Anemia of Chronic Disease

Naseema Gangat and Alexandra P. Wolanskyj

Anemia of chronic disease (ACD) or inammation may be secondary to infections, autoimmune

disorders, chronic renal failure, or malignancies. It is characterized by an immune activation with an
increase in inammatory cytokines and resultant increase in hepcidin levels. In addition, inappropriate
erythropoietin levels or hyporesponsiveness to erythropoietin and reduced red blood cell survival
contribute to the anemia. Hepcidin being the central regulator of iron metabolism plays a key role in
the pathophysiology of ACD. Hepcidin binds to the iron export protein, ferroportin, present on
macrophages, hepatocytes, and enterocytes, causing degradation of the latter. This leads to iron trapping
within the macrophages and hepatocytes, resulting in functional iron deciency. Production of hepcidin
is in turn regulated by iron stores, inammation, and erythropoiesis via the BMP-SMAD and JAK-STAT
signaling pathways. Treatment of anemia should primarily be directed at the underlying disease, and
conventional therapy such as red blood cell transfusions, iron, erythropoietin, and novel agents targeting
the hepcidin-ferroportin axis and signaling pathways (BMP-SMAD, JAK-STAT) involved in hepcidin
production also may be considered.
Semin Hematol 50:232238. C 2013 Elsevier Inc. All rights reserved.

A nemia of chronic disease (ACD) or anemia of

chronic inammation is the leading cause of
anemia in hospitalized patients and is the second
most common cause of anemia after iron deciency
anemia.1 The major etiologies are acute and chronic
hepcidin generation; and standard and new therapeutic
agents under development for ACD.

infections, autoimmune disorders, chronic renal insuf-
ciency, and malignancies (both hematologic and solid
tumors). In most instances, the anemia is mild normo-
cytic/normochromic, but it may be microcytic/hypochro-
mic in a few cases, making it indistinguishable from iron
deciency anemia. Pathophysiology is multifactorial and
complex, involving disordered iron metabolism and dis-
tribution secondary to increased hepcidin, a peptide
hormone that is the central regulator of iron metabolism.2
Given the key role hepcidin plays in iron homeostasis,
several novel agents targeting the hepcidinferroportin axis
as well as signaling pathways (BMP6-HJV-SMAD and IL-
6-JAK-STAT) involved in hepcidin production are under
development for treating this disorder.3 In this review, we
will provide a comprehensive update on the causes and
pathophysiology of ACD; its laboratory characteristics;
iron metabolism and its regulation by hepcidin, regulation
of hepcidin, and key signaling pathways involved in
Division of Hematology, Mayo Clinic, Rochester, MN.
Conicts of interest:
Address correspondence to Alexandra P. Wolanskyj, MD, Division of
Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
E-mail: wolanskyj.alexandra@mayo.edu
0037-1963/$ - see front matter
& 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.seminhematol.2013.06.006
IRON HOMEOSTASIS
Iron Metabolism
Iron is an essential micronutrient required for heme
biosynthesis, which is subsequently incorporated into
hemoglobin in red blood cells. In addition, iron is present
in proteins such as cytochromes involved in respiration,
myoglobin, and other iron-containing proteins. The total
iron content in the body is tightly regulated since excess
iron is toxic via generation of free radicals and its
propensity to deposit in various organs such as liver,
cardiac myocytes, and endocrine organs.4 The body
requires more than 20 mg of iron daily, of which only
1 to 2 mg is derived from intestinal absorption. The
majority of iron is provided through recycling by the
degradation of senescent red blood cells within macro-
phages in the liver, spleen, and bone marrow (reticulo-
endothelial system).5 The major iron storage sites are the
hepatocytes and macrophages, and along with duodenal
enterocytes involved in iron absorption, they release iron
into the extracellular uid or plasma. Since iron is not
excreted from the body, the entire process of intestinal
iron absorption and release of iron from macrophages and
hepatocytes is stringently regulated by the peptide hor-
mone hepcidin (Figure 1).6 Disordered iron metabolism is
the hallmark of ACD as a consequence of increased
hepcidin levels. The increase in hepcidin levels by either
increased production or decreased clearance leads to a

232 Seminars in Hematology, Vol 50, No 3, July 2013, pp 232238

Anemia of chronic disease 233

Figure 1. Regulation of iron metabolism by hepcidin. Hepcidin production by the liver is regulated by inammation via
cytokines, iron levels/stores, and erythropoiesis. Hepcidin binds to its receptor ferroportin (iron export protein) present on
hepatocytes, macrophages and duodenal enterocytes, resulting in internalization and degradation of ferroportin. In
addition, hepcidin inhibits intestinal absorption of iron by duodenal enterocytes. The end result is that iron is trapped
within the hepatocytes and macrophages resulting in hypoferremia, functional iron deciency and iron-restricted
erythropoiesis. Abbreviations: Fpn, ferroportin; Tf, transferring; TfR, transferrin receptor. Modied with permission from
Ganz et al. Cold Spring Harb Perspect Med 2012;2:a011668.

block in release of iron from iron storage cells (ie,
enterocytes, macrophages, hepatocytes) to the plasma
and hence hypoferremia, resulting in functional iron
deciency and iron-restricted erythropoiesis.7,8
Hepcidin: Regulator of Iron Metabolism
Hepcidin is a 25amino acid peptide with anti-
microbial properties that is produced by the liver in
response to increases in total body iron and inamma-
tion.2,9,10 The production of hepcidin is regulated by
iron stores, pro-inammatory cytokines, and the anemia/
erythroid response axis.11,12
The central role of hepcidin in iron metabolism
(reviewed in Figure 1) was elucidated from studies
performed in iron overload disorders such as hereditary
hemochromatosis, characterized by low hepcidin levels.
Hemochromatosis (HFE), hemojuvelin (HJV), transferrin
receptor2 (TfR2), and hepcidin (HAMP) are the major
genes involved.1316 In juvenile hemochromatosis, muta-
tions in either HJV or HAMP occur, which results in low
hepcidin levels.16,17
The increase in hepcidin production in response to
inammation is a protective mechanism in the case of
infections in which iron restriction would limit bacterial
growth. However, in ACD or inammation, it is a
maladaptive mechanism whereby iron remains sequestered
in the macrophages and hepatocytes and is not available
for erythropoiesis, resulting in anemia. Hepcidin produced
by the hepatocytes binds to its receptor ferroportin, which
is an iron export protein that is present on limited cells
such as macrophages, hepatocytes, duodenal enterocytes,
and placental syncytiotrophoblasts.18,19 Hepcidin binding
to ferroportin leads to ubiquitinization, followed by
internalization and degradation of ferroportin.20,21 The
end result is that iron cannot be released into the plasma
and remains trapped inside the macrophages and hepato-
cytes, resulting in an increase in iron stores reected in
high levels of serum ferritin.22,23 In addition, hepcidin
inhibits intestinal absorption of iron.24 Therefore, ACD is
characterized by low serum iron, transferrin, and total iron
binding capacity, by normal transferrin saturation, and by
increased ferritin, the latter in contrast to iron deciency
anemia. The low transferrin levels are due to down-
regulation of transferrin synthesis as a result of an increase
in ferritin.
Regulation of Hepcidin by Iron
Production of hepcidin is transcriptionally regulated by
total body iron, which includes serum iron and iron stores.
In iron overload conditions, such as hereditary hemochro-
matosis, the increased total body iron, because of the
existence of a mutated gene involved in hepcidin gene
regulation (HFE, HJV, TfR2) inhibits hepcidin produc-
tion. However, in ACD, high levels of interleukin-6 (IL-6)
lead to an increase in hepcidin production, with low serum
iron levels as a consequence. The major signaling pathway
involved in hepcidin generation is the bone morphoge-
netic protein/sons of mothers against decapentaplegic
(BMP)/SMAD pathway, which is also key in develop-
ment, morphogenesis, and osteogenesis (Figure 2).2527
Low intracellular iron levels within the hepatocytes leads
to an increase in BMP-6 production. BMP-6 belongs to
234 N. Gangat and A.P. Wolanskyj

Figure 2. Signaling pathways regulating hepcidin production. BMP-SMAD and IL-6-JAK-STAT signaling pathways are the
two major pathways involved in hepcidin production. Low intracellular iron results in increased BMP-6 production. BMP-6
binds to the BMP-R, activating a series of phosphorylation events that result in generation of the SMAD 1/5/8-SMAD4
complex that translocates to the nucleus, binds to the hepcidin gene promoter, and turns on transcription. Extracellular
iron is bound to transferrin and when iron binds to transferrin receptor 1(TfR1), HFE-TfR2 sends a signal to the BMP
receptor complex. In addition, hemojuvelin (HJV) potentiates BMP-SMAD signaling. Production of inammatory cytokines
(IL-6) activates the JAK-STAT3 signaling pathway. IL-6 binds to the IL-6 receptor. JAK1/JAK2 are tyrosine kinases associated
with the IL-6-R. A series of phosphorylation events leads to phosphorylation of STAT3 which forms homodimers and
translocates to the nucleus, binding to the hepcidin gene promoter, and turns on hepcidin production. Modied with
permission from Ganz et al, Cold Spring Harb Perspect Med 2012; 2:a011668.

the transforming growth factor-beta family of ligands and
binds to its receptor BMP (BMP-R) located on the surface
of hepatocytes. Hemojuvelin (HJV) serves as a co-receptor
for BMP and potentiates BMP/SMAD signaling.28 Ligand
binding to its receptor (BMP-R), which is a serine-
threonine kinase, triggers a series of phosphorylation
events with resultant phosphorylation of SMAD 1/5/8,
which in turn leads to phosphorylation of SMAD4.
SMAD 1/5/8/SMAD4 complex translocates to the nucleus
and binds to the promoter of the hepcidin gene and turns
on hepcidin gene expression. Extracellular iron, which is
bound to transferrin, the iron carrier protein, also serves to
regulate hepcidin gene expression. Transferrin receptors
TfR1 and 2 are located on the hepatocyte surface in
association with HFE. When transferrin-iron binds to
TfR1 and is internalized into the hepatocyte, TfR2
associates with HFE and sends a signal to potentiate
BMP-SMAD signaling and hence increases hepcidin gene
expression. The critical role of the BMP-SMAD signaling
pathway in regulating hepcidin expression was determined
by studies performed in SMAD knockout mice that failed
to produce hepcidin (Figure 2).29
Regulation of Hepcidin by Inammation
Inammation, both acute and chronic such as seen in
the case of infections, autoimmune conditions, and
malignancy, serves as a potent stimulus for hepcidin
production.30 Herein, the JAK-STAT signaling pathway
plays a key role (Figure 2).31,32 Pro-inammatory cyto-
kines such as IL-6, IL-1, and tumor necrosis factor-alpha
are released and serve as ligands for this signaling pathway.
JAK1/2 are non-receptor tyrosine kinases that are associ-
ated with the IL-6 receptor (IL-6-R). IL-6 is the major
ligand involved.12 When IL-6 binds to its receptor, there is
activation of the JAK-STAT signaling pathway by a series
of phosphorylation events. JAK leads to phosphorylation
of STAT3. Phosphorylated STAT3 homodimerizes and
translocates to the nucleus, binding to the promoter of the
hepcidin gene and turning on hepcidin gene expression. In
mice studies, injection with lipopolysaccharides (LPS)
mimics a similar series of events.33 It is to be noted that
intact BMP-SMAD signaling is required for IL-6/JAK/
STAT signaling to act on hepcidin gene expression, since
the ability of IL-6 to increase hepcidin gene expression is
considerably diminished in SMAD4 knockout mice.34
Regulation of Hepcidin by Erythropoiesis and
Hypoxia
With certain types of anemia such as thalassemia and
the sideroblastic anemias, the anemia suppresses hepcidin
production indirectly by an increase in erythropoietin and
subsequent expansion of erythroid progenitors in the bone
Anemia of chronic disease
marrow and by another mechanism(s) still not under-
stood. It is possible that in thalassemia overexpression of
growth differentiation factor 15 (GDF15), a member of
the transforming growth factor-beta superfamily occurring
as a consequence of erythroid expansion, may inhibit
hepcidin expression.35 The regulation of hepcidin by
hypoxia is modulated via the hypoxia inducible factor
von Hippel Lindau (HIF-1VHL) pathway. Under
hypoxic conditions HIF-1 is unable to undergo hydrox-
ylation by proline/lysine hydroxylase, escaping ubiquitina-
tion and degradation. Under these conditions. HIF-1
translocates to the nucleus where it increases production of
erythropoietin and red blood cell expansion; the latter in
turn suppresses hepcidin production.36,37
PATHOPHYSIOLOGY OF ACD
Pathophysiology of ACD is complex but can be
summarized as three main causations, rooted in the
increase in pro-inammatory cytokines. Increase in hepci-
din plays a key role.1 In addition, inappropriate eryth-
ropoietin levels or hyporesponsiveness to erythropoietin,
and suppression of erythropoiesis in the bone marrow
coupled with reduced red blood cell survival, contribute to
the anemia seen in chronic disease, as illustrated in
Figure 3.
LABORATORY CHARACTERISTICS OF ACD
ACD is a mild to moderate normocytic normochromic
anemia, with less than 25% of cases depicting a microcytic
hypochromic anemia, in which case the mean corpuscular
volume is rarely less than 70.1 This is in contrast to iron
Figure 3. Pathophysiology of anemia of chronic disease.
Summarized as three main causations rooted in increase
in pro-inammatory cytokines: (i) increase in hepcidin
levels, (ii) inappropriate erythropoietin levels or hypor-
esponsive to erythropoietin, (and iii) suppression of
erythropoiesis in the bone marrow coupled with reduced
red blood cell survival. Abbreviation: EPO; erythropoietin.
235
deciency anemia, which is microcytic, hypochromic with
anisocytosis and poikilocytosis noted on peripheral blood
smear. Serum iron, total iron binding capacity, and
transferrin saturation are all low in ACD, and are
accompanied by an increase in serum ferritin and bone
marrow iron stores. On the other hand, in iron deciency
anemia, serum iron, transferrin saturation, and ferritin are
low, with an increase in total iron binding capacity. It is
often challenging to distinguish between ACD and iron
deciency anemia based on available laboratory tests, and
even more complex are situations in which the two
conditions coexist. Measurement of soluble transferrin
receptor, a truncated form of the membrane receptor,
may be used to distinguish between the two entities. In
iron deciency, soluble transferrin receptor levels are high
since the availability of iron is low, but in ACD soluble
transferrin receptor levels are normal.38,39 Given the
central role of hepcidin in regulating iron metabolism,
measuring serum hepcidin levels would serve to distin-
guish between the two entities, but the issue remains the
lack of availability of a standard hepcidin assay. Hepcidin
levels are reduced in iron deciency, and measurement of
blood or urine hepcidin levels may be indicative of true
iron deciency.39 Mass spectrometry and, more recently,
enzyme-linked immunoassays (ELISA) for quantitation of
hepcidin in serum, plasma, and urine have been devel-
oped.40,41 A comparative study of different assays for
hepcidin levels was performed, which found that despite
signicant differences in the absolute value at each
laboratory, results for samples correlated well and analyt-
ical variance was low.40 Furthermore, issues in interpreting
hepcidin levels include diurnal uctuations of hepcidin
(lower in the morning, higher in the afternoon), and
relative sensitivity to the iron content of the diet.41,42
TREATMENT OF ACD
Treatment is primarily directed at the underlying
disease in the case of infections, autoimmune disorders,
and malignancy, but most of these conditions are chronic
and eradication of the underlying disease is difcult.
Improvement of the anemia contributes to improvement
in the quality of life of these patients.43,44 Currently
available treatments may be categorized either as conven-
tional therapy or novel agents as summarized in Table 1.
Conventional Therapy
Red blood cell transfusions should be provided for
hemoglobin o8 g/dL, particularly for patients with
known coronary artery disease. It is to be kept in mind
that repeated use of blood transfusions leads to iron
overload, risk of transmission of infections, and allo-
immunization.1
Since ACD is accompanied by functional or in some
cases absolute iron deciency, iron supplementation might
be of benet particularly for patients with low ferritin and
236
Table 1. Treatment Options for Anemia of Chronic Disease*
Therapy Types Description
Conventional Red blood cell transfusions
Intravenous iron with
erythropoiesis-stimulating agents
Erythropoiesis-stimulating
agents
Novel Direct hepcidin antagonists
Monoclonal antibodies
siRNA
Anticalins
Spiegelmers
BMP-HJV-SMAD inhibitors
IL-6 antagonists
JAK-STAT inhibitors
Ferroportin agonists/stabilizers
*Therapy should primarily be directed towards the underlying disease.
hyporesponsiveness to erythropoeisis-stimulating agents
(ESAs).45 Intravenous iron is used instead of oral iron
because of the increase in hepcidin levels and inhibition of
intestinal absorption of iron.
ESAs such as epoetin-alpha, epoetin-beta, and
darbopoeitin-alpha are widely used in patients with
anemia secondary to chronic renal failure.46 However,
studies have shown an increased risk of cardiovascular
events with liberal use of ESAs.47,48 Therefore, it is critical
to adjust the ESA dose to keep hemoglobin o13 g/dL.49
In addition, ESA use has been associated with disease
progression in a variety of tumors.50
Since blood transfusions, iron therapy, and ESAs are
not without detrimental effects, the search continues for
better therapies targeting the underlying mechanism that
contributes to ACD.
Novel Agents
Hepcidin antagonists (monoclonal antibodies, small
interfering RNA [siRNA], antisense oligonucleotides,
hepcidin binding proteins, and aptamers) are being
developed. Anti-hepcidin monoclonal antibodies are under
development by Amgen and Eli Lilly according to their
website. These antibodies bind to hepcidin and prevent it
from binding to ferroportin.51 RNA interference (RNAi)
and antisense oligonucleotides interfere with either tran-
scription or translation of hepcidin or its regulators such as
N. Gangat and A.P. Wolanskyj
Dosing
12 U, at the physicians discretion
Iron sucrose 100 mg/dose
Iron dextran 25 mg test dose followed by
500 mg to 2,000 mg
Epoetin-alpha, -beta 20,000 to 60,000 U
weekly
Darbepoetin 300 g every 3 weeks
if hemoglobin o11 g/dL. Hold dose if
hemoglobin 412 g/dL.
mAb2.7, Ab12B9m
ALN-HPN
PRS-080
NOX-H94
LDN-193189
Tocilizumab
Siltuximab
AG490
PpYLKTK
Anti-ferroportin monoclonal antibody
HJV and could potentially be effective therapeutic agents
except for technical challenges encountered in the delivery
of RNAi.51,52 In addition, hepcidin binding proteins,
anticalins, and spiegelmers are also being developed.53,54
Spiegelmers are mirror image aptamers that are single-
stranded synthetic oligonucleotides that bind with high
afnity and specicity to a wide range of targets such as
peptides, proteins, etc, being produced by NOXXON
Pharma per their website. The anti-hepcidin Spiegelmer
NOX-H94 is in a phase IIa clinical trial to treat anemia
associated with chronic disease. This phase IIa study was
initiated following the successful completion of the clinical
phase I program, which was presented at the American
Society of Hematology (ASH) meeting in Atlanta, GA in
December 2012.55,56 The phase I study consisted of a
comprehensive single and multiple ascending dose study
in healthy volunteers and a subsequent human pharma-
codynamic study to assess the ability of NOX-H94 to
prevent endotoxin-induced hypoferremia in healthy sub-
jects. This endotoxemia study delivered the rst clinical
evidence that NOX-H94 is capable of neutralizing high
levels of hepcidin in humans and maintaining higher
serum iron concentrations compared to subjects receiving
placebo.
The increased production of hepcidin in ACD serves as
the rationale for development of inhibitors targeting the
BMP-HJV-SMAD and IL-6-JAK-STAT pathways that are
involved in hepcidin synthesis. Dorsomorphin is a small
Anemia of chronic disease
molecular inhibitor of BMP receptor, and a derivative of
dorsomorphin, LDN-193189, is a more selective BMP
inhibitor. The latter has been shown to reverse anemia
associated with chronic arthritis in rats.57 Other agents
include anti-BMP6 monoclonal antibody and soluble
HJV.25,27 In addition, heparin also has been shown to
decrease BMP-SMAD signaling and inhibit hepcidin
transcription.58
In regards to the IL-6-JAK-STAT pathway, monoclo-
nal IL-6 and IL-6R antibodies and the JAK2 and STAT3
inhibitors all have been shown to downregulate hepcidin
expression.5961
Vitamin D deciency is associated with an increased
prevalence of ACD, and vitamin D replacement lowers
hepcidin levels.62
Since hepcidin excess blocks ferroportin by causing
degradation of the latter, agents that stabilize ferroportin
or inhibit the interaction with hepcidin are an attractive
target.63 Eli Lily has developed an antiferroportin mono-
clonal antibody that blocks hepcidinferroportin
interaction.
CONCLUSION
In the last decade, we have gained immense insight
regarding the complex pathophysiology of ACD with
increase in hepcidin levels and resultant disordered iron
metabolism playing a key role. Based on the central role of
hepcidin and its regulators in ACD, several novel targeted
agents are currently under development; however, therapy
remains primarily directed at the underlying cause.
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