Iron Metabolism in

Anaemia of Chronic Disease

Guenter Weiss, MD
Professor of Medicine
Department of Internal Medicine, Clinical
Immunology, and Infectious Diseases
Medical University of Innsbruck
Innsbruck, Austria
 Anaemia of Chronic Disease (ACD)

• Most frequent anaemia among hospitalised

patients
• Mild to moderate, normo-/normochromic
• Develops in patients with cellular immune
activation
• Degree of anaemia correlated to immune
activation
 Inflammatory Diseases Associated
with the Development of ACD

I. Infections (acute and chronic)

A. Viral infections including HIV
B. Bacterial
C. Parasitic
D. Fungal
E. Helminth
II. Malignancies
A. Haematologic
B. Solid tumor
III. Autoimmune
A. Rheumatoid arthritis
B. Systemic lupus erythematosus and connective tissue
diseases
C. Vasculitis
D. Inflammatory bowel disease
IV. Chronic kidney disease and inflammation
 Pathophysiology—Cornerstones

• Iron retention within the reticulo-endothelial

system
• Impairment of erythrocyte progenitor formation
• Inadequate formation and function of
erythropoietin
 Intestinal Iron Absorption
Enterocyte

Fe3+ Tf Fe3+
DcytB Hephaestin

Fe2+ Fe2+ Fe2+

DMT1 Ferroportin -
Heme Heme-
oxygenase
Fe Fe2+ Hepcidin
+
HCP-1
Luminal Baso-lateral
Slide courtesy of G. Weiss, MD
Hentze MW, et al. Cell. 2010;142:24-28.
 Hepcidin
Master Regulator of Iron Homeostasis
• 20-,22-,25- AA peptide with antimicrobial potential
• Expression induced by iron in the liver
• Stimulated also by LPS and IL-6 by an iron independent
pathway—acute phase protein (blocked by TNF-a)
• Hepcidin over-expression leads to iron-deficient anaemia
and hepcidin knock-out to iron overload
• Hepcidin inhibits duodenal iron absorption and
macrophage iron release
• Mechanism of action: interferes with ferroportin, thereby
leading to ferroportin degradation and blockage of iron
export
 Control of Body Iron Homeostasis by
Hepcidin
Luminal Baso-lateral
Enterocyte Macrophage
Fe3+ Tf Fe3+

DcytB
Heph HO-1

Fe2+ Fe2+ Fpn1 Fe2+ Fe2+

DMT1 -
Heme
Fe2+

Heph
+ HO-1

Fpn1
Fe
HCP-1?
-
Hepcidin
Tf-Fe+3
Fe2+ Tf Fe3+
- Hepcidin + Inflammation (IL-6, LPS)
+
Tf-Fe+3 Liver
Slide courtesy of Dr. G. Weiss. Hentze MW, et al. Cell. 2010;142:24-28
 Pathophysiology—Cornerstones

• Iron retention within the reticulo-endothelial

system
• Inadequate formation and function of
erythropoietin
• Impairment of erythrocyte progenitor formation
 Pathways for Iron Retention in ACD
A collaborative work of acute phase proteins
(Hepcidin) and cytokines
Hepcidin
ACD is an immunity
Hepcidin
Fe+2 Duodenum
+ driven disease
Liver
-
Fe+2
b
+
IL-6
LPS
Monocyte IL-1 + +
Tf/TfR
TNF- Fe+2 Ferritin
α
IL-10
CD3+
IFN-γ FP-1 Macrophage
a -
-
Fe+2 +
Hepcidi
n c
Slide courtesy of Dr. G. Weiss.
Weiss G. Biochim Biophys Acta. 2009;1790:682-693.
 Pathophysiology—Cornerstones

• Iron retention within the reticulo-endothelial

system
• Impairment of erythrocyte progenitor formation
• Inadequate formation and function of
erythropoietin
 Cytokine Effects on Epo Production
IL-6
LPS Putative molecular mechanisms:
IL-1 • TNF-α/IL-1 induce NF-kB/GATA-2
Monocyte
TNF-α with suppression of Epo gene
promotor
IL-10
CD3+
• Cytokine mediated radical formation
IFN-γ negatively affects Epo-producing cells
in the kidney
• Interaction with Epo/EpoR signal
transduction
(JAK2/STAT5/MAPK/PKC)
- - ? • Reduction of EpoR expression on
Epo CFU-e
• Impaired Epo function because of
- reduced iron availabiltiy
Kidneys • Impaired Epo function due to
Bone marrow impaired erythroid progenitor
proliferation
Fe+2

Slide courtesy of Dr. G. Weiss.

Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.
 Pathophysiology—Cornerstones

• Iron retention within the reticulo-endothelial

system
• Inadequate formation and function of
erythropoietin
• Impairment of erythrocyte progenitor formation
 Cytokine Effects on Erythroid Progenitor
Cell Proliferation
IL-
LPS 6 Putative molecular mechanisms:
IL-
Monocyte 1 • TNF-α -inhibitory effect via stroma
TNF-a
cells
IL-10
CD3+
• IL-1 acts primarily via IFN-g induction
IFN-abg
• IFN-γ induces apotposis of CFU-e
• IFN-γ: caspase mediated apoptosis
involving ceramide
- • IFN-γ induces NO; inhibits heme
synthesis
Epo
- • Cytokines (IFN-γ) inhibit Epo and
SCF formation and functionality
- Kidneys • Iron restriction due to
Bone marrow cytokines/hepcidin
Fe+2

Slide courtesy of Dr. G. Weiss.

Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.
 ACD Is an Immunity-Driven Disease
Hepcidin
Hepcidin Duodenum
+
Fe+2
Liver -
Fe+2 Spleen
IL-6
LPS
IL-1
Monocyte ++
Fe
TNF-α 2

IL-10 DMT1
CD4+
IFN-γ
+ Fe+2 +
Tf/TfR Ferritin

- - Macrophage
Epo - FP-1
- -
Bone marrow -
Fe+2
Fe+ Hepcidin
2

Slide courtesy of Dr. G. Weiss.

 Positive Effects of ACD?

• Withholding iron from infectious

pathogens in order to limit their growth1
– Iron acquisition linked to pathogenicity in
microbes, fungi?
• Reducing the supply of oxygen to rapid
proliferating tissues
• Strengthening of immune response

Weinberg ED. Biochim Biophys Acta. 2009;1790:600-605.

 Iron Loading of Macrophages Impairs Their Ability to
Kill Intracellular Pathogens by IFN- Mediated Pathways

IFN- IFN-
MEF, macrophage effector function

- Fe + Fe

MEF MEF

Macrophage Macrophage

Slide courtesy of Dr. G. Weiss.

Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023. Nairz M, et al. Cell Microbiol. 2009;11:1365-
1381. Wessling-Resnick M. Annu Rev Nutr. 2010;30:105-122.
 Iron, Immunity, and Infection

• Iron affects cell-mediated immune function and thus

host responses towards pathogens
• Microbes need iron for proliferation and pathogenicity
• Cytokines and acute-phase proteins regulate iron
metabolism genes under inflammatory conditions,
leading to
– Development of anaemia of chronic disease
– Iron limitation for pathogens
• Thus, ACD may result from the endeavour of the
body to limit the availability of iron for invading
pathogens and to strengthen antimicrobial immune
effector pathways
 ACD Diagnosis
Parameter ACD IDA
Serum iron concentration Reduced to normal Reduced
Transferrin levels Reduced to normal Increased
Transferrin saturation Reduced to normal Reduced
Ferritin Normal to increased Reduced
Serum transferrin receptor Normal Increased
sTfR/log ferritin Low (<1) High (>2)
Zinc protoporphyrin IX High High
Percentage hypochromic RBC N/A High
Cytokines (TNF, IL-1, IL-6) Increased Normal

Cytokine levels are inversely correlated with the degree of anaemia

Sole iron determination in serum is clinically not useful
Slide courtesy of Dr. G. Weiss.
Several Patients Suffer from a Combination of ACD and
Iron Deficiency (ACD/IDA) as a Consequence of
Inflammatory Anaemia and Blood Loss (Mostly on the
Basis of Gastrointestinal or Urogenital Bleeding)

Parameter ACD Both (ACD + IDA)

Serum iron Reduced Reduced

Transferrin levels Reduced to normal Reduced

TfS Reduced Reduced

Ferritin Normal to increased Reduced to normal

sTfR Normal Normal to increased

sTfR/log ferritin Low (<1) High (>2) ?

Cytokine levels Increased Increased

Why Is the Differential Diagnosis
Between ACD and ACD + IDA
Important?

Because these patients need

contrasting therapies!
 Differential Diagnosis Between ACD and
ACD Plus IDA
Anaemia

Biochemical or clinical
evidence of inflammation

Transferrin saturation <16%

Rule out other causes of anaemia

Ferritin <30 mg/L Ferritin 30–100 mg/L Ferritin >100 mg/L

sTfR determination

sTfR/log ferritin >2 sTfR/log ferritin <1

ACD/IDA ACD/IDA ACD

With permission from Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.
 Diagnostic Window with sTfR/log Ferritin
How suitable are other haematologic parameters (MCH, MCV,
hepcidin) for the differential diagnosis of ACD vs ACD/IDA?
Anaemia

Biochemical or clinical
evidence of inflammation

Transferrin saturation <16%

Ferritin <30 mg/L Ferritin 30–100 mg/L Ferritin >100 mg/L

sTfR determination

sTfR/log ferritin >2 sTfR/log ferritin <1

>1 to <2?
ACD/IDA ACD/IDA ACD
With permission from Weiss G, Goodnough LT. N Engl J Med. 2005;352:1011-1023.
 Valuable Diagnostic Tools for the Differential
Diagnosis Between ACD and ACD/IDA
(Separated by the sTfR/log Ferritin Ratio)
Parameter ACD ACD+IDA
sTfR/log Ferritin <1 sTfR/log Ferritin >2
Haemoglobin Decreased Decreased
(No difference from ACD)
Hepcidin Increased Significantly lower than in
ACD and in age-matched
controls without anaemia
Mean cellular Normal (as in age-matched Below the lower limit
haemoglobin (MCH) controls without anaemia) of normal

Number of reticulocytes with ? Increased

reticulocyte haemoglobin
content (CHr) <29-32pg

sTfR and CHr are also used in combination for the Thomas blot to
estimate iron availability for erythropoiesis in patients with inflammation
 Assessment of Iron Status in the
Setting of Inflammation and Anaemia
• Hepcidin expression is more affected by the needs of iron
for erythropoiesis than by inflammation

• Hepcidin levels closely correlate to sTfR/ log ferritin ratio

in patients with inflammation, thus both parameters
(hepcidin currently not widely available) can differentiate
between absolute vs functional iron deficiency

• Haematologic indices (eg, MCH, CHr, and combinations

with sTfR) may add additional information on true iron
availability for erythropoiesis in patients with ACD and/or
sTfR/ log ferritin between 1 and 2
 ACD Best Therapy

Treatment or Cure of the

Underlying Disease!
 Current Therapeutic Options in ACD

• Blood transfusions
• Recombinant human erythropoietin
• Iron
Therapeutic measures are aimed to increase
haemoglobin levels in ACD patients

However, the impact of such interventions on iron

overload on the reticulo-endothelial system,
immunity, radical formation, and most importantly
the underlying disease, are largely unknown
 ACD Therapy
Blood Transfusions
• Can be readily used for rapid correction of
severe anaemia
– Immediate increase of haemoglobin
– 1 unit contains ~200 mg of iron
• Uncertainties
– Negative effects on immune effector function
 Risk of infections
 In some studies, associated with increased risk of cancer
(Possible bias – more need for transfusions may reflect more
advanced disease)
 Negative effects seen with transfusions older than 3 weeks?
 Effects also seen with leukocyte-depleted products?
 ACD Therapy
Iron
• NO, if infections or cancer underlie ACD;
ferritin >100 ng/mL
– May favor proliferation of pathogens
 By countering iron-withholding strategy
 By impairing immune function
– May not reach erythroid cells due to diversion into
reticulo-endothelial system
– May cause tissue damage via formation of toxic
radicals by the Fenton reaction (triggered by TNF-a)
• However, in autoimmune diseases, iron may
inhibit pro-inflammatory immune effector
pathways, thus reducing disease activity
Kaltwasser JP, et al. J Rheumatol 2001; 28:2430-2436.
Weiss G, et al. Kidney Int. 2003;64:572-578.
 ACD Therapy
Iron
• What to do in ACD with true iron deficiency
(ACD and IDA)?
– Iron is needed for basic metabolic functions and
cannot be mobilized
• How to substitute iron?
– Iron is very poorly absorbed in ACD (down-
regulation of ferroportin in the duodenum by
hepcidin)1

1. Theurl I, et al. Blood. 2009;113:5277-5286.

 ACD Therapy
Iron
• What to do in ACD with true iron deficiency (ACD
and bleeding)?
– Iron is needed for basic metabolic functions and cannot be
mobilized
• How to substitute iron?
– Iron is very poorly absorbed in ACD (down-regulation of
ferroportin in the duodenum by hepcidin)1
• IV iron administration is very effective in
inflammatory bowel disease and ACD but also
increases haemoglobin in cancer patients2
• Caveat
– No prospective studies on such intervention on the course
of underlying malignant diseases
– Retrospective analyses: iron supplementation may
negatively impact disease progression in cancer
1. Theurl I, et al. Blood. 2009;113:5277-5286. 2. Auerbach M, et al. J Clin Oncol. 2004;22:1301-1307.
 Iron Therapy in Dialysis Patients

 Prospective study investigating the incidence of

infectious complications in ESRD patients
receiving IV iron therapy
― Group 1: ferritin <100 ng/mL and TfS <20%
― Group 2: ferritin >100 ng/mL and TfS >20%
― Observation period: 1 year
 Frequency of septicaemia in Group 2 was 2.5-
fold higher than in Group 1
 Too much iron may be harmful in ACD!

Plotkin SA. Clin Infect Dis. 2004;38:1030-1039.

Why Is the Differential Diagnosis
Between ACD and ACD + IDA
Important?

Because these patients need

contrasting therapies!!!
No iron in ACD
Iron needed in ACD/IDA
 Therapy—
Erythropoietin-Stimulating Agents (ESA)
• Effective in increasing haemoglobin levels in
ACD: patients with cancer, infections, and
autoimmune disorders
• Response rate to treatment depends on
underlying disease, stage, immune activation,
and iron availability
• Increase of haemoglobin with ESA treatment is
associated with a gain in QOL and a decreased
need for blood transfusions
• Uncertainties based on recent studies indicating
increased mortality in certain patient groups in
association with ESA therapy; biologic role of
EpoR on tumor cells undefined
 Therapeutic End Points

• Optimal haemoglobin related to the course of

the disease underlying ACD, minimization of
cardiovascular risk, best QOL?
• The maximum incremental gain in QOL in
patients with anaemia and cancer occurs
(upon anaemia treatment with ESA) when the
haemoglobin is between 11 and 13 g/dL1
• However, a normal target haemoglobin may
not be optimal!

1. Crawford J, et al. Cancer. 2002;95:888-895.

 Therapeutic End Points

• Normalization of haemoglobin levels in end stage

renal disease patients was associated with a
significant increase of cardiovascular mortality as
compared with patients with haemoglobin levels
below the normal range1
• Dialysis patients: risk of death was highest with
haematocrit levels between 33% and 36%2
• Avoid over-correction of anaemia (Hgb >12 g/dL)
• Currently recommended therapeutic end point:
Hgb 11–12 g/dL (some guidelines cite up to
13 g/dL for men)
1. Besarab A, et al. N Engl J Med. 1998;339:584-590. 2. Locatelli F, et al. Nephrol Dial Transplant.
2004;19:121-132.
 Anaemia of Chronic Disease
Unanswered Questions—THERAPY

• Effects of anaemia correction by different

treatments (iron, transfusion, ESA) on the
underlying disease
• Evaluation of the positive effects
(radio/chemosensitizer, cardiac performance,
QOL) vs the putative negative effects (feeding
of pathogens, immunodepression) of various
treatments
 Anemia of Chronic Disease
Unanswered Questions—THERAPY
• Urgent need for randomized, prospective trials
– Definition of therapeutic end points, which are
associated with
 Good QOL
 Best outcome concerning the underlying disease
 Cardiovascular endpoints

• Emerging therapies
– (Anti)-cytokine therapies
– Iron chelation
– Hepcidin/ferroportin agonists/antagonists
– Combination therapy (Epo + iron)
– Epo R modulation