD) value >2) from ACD (value <1).[17]
Result
low (<1)
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