Chronic Anemia (Long-Standing Anemia)

What chronic anemia means

Red blood cells carry oxygen from the lungs to the body using hemoglobin. Anemia means there is too little hemoglobin to meet the body's needs. In chronic anemia, the low level persists, usually because of an ongoing problem with blood production, blood loss or red cell destruction.

The body compensates for slowly developing anemia by increasing heart output, releasing oxygen more easily from hemoglobin and expanding plasma volume. That is why someone can have a hemoglobin of 8 or 9 g/dL with only mild symptoms, while the same drop over hours would cause collapse.

Causes of chronic anemia

Iron deficiency from chronic blood loss

Iron-deficiency anemia is the most common type worldwide. Ongoing losses include heavy periods, bleeding from the stomach or bowel (ulcers, polyps, bowel cancer, regular NSAID use), and frequent blood donation. Poor absorption from celiac disease, stomach surgery and some medicines also contributes. In men and in women after menopause, iron deficiency always needs a search for gut bleeding.

Anemia of chronic disease (anemia of inflammation)

Anemia of chronic disease occurs with long-term inflammation, infection or cancer, such as rheumatoid arthritis, inflammatory bowel disease, chronic infections and malignancy. Inflammation raises a hormone called hepcidin, which locks iron away in storage so it cannot be used to make red cells. It is usually mild to moderate.

Chronic kidney disease

Damaged kidneys make less erythropoietin (EPO), the hormone that tells the bone marrow to make red cells. Anemia becomes common as chronic kidney disease advances.

Vitamin deficiencies

• Vitamin B12 deficiency: from pernicious anemia (an autoimmune condition), stomach surgery, a vegan diet without supplements, or long-term metformin or acid-reducing medicines. It can cause nerve damage as well as anemia.
• Folate deficiency: from poor diet, alcohol, pregnancy and some medicines.

Inherited conditions

• Thalassemia: reduced hemoglobin production; trait forms cause lifelong mild anemia with small red cells, often mistaken for iron deficiency.
• Sickle cell disease: ongoing red cell destruction.
• Hereditary spherocytosis and enzyme deficiencies such as G6PD deficiency.

Bone marrow problems

Myelodysplastic syndrome, aplastic anemia, leukemia, myeloma and marrow infiltration by cancer. Clues include low white cells or platelets as well as low red cells.

Other causes

Hypothyroidism, liver disease, alcohol use, HIV and some medicines (including chemotherapy and some anti-seizure drugs).

Symptoms

• tiredness and low energy
• breathlessness and a pounding heart with exercise
• pale skin, inner eyelids and nail beds
• headaches and dizziness
• cold hands and feet
• poor concentration
• worsening angina or heart failure in people with heart disease

Cause-specific clues:

Diagnosis

• Complete blood count: hemoglobin, red cell size (MCV), white cells and platelets.
• Red cell size points to the cause: small cells (iron deficiency, thalassemia, sometimes chronic disease), normal-sized cells (kidney disease, chronic disease, marrow problems), large cells (B12 or folate deficiency, alcohol, liver disease, hypothyroidism, myelodysplasia).
• Iron studies: ferritin (low in iron deficiency, normal or high in inflammation), transferrin saturation and serum iron.
• Vitamin B12 and folate levels.
• Reticulocyte count: shows whether the marrow is responding.
• Kidney, liver and thyroid function.
• Hemoglobin electrophoresis for thalassemia and sickle cell.
• Blood film examined under a microscope.
• Endoscopy and colonoscopy for unexplained iron deficiency, especially over 50.
• Bone marrow biopsy if a marrow disorder is suspected.

Treatment

• Iron replacement: tablets, often every other day to improve absorption and reduce stomach upset, or IV iron when tablets fail, absorption is poor or kidney disease is present. Hemoglobin usually rises within 2 to 4 weeks, with stores refilled over about 3 months.
• Vitamin B12: injections or high-dose tablets; lifelong in pernicious anemia.
• Folic acid tablets.
• Kidney-related anemia: iron plus erythropoiesis-stimulating agents (synthetic EPO) or newer HIF-PH inhibitor tablets, aiming for a moderate target rather than normal hemoglobin.
• Anemia of chronic disease: treating the underlying condition is most effective.
• Blood transfusion: for severe or symptomatic anemia. Many guidelines use a hemoglobin threshold of about 7 g/dL in stable patients, or 8 g/dL in people with heart disease or undergoing surgery. Regular transfusions are needed in some inherited and marrow conditions, with treatment to remove excess iron.

Complications

• heart strain, worsening angina and heart failure
• reduced exercise capacity and quality of life
• in pregnancy, preterm birth and low birth weight
• in children, delayed development with iron deficiency
• iron overload from repeated transfusions

Living with chronic anemia

• Keep regular follow-up blood tests.
• Take supplements as directed; take iron tablets with vitamin C and away from tea, coffee, calcium and antacids.
• Pace activities and build up exercise gradually.
• Eat iron-rich foods such as red meat, poultry, fish, beans, lentils and fortified cereals.
• Report new symptoms such as bleeding, breathlessness or chest pain.

Frequently asked questions

What causes chronic anemia?

The most common causes are iron deficiency from ongoing blood loss, chronic kidney disease, long-term inflammation or infection, vitamin B12 or folate deficiency, and inherited conditions such as thalassemia. Bone marrow disorders are less common. Blood tests usually narrow down the cause.

What are the symptoms of long-term anemia?

Symptoms include tiredness, breathlessness on exertion, a fast or pounding heartbeat, pale skin, headaches, dizziness, cold hands and feet and poor concentration. Because it develops slowly, some people adapt and notice few symptoms until the anemia is quite severe.

Is chronic anemia serious?

It can be. Mild chronic anemia is often manageable, but untreated anemia strains the heart and reduces quality of life. The underlying cause, such as hidden bowel bleeding, kidney disease or a marrow problem, may be serious in itself and needs to be identified.

Can chronic anemia be cured?

It depends on the cause. Anemia from iron or vitamin deficiency can usually be corrected fully once the cause is treated. Anemia from kidney disease, inflammation or inherited conditions can be managed but often needs ongoing treatment.

What is the difference between chronic anemia and anemia of chronic disease?

Chronic anemia means any anemia lasting a long time, from any cause. Anemia of chronic disease is one specific type, caused by long-term inflammation, infection or cancer that blocks the body's use of iron.