Anemia of Chronic Disease
http://www.100md.com
《新英格兰医药杂志》
Anemia of chronic disease as a distinct entity was pioneered by Maxwell Wintrobe and George Cartwright in the 1940s and was soon recognized as being typically associated with chronic inflammation (chronic infections, rheumatologic diseases, and sometimes malignant diseases). By the 1960s, the general mechanisms of the anemia — namely, the impaired reuse of iron for erythropoiesis, reduced production of erythropoietin in response to anemic hypoxia, and a moderate decrease of the life span of red cells — were well recognized. Over the decades, the distinctive laboratory features of this anemia have aided clinicians in its diagnosis, often providing the initial clue to the presence of an occult illness and indications of recovery from an illness. The discovery of inflammatory cytokines and how they act led to the identification of these mediators of inflammation as key players in all the disturbances affecting the production of red cells in anemia of chronic disease. Moreover, new technologies have yielded products such as recombinant erythropoietin and antibodies against proinflammatory cytokines as potential therapeutic agents for the anemia.
In Anemia of Chronic Disease, the editors have compiled extensive reviews of these events. The three initial chapters describe the current knowledge of the integral components of the pathophysiology of anemia of chronic disease — iron metabolism, the inflammatory response, and the actions of erythropoietin. Of these chapters, the one on the swiftly advancing field of iron metabolism is particularly lucid. In the subsequent section, four chapters scrutinize the literature on the disturbed iron metabolism, the involvement of inflammatory cytokines, the impaired erythropoietin production, and the curtailed survival of erythrocytes in anemia of chronic disease. A fifth chapter addresses the recently discovered "iron regulatory hormone" hepcidin, elsewhere dubbed "small molecule, large future," which is likely to provide the missing links in the mechanisms of anemia of chronic disease.
Eugene Weinberg's reasoning that withholding iron from the erythron represents the body's defense strategy against infection and inflammation (at the price of anemia) is almost an admonishment not to tamper with nature. This concept is illustrated further in the discussion of tuberculosis and HIV infections by Johan Boelaert. However, half the book deals with aspects of the treatment or correction of anemia. Some of the authors support published treatment guidelines for administering erythropoietin and iron for the sake of improving patients' well-being (the quality of life), whereas others hold a conservative view that reflects the absence of evidence that the correction of anemia benefits patients with underlying diseases or improves the response to primary treatment. In addition, the potential hazards of the available therapies are extensively addressed, and the need for controlled, prospective studies to identify the best therapy for anemia of chronic disease in patients with diverse underlying diseases is acknowledged. A chapter on the risks of allogeneic blood transfusion is useful for its thorough review, although it is not specific to the topic of anemia of chronic disease. Another chapter, on anemia in renal disease, is excellent, but the anemia of chronic renal failure is really a separate entity.
The book has some drawbacks. In several instances, one is overwhelmed by the absence of editorial intervention: an elementary description of the clinical features of anemia is unnecessary in a book such as this; reiterations of iron metabolism and the diagnostic features of anemia of chronic disease throughout are distracting. Given the international complement of authors, the variable quality of the writing may be forgivable.
Researchers will find the book nearly up to date on all aspects of anemia of chronic disease, save for the fast-moving field of iron metabolism. Clinicians will find the necessary diagnostic approach to this very common anemia, as well as several guides to its treatment and the related controversies, but they are also reminded that the ultimate recovery from the anemia comes with the cure of its root cause — the underlying disease.
Sylvia S. Bottomley, M.D.
University of Oklahoma Health Sciences Center
Oklahoma City, OK 73104
sylvia-bottomley@ouhsc.edu((Basic and Clinical Oncol)
In Anemia of Chronic Disease, the editors have compiled extensive reviews of these events. The three initial chapters describe the current knowledge of the integral components of the pathophysiology of anemia of chronic disease — iron metabolism, the inflammatory response, and the actions of erythropoietin. Of these chapters, the one on the swiftly advancing field of iron metabolism is particularly lucid. In the subsequent section, four chapters scrutinize the literature on the disturbed iron metabolism, the involvement of inflammatory cytokines, the impaired erythropoietin production, and the curtailed survival of erythrocytes in anemia of chronic disease. A fifth chapter addresses the recently discovered "iron regulatory hormone" hepcidin, elsewhere dubbed "small molecule, large future," which is likely to provide the missing links in the mechanisms of anemia of chronic disease.
Eugene Weinberg's reasoning that withholding iron from the erythron represents the body's defense strategy against infection and inflammation (at the price of anemia) is almost an admonishment not to tamper with nature. This concept is illustrated further in the discussion of tuberculosis and HIV infections by Johan Boelaert. However, half the book deals with aspects of the treatment or correction of anemia. Some of the authors support published treatment guidelines for administering erythropoietin and iron for the sake of improving patients' well-being (the quality of life), whereas others hold a conservative view that reflects the absence of evidence that the correction of anemia benefits patients with underlying diseases or improves the response to primary treatment. In addition, the potential hazards of the available therapies are extensively addressed, and the need for controlled, prospective studies to identify the best therapy for anemia of chronic disease in patients with diverse underlying diseases is acknowledged. A chapter on the risks of allogeneic blood transfusion is useful for its thorough review, although it is not specific to the topic of anemia of chronic disease. Another chapter, on anemia in renal disease, is excellent, but the anemia of chronic renal failure is really a separate entity.
The book has some drawbacks. In several instances, one is overwhelmed by the absence of editorial intervention: an elementary description of the clinical features of anemia is unnecessary in a book such as this; reiterations of iron metabolism and the diagnostic features of anemia of chronic disease throughout are distracting. Given the international complement of authors, the variable quality of the writing may be forgivable.
Researchers will find the book nearly up to date on all aspects of anemia of chronic disease, save for the fast-moving field of iron metabolism. Clinicians will find the necessary diagnostic approach to this very common anemia, as well as several guides to its treatment and the related controversies, but they are also reminded that the ultimate recovery from the anemia comes with the cure of its root cause — the underlying disease.
Sylvia S. Bottomley, M.D.
University of Oklahoma Health Sciences Center
Oklahoma City, OK 73104
sylvia-bottomley@ouhsc.edu((Basic and Clinical Oncol)