nutrients

Communication
Anemia of Chronic Diseases: Wider
Diagnostics—Better Treatment?
Michał Wiciński 1 , Grzegorz Liczner 1 , Karol Cadelski 1 , Tadeusz Kołnierzak 1 ,
Magdalena Nowaczewska 2 and Bartosz Malinowski 1, *
1 Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University, M. Curie 9, 85-090 Bydgoszcz, Poland; [email protected] (M.W.);
[email protected] (G.L.); [email protected] (K.C.); [email protected] (T.K.)
2 Department of Otolaryngology, Head and Neck Surgery, and Laryngological Oncology, Collegium Medicum
in Bydgoszcz, Nicolaus Copernicus University, M. Curie 9, 85-090 Bydgoszcz, Poland;
[email protected]
* Correspondence: [email protected]




Received: 24 April 2020; Accepted: 10 June 2020; Published: 16 June 2020


Abstract: Anemia of chronic diseases is a condition that accompanies a specific underlying disease,
in which there is a decrease in hemoglobin, hematocrit and erythrocyte counts due to a complex
process, usually initiated by cellular immunity mechanisms and pro-inflammatory cytokines and
hepcidin. This is the second most common type of anemia after iron deficiency anemia in the world.
Its severity generally correlates with the severity of the underlying disease. This disease most often
coexists with chronic inflammation, autoimmune diseases, cancer, and kidney failure. Before starting
treatment, one should undertake in-depth diagnostics, which includes not only assessment of complete
blood count and biochemical parameters, but also severity of the underlying disease. The differential
diagnosis of anemia of chronic diseases is primarily based on the exclusion of other types of anemia,
in particular iron deficiency. The main features of anemia of chronic diseases include mild to moderate
lowering of hemoglobin level, decreased percentage of reticulocyte count, low iron and transferrin
concentration, but increased ferritin. Due to the increasingly better knowledge of the pathomechanism
of chronic diseases and cancer biology, the diagnosis of this anemia is constantly expanding with new
biochemical indicators. These include: the concentration of other hematopoietic factors (folic acid,
vitamin B12 ), hepcidin, creatinine and erythropoietin. The basic form of treatment of anemia of
chronic diseases remains supplementation with iron, folic acid and vitamin B12 as well as a diet rich
in the above-mentioned hematopoietic factors. The route of administration (oral, intramuscular or
intravenous) requires careful consideration of the benefits and possible side effects, and assessment of
the patient’s clinical status. New methods of treating both the underlying disease and anemia are
raising hopes. The novel methods are associated not only with supplementing deficiencies, but also
with the administration of drugs molecularly targeted to specific proteins or receptors involved in the
development of anemia of chronic diseases.

Keywords: iron homeostasis; anemia; iron supplementation; oxidative stress; nutrition; hematological
parameters; biochemical parameters; erythropoiesis

1. Introduction
Erythropoiesis is a multi-stage process of multiplication and erythrocyte differentiation from
hematopoietic stem cells, which normally takes place in the bone marrow of flat bones and the epiphyses
of human long bones. A unique feature of stem cells is their ability to self-renewal and differentiation.
From the hematopoietic stem cell, a myelopoietic stem cell is formed, which subsequently undergoes a

Nutrients 2020, 12, 1784; doi:10.3390/nu12061784 www.mdpi.com/journal/nutrients

Nutrients 2020, 12, 1784 2 of 17

transformation to the erythropoietic progenitor cell. It matures through successive divisions and becomes
a precursor cell, demonstrating at this stage some characteristics of the final cell. Further maturation
occurs through changing the nature of the cell nucleus from basophilic to acidophilic, up to its loss in
order to minimize metabolism and inhibit the possibility of division. Mature, enucleated erythrocytes
are released into the blood through the selective bone marrow barrier, formed by endothelial cells of
the marrow vessels. Under pathological conditions, erythropoiesis can occur in the liver and spleen.
Consequently, immature forms of erythrocytes appear in the peripheral blood, including reticulocytes
and erythroblasts containing the cell nucleus. Erythropoiesis is subject to both local and systemic
regulation. Although erythrocyte maturation is tightly programmed in the genome of hematopoietic
stem cells, there are a number of factors that modify the process. These include adhesion molecules,
cytokines, ligands and receptors binding them, tyrosine kinases activating transcription factors in the
cell nucleus. Adhesive molecules are responsible for the adhesion of blood cells to the medium, while
hematopoietic cytokines determine their survival and multiplication. Normal cells require constant
cytokine stimulation, since the lack of such signal causes direction of the cell to the apoptosis pathway.
Proper cytokine supply is the basic mechanism that regulates cell homeostasis and ensures stability in
the structure and number of specific blood cells at a given site. The factor that regulates erythropoiesis
at the systemic level is glycoprotein peptide hormone secreted by the liver (20%) and, to a greater extent,
by type I peritubular cells of the interstitial tissue of the kidney cortex (80%), called erythropoietin [1].
It stimulates various stages of erythropoiesis due to binding to transmembrane EPO-R receptors,
present mainly on precursor cells of the erythropoietic lineal, i.e., proerythroblasts. After ligand
attachment, it creates a homodimer receptor and then activates tyrosine kinases JAK (Janus-activated
kinase) and other transcription factors. It is noted that the amount of erythropoietin receptors is inversely
proportional to the degree of erythrocyte maturity. They are no longer found in the cell membrane of
reticulocytes and erythrocytes [1,2]. Conversely, the expression of this receptor in neoplastic cells appears
to be a disturbing phenomenon. This hampers the administration of recombinant erythropoietin in patients
with malignant neoplasm, which in this situation can promote tumor cell growth [3]. The situation
triggering the release of erythropoietin is hypoxia of tissues of various origins (heart and lung diseases,
smoking or being at high altitudes).
Therefore, EPO-R receptors occurs in tissues with high metabolism and high sensitivity to hypoxia,
i.e., brain, heart muscle, skeletal muscle and kidneys [2]. In turn, the secretion of erythropoietin is
disturbed in chronic kidney disease, where the production of this hormone is gradually reduced.
Deficiency of erythropoietin or a lack of sensitivity to its target tissue is one of the development
mechanisms of chronic diseases anemia. In addition to erythropoietin, other hematopoietic factors
are necessary for the proper conduct of the erythropoiesis process. These include iron, vitamin B12 ,
folic acid, vitamin C, vitamin B6 , proteins and hormones. The absence of any hematopoietic factor or
the appearance of factors directly damaging the bone marrow or mature erythrocytes will also result in
the occurrence of anemia.

2. Iron Metabolism—General Remarks

Iron is one of the most important microelements of the body necessary for the synthesis of
hemoglobin. In addition to its main building function, it also has a regulatory role. As a component
of heme and cytochrome enzymes, it enables cellular respiration through electrons transfer in the
electron transport chain, supports antioxidative processes and DNA synthesis (RNA reductase is an
iron-dependent enzyme needed for DNA replication). The iron content in the human body oscillates
around 3–4 g, of which approx. 2.5 g (65%) is in hemoglobin, approx. 400 mg (10%) in myoglobin,
catalase and cytochrome, from 3 to 7 mg (0.1%) is bound by transferrin, while the rest is backup (25%).
The stored iron can be divided into active (ferritin) and inactive (hemosiderin) pools [4].
The daily diet provides an average of 10–15 mg of iron, of which only 5–10% (i.e., 1 mg) is absorbed
into the body. The human body uses 20–25 mg of iron daily for hemoglobin synthesis. Most of this
element comes from the natural degradation of erythrocytes due to their damage or aging. However,
Nutrients 2020, 12, 1784 3 of 17

there are situations in which its excessive accumulation in the body occurs. It may result from the
excessive absorption of this element from the gastrointestinal tract (hemochromatosis), its excessive
supply with food or from improper iron metabolism (shortage for erythropoiesis or excessive release
from the liver or red blood cells). Currently, the ability of free iron to initiate oxidative stress is widely
discussed, consisting mainly of the production of free radicals, including reactive oxygen species,
which damage nucleic acids, lipids and proteins contributing to carcinogenesis [5,6].

3. Iron Absorption and Characterization of Proteins Involved in the Metabolism

Absorption of iron in the gastrointestinal tract is a complicated process involving many proteins
(DMT1 protein, ferroportin, ferritin, hepcidin, hephaestin, transferrin, lactoferrin). At the cellular level,
deficiency of this element increases the synthesis of the transferrin receptor and increases the absorption
of iron in the gastrointestinal tract. While at the systemic level, its deficiency significantly reduces the
synthesis of ferritin (unless the deficiency is accompanied by inflammation that is present at the same
time, because ferritin is an acute phase protein). The so-called active iron, i.e., rapidly exchanging,
is associated with ferritin and is found primarily in hepatocytes and liver macrophages, spleen,
bone marrow and muscles. The role of ferritin is primarily intracellular iron storage, which prevents
the formation of reactive oxygen species (ROS) generated by the Fenton reaction. The ferritin molecule
consists of soluble protein—apoferritin and the internal part containing iron ions. The protein part of
ferritin is constructed from 24 chains consisting of light L and heavy H subunits forming a quadruple
helix. The H subunit has oxidoreductive properties, which are attributed to ferroxidase center. Fe2+ ions
after penetrating through the apoferritin coating into ferroxidase centers are oxidized to Fe3+ trivalent
form. Inflammation increases the expression of the H subunit of ferritin, which, thanks to ferroxidase
centers, has the ability to sequestrate iron and protect against oxidative stress. The consequence of
this phenomenon is a deficit of available iron and anemia observed in chronic inflammation. Under
physiological conditions, only the glycosylated form of the L ferritin subunit is present. The quantitative
proportions of light and heavy chains forming ferritin differ depending on the state of iron homeostasis
and the type of tissue. The H subunit predominates in cells requiring high iron availability, such as
erythrocytes and myocardial cells. In iron storage organs (liver, spleen), ferritin is mainly built of
the L subunit, which does not contain ferroxidase centers, and its main role is to store bioavailable
iron atoms [7,8]. The role of ferritin as a carrier protein has recently been confirmed. It is assumed
that ferritin can transport 100 to 1000 times more iron than transferrin. To serve as an iron-providing
protein, ferritin must be released from the cells in which it is produced. Some studies suggest that
intracellular ferritin may be transported to the lysosome for its degradation and release of iron, which
is then recycled. This process is called ferritinophagy. The iron exported to the cytosol is then used
in several physiological processes that include the synthesis of mitochondrial heme and erythrocyte
differentiation. In the transport of cytosolic ferritin to the lysosome, a nuclear receptor co-activator 4
(NCOA4) is required, which binds to ferritin through the C-terminal domain and delivers it to the
forming autophagosome. NCOA4 activity and severity of ferritinophagy are regulated by intracellular
iron levels. Under the conditions of full availability of this element, ubiquitin E3 ligase (HERC2)
binds NCOA4 and leads to its proteasomal degradation. The reduced level of NCOA4 promotes
stabilization of ferritin by reducing the level of intracellular iron and inhibiting ferritinophagy, which,
by producing reactive oxygen species (ROS), causes ferroptosis. NCOA4 deficiency in animal models
is manifested in the inability to degrade ferritin and leads to a decrease in the intracellular iron
bioavailability. Ferritinophagy is involved in NCOA4-mediated erythropoiesis, which enables the
release of iron from ferritin, which is necessary for the synthesis of mitochondrial heme. Therefore,
NCOA4 deficiency may be one of the mechanisms responsible for the development of anemia of
chronic diseases [9,10]. The iron in foods is present in the form of the Fe3+ ion, which under the
influence of gastric juice and Fe reductase (DCYTB) is reduced to the Fe2+ ion [11]. Its absorption
depends on the body’s demand for this element and takes place mostly in the proximal part of the
small intestine, where optimal conditions prevail. Bile secreted by the liver enters the duodenum,
Nutrients 2020, 12, 1784 4 of 17

where high-affinity bonds form between iron and bile salts. As a result, well-soluble iron compounds
(cation-bile salt complexes) are formed, which reach the intestinal mucosa more easily. Bile, by binding
iron ions, thus prevents the precipitation of sparingly soluble iron oxides (Fe2 O3 ). Bile salts are
therefore important buffers of iron ions, increasing their absorption in the digestive tract [12,13]. At the
time of iron deficiency, the expression of DMT1 (divalent metal transporter 1) increases, which is
responsible for its increased absorption. At the same time, the ferroportin-controlled release of iron
into the blood increases. Hepcidin—a 25-amino acid peptide predominantly synthesized by liver
cells that antagonizes ferroportin, plays a key role in regulating iron metabolism [14–16]. It binds to
ferroportin, which limits the release of iron from enterocytes, monocytes, macrophages and hepatocytes
into the blood. The amount of secreted hepcidin correlates with the intensity of erythropoiesis and
iron reserves in the human body, and most importantly, its synthesis and release are stimulated by
inflammatory cytokines, which are produced in excess in the course of chronic diseases [17]. The iron
already released into the circulation is oxidized with the participation of hephaestin (HEPH) to the Fe3+
ion and combined with transport proteins, i.e., transferrin and lactoferrin. Transferrin is a glycoprotein
synthesized in the liver by hepatocytes, glial cells, lymphocytes, Sertoli cells and mammary gland
cells. The rate of synthesis of this protein, like hepcidin, is strictly conditioned by the body’s demand
for iron and the concentration of this element in the blood serum. Under normal conditions, 30 to
40% of transferrin is saturated with iron, the remaining 60% is in the form of apotransferrin [18].
The mechanism that secures the loss of these proteins in the urine during glomerular filtration is their
high molecular weight of about 80 kDa. The mature transferrin molecule is formed by a long 679 amino
acid polypeptide chain, which is made up of two similar N- and C-terminal domains connected by
a short peptide. Each of these domains, by adopting an alternating β and α structure stabilized by
19 disulfide bridges, has one hydrophilic iron ion binding site, which ultimately allows the transport
of two iron atoms by one transferrin molecule [19]. The iron carriers reach the precursor cells of the
erythropoietic line (proerytroblasts), which express on their surface transferrin receptors, thanks to
which fusion with iron transporting proteins is possible. The iron released by endocytosis is used for
hemoglobin production and partly stored by ferritin. The iron-depleted transferrin (apotransferin)
leaves the precursor cell and goes back to the bloodstream, where it functions as described above [20,21].
The presence of transferrin receptors is mainly represented by tissues with high metabolism and cells
that are actively dividing. This partly may explain the increase in iron demand in people suffering from
certain types of neoplasm which results not only from the constant use of this element in the production
of hemoglobin, but also DNA synthesis by malignant cells [18]. Despite the fact that in the case of
malignant neoplasms this is not one of the main causes determining the occurrence of anemia of chronic
diseases (more often caused by chemotherapy-induced myelosuppression, blood loss, compromised
iron distribution, etc.), attempts are being made to use drugs targeting the transferrin receptor, which
blockade would interfere with the metabolism of actively dividing cells [22]. Nevertheless, transferrin
itself as a transporter protein can be used to bind oxidative stress-generating free iron or to transfer a
molecularly targeted drug to malignant cells [23].

4. Regulation of Iron Metabolism at the Cellular and Systemic Level

The expression of key proteins involved in iron absorption is controlled at many levels:
transcriptional, post-transcriptional and post-translational. It turns out that the individual stages of the
iron absorption process are subject to separate regulations. In the last decade, particular attention has
been paid to the effects of hypoxia and molecular mechanisms of iron homeostasis. The transcriptional
regulation of genes involved in the absorption and transport of iron across the intestinal mucosa was
largely unknown until the HIF-2 transcription factor was discovered. HIF transcription factors are
central mediators of cellular adaptation to hypoxia. They form heterodimers containing a regulatory α
subunit, responsive to iron deficiency and hypoxia, and a β subunit with constitutive expression known
as the aryl hydrocarbon receptor nuclear translocator (ARNT). There are three α subunit isoforms
(HIF-1α, HIF-2α and HIF-3α) that are regulated at post-translational level [24]. HIF-1 has been the
Nutrients 2020, 12, 1784 5 of 17

most widely studied subunit to date. HIF-1 has been shown to be involved in angiogenesis, glycolytic
metabolism, apoptosis and cellular stress [25]. HIF-1 has also been shown to regulate expression of
transferrin 1 receptor (TfR1) and expression of heme oxygenase 1 (HO-1) [26,27]. HIF-2 plays a key role
in adult erythropoiesis by increasing the hepatic production of erythropoietin and the absorption of
iron from the gastrointestinal tract. In enterocyte, HIF-2 regulates iron absorption by directly activating
transcription of the divalent metal transporter 1 (DMT1), iron reductase (DCTYB) and ferroportin (FPN).
Nutrients 2019, 11, x FOR PEER REVIEW 5 of 17
In addition, HIF-2 inhibits hepcidin production in the liver, which molecularly binds to the iron exporter,
i.e., ferroportin
(DMT1), iron [28]. In patients
reductase with and
(DCTYB) chronic kidney (FPN).
ferroportin diseaseIn(CKD),
addition,the HIF-2
lack ofinhibits
EPO production
hepcidin by
the interstitial
productiontissue of thewhich
in the liver, kidneys results in
molecularly defective
binds erythropoiesis,
to the iron which consequently
exporter, i.e., ferroportin leads to
[28]. In patients
anemia.with Under
chronic kidney disease (CKD),
physiological the lackexposure
conditions, of EPO production
to hypoxia by the interstitial
stabilizes tissueinofEPO-producing
HIF-2 the kidneys
kidney results
cells,inleading
defective to erythropoiesis,
increased productionwhich consequently
of this hormone. leads to At anemia.
normal Underoxygenphysiological
partial pressure
conditions, exposure to hypoxia stabilizes HIF-2 in EPO-producing
(21%), the α subunits are hydroxylated and quickly degraded by iron and oxygen kidney cells, leading to increased
dependent enzymes
production of this hormone. At normal oxygen partial pressure (21%), the α subunits are
(prolyl 4-hydroxylase, PHD). When the iron level is low, the prolyl hydroxylase activity decreases, thus
hydroxylated and quickly degraded by iron and oxygen dependent enzymes (prolyl 4-hydroxylase,
the α subunits are destroyed much more slowly. During hypoxia, the hydroxylation (stabilization) of
PHD). When the iron level is low, the prolyl hydroxylase activity decreases, thus the α subunits are
the αdestroyed
subunit ismuchinhibited, which enables
more slowly. its translocation
During hypoxia, to the nucleus
the hydroxylation and interaction
(stabilization) (dimerization)
of the α subunit is
with inhibited,
the β subunit.
which The enablesfunctional heterodimer
its translocation to the moves
nucleus to andtheinteraction
nucleus to regulate thewith
(dimerization) transcription
the β
of target genes
subunit. The(DCYTB,
functionalDMT1,
heterodimerFPN) by binding
moves to specific
to the nucleus sequences
to regulate called hypoxia-responsive
the transcription of target genes
elements (HRE).
(DCYTB, DMT1, Direct
FPN)binding of the
by binding to HIF heterodimer
specific to HRE
sequences called elements in the promoter
hypoxia-responsive regulatory
elements (HRE).
regions has been demonstrated for DCYTB and DMT1. Their induction probably mediates thebeen
Direct binding of the HIF heterodimer to HRE elements in the promoter regulatory regions has increase
in irondemonstrated for DCYTBinand
absorption observed DMT1. with
conditions Their low
induction
iron and probably
oxygenmediates
content the [29].increase in ironin the
The increase
number absorption
of CKDobserved in conditions
cases underlines thewith
needlow foriron andtherapeutic
novel oxygen content [29]. The increase
approaches in the
for treating numberSince
anemia.
of CKD cases underlines the need for novel therapeutic approaches for treating anemia. Since the
the discovery of HIF, a concept of HIF stabilization has been suggested to support EPO production in
discovery of HIF, a concept of HIF stabilization has been suggested to support EPO production in
CKD anemia. This is now possible thanks to a new class of drugs—PHD inhibitors or HIF stabilizers
CKD anemia. This is now possible thanks to a new class of drugs—PHD inhibitors or HIF stabilizers
that prevent degradation
that prevent degradation of the HIFHIF
of the α subunit
α subunit viaviathe
theproteasome.
proteasome. This This can improvethe
can improve thequality
qualityofof life
of patients with CKD by avoiding multiple transfusions, iron supplementation,
life of patients with CKD by avoiding multiple transfusions, iron supplementation, or reducing doses or reducing doses of
erythropoiesis stimulating agents
of erythropoiesis stimulating agents [30].[30].
The absorption
The absorption andand metabolism
metabolismofofironironhave
have been presentedininFigure
been presented Figure 1. 1.

Figure 1.3+Fe ions with food reach the stomach, where with the participation of hydrochloric acid and
3+
Figure 1. Fe ions with food reach the stomach, where with the participation of hydrochloric acid and
then (in duodenum) with ferric reductase enzyme (DCYTB) are transformed into Fe2+ ions. Bile
then (in duodenum) with ferric reductase enzyme (DCYTB) are transformed into Fe2+ ions. Bile secreted
secreted by the liver stabilizes iron by inhibiting its precipitation in the form of oxides. Thanks to
DMT1 protein (divalent metal transporter 1), iron passes into the enterocyte and then it is released
into the blood by ferroportin. Hepcidin produced by the liver limits the release of iron from
enterocytes into the blood by binding to ferroportin. The divalent iron released into the blood is
reoxidized with the contribution of hephaestin and ceruloplasmin to a trivalent ion, which, when
combined with apotransferrin, forms transferrin and reaches the erythroblasts in the bone marrow.
Nutrients 2020, 12, 1784 6 of 17

by the liver stabilizes iron by inhibiting its precipitation in the form of oxides. Thanks to DMT1 protein
(divalent metal transporter 1), iron passes into the enterocyte and then it is released into the blood by
ferroportin. Hepcidin produced by the liver limits the release of iron from enterocytes into the blood by
binding to ferroportin. The divalent iron released into the blood is reoxidized with the contribution of
hephaestin and ceruloplasmin to a trivalent ion, which, when combined with apotransferrin, forms
transferrin and reaches the erythroblasts in the bone marrow.

5. Pathogenesis of Anemia of Chronic Disease

Anemia of chronic disease, also known as secondary anemia is the most common hematological
disorder of the erythropoietic line after iron deficiency anemia in the world [31]. There is a permanent
increase in the incidence of this type of anemia which is associated with the aging of the population
and the tendency to develop chronic diseases, mainly malignant tumors and chronic kidney disease.
Its incidence varies from 40% in patients with solid tumors and reaches almost 100% among patients
with leukemia or lymphoma [32]. It was proven that anemia significantly worsens the quality of
life of patients with chronic diseases, and in some types of cancer (lung cancer, locally advanced
head and neck squamous cell carcinomas, cervical cancer) is an independent adverse prognostic
factor [33–35]. It is currently assumed that there are several mechanisms leading to overt anemia of
chronic diseases. They are interrelated. The first refers to the reduced iron reservoir needed for heme
synthesis. This deficiency results from excessive production of hepcidina regulatory protein produced
by the liver under the influence of cytokine stimulation, which inhibits the absorption of iron from
the gastrointestinal tract and at the same time reduces its release into the blood [36]. Inflammatory
cytokines, i.e., IL-1, IL-6, IL-10 and IFN-γ or TNF-α are the main factors contributing to the increase in
hepcidin gene expression [37]. The second mechanism involved in the pathogenesis of anemia of chronic
diseases is impaired production of erythropoietin. It results either from the advancement of chronic
kidney disease being a consequence of the coexistence of other diseases (e.g., diabetes), whose natural
course is associated with progressive nephropathy, or the direct action of the above-mentioned
proinflammatory cytokines, which inhibit the expression of erythropoietin and, consequently, impede
erythropoiesisin response to hypoxia [38,39]. In addition, the presence of proinflammatory cytokines
reduces the sensitivity of proerythroblasts to erythropoietin and significantly reduces the survival of
mature erythrocytes in peripheral blood [31]. The relationship between the stage of cancer and the
concentration of endogenous erythropoietin and the degree of anemia associated with it is currently
being intensively studied. Receptors for erythropoietin are located not only on the surface of erythrocyte
precursors, but also on cells of certain types of tumors (breast cancer, prostate cancer, squamous cell
carcinomas of the head and neck, multiple myeloma) and capillary wall cells of selected tumors [40–42].
Thus, recombinant analogues and derivatives of human erythropoietin used in the treatment of anemia
of chronic diseases can promote tumor growth and immortality (including through pro-angiogenic
and anti-apoptotic effects). Therefore, effective EPO-R blockade remains to be considered, which may
in the future become one of the methods of cancer treatment.

6. Diagnosis of Anemia of Chronic Disease

The diagnosis of anemia of chronic diseases is associated with the exclusion of other types of
anemia, including iron deficiency anemia. Although both types of these disorders share a deficiency of
this element, there are several important features that allow them to differentiate. When examining the
causes of anemia of chronic diseases, one should remember about disturbed hemoglobin production,
the hemolytic and deficient component of this disease as well as the complicated humoral and cellular
regulation of the hematopoietic process. The emergence of novel biochemical and molecular markers
of secondary anemia is associated with a better understanding of the biology of cancer and the diseases
it accompanies. Anemia of chronic diseases is described among people with infectious diseases
of viral (e.g., HIV), fungal, parasitic and bacterial (e.g., tuberculosis) etiology [43,44]. People who
undergo immunosuppressive therapy after organ transplantation or for the treatment of autoimmune
Nutrients 2020, 12, 1784 7 of 17

diseases (rheumatoid arthritis, systemic lupus erythematosus, etc.) are also often affected by secondary
anemia [45–47].
The Table 1 below presents the parameters differentiating iron deficiency anemia from anemia of
chronic diseases, including the assessment of blood counts, concentration of selected hematopoietic
factors and biochemical parameters as well as the presence of other chronic diseases.

Table 1. Comparison of iron deficiency anemia with anemia of chronic disease. (modified based on 14, 31).

Feature Iron Deficiency Anemia Anemia of Chronic Disease

the presence of other chronic diseases rarely often
average baseline hemoglobinconcentration ≥9 g/dL ≤9 g/dL
serum iron concentration decreased significantly decreased
MCV/MCH decreased normal
serum ferritin concentration low increased
serum hepcidin concentration low high
percentage of reticulocytes in the blood serum high low
serum folic acid concentration normal decreased
serum vitamin B12 concentration normal decreased
serum creatinine concentration normal increased
serum erythropoietin concentration increased decreased

7. Treatment of Anemia of Chronic Diseases

Along with the diagnosis of secondary anemia, it is necessary to specify the stage and previous
way of treatment of the underlying disease, which is associated with it, and the extent of deficiencies of
basic hematopoietic factors. Although the exact management of this disease has not yet been defined,
two directions of action to treat this type of anemia are still being adopted: silencing the underlying
disease and supplementing deficiencies [48,49]. These actions can be taken in parallel or individually,
depending on the severity of the anemia and the patient’s condition. Sometimes it is necessary to
transfuse blood products to the patient, which is most often the case in advanced malignant disease.
However, this gives a short-term effect and requires hospitalization [50]. The neoplastic process is
associated with a high demand of rapidly dividing cells for hematopoietic factors, which become
necessary not only for the synthesis of nucleic acids or proteins, but also the supply of the tumor
with blood itself. The vicious circle mechanism occurs when the neoplastic cells begin to produce
proinflammatory cytokines and other bone marrow-damaging substances or mature erythrocytes.
With the growth of the tumor and the occurrence of distant metastases, the appearance of anemia
becomes likely. Therefore, focus on causal treatment is the primary treatment for the anemia of chronic
disease. Nevertheless, extensive iron (oral or intravenous), vitamin C, folic acid and vitamin B12
supplementation should be considered, and in advanced chronic kidney disease and in malignancy
during chemotherapy, additionally administration of erythropoietin preparations [50–52]. In clinical
observation, the implementation of such treatment significantly delays or prevents the occurrence of
anemia of chronic diseases. Administration of ferrous chloride instead of ferrous sulfate or gluconate
allows to bypass gastrointestinal side effects resulting from oral supplementation of this element [53].
Vitamin C has been shown to facilitate its absorption in the gastrointestinal tract, thanks to which it is
often found as an additional component of iron preparations. In addition, vitamin C has an antioxidant
effect. If oral iron therapy is insufficient, intravenous administration in the form of an iron hydroxide
complex with sucrose or polyisomaltose should be considered [20]. Supplementation with vitamin B12
and folic acid is particularly justified during immunosuppressive therapy, including methotrexate in
patients with rheumatoid arthritis. Perhaps the intensive development of immunotherapy in neoplastic
and autoimmune diseases will allow treatment more specifically focused on the pathomechanism of
anemia of chronic diseases. The use of an anti-IL-6 receptor (tocilizumab) antibody in anemia associated
Nutrients 2020, 12, 1784 8 of 17

with rheumatoid arthritis, confirming its positive effect on hemoglobin increase [54,55]. There are also
reports of the possibility of blocking the action and production of hepcidin, whose presence in the
anemia of chronic diseases impairs the absorption and release of iron into the blood. Such management
has been used successfully in mice given anti-hepcidin antibody [56]. At present, hemodialysis is the
only possible way to eliminate hepcidin from blood serum in humans, which in this situation brings
more complications than benefits for the patient [57]. The most elucidated method of treating anemia
associated with neoplasm, in addition to the hematopoietic factors supplementation and transfusion
of blood-derived preparations described above, is the use of recombinant erythropoietin analogues
and derivatives. Currently, three preparations of human recombinant erythropoietin are available
on the market: rhEPOα and rhEPOβ, which is a product of genetic engineering, and a modified
derivative of human erythropoietin—darbepoetin, which has a much longer half-life and therefore
requires less frequent administration than the other two forms [58,59]. Numerous clinical studies have
proved the positive effect of these drugs on the increase of hemoglobin and improvement of well-being
among patients receiving chemo- and radiation therapy. An indication for their use cannot, however,
be prophylaxis of anemia or improvement of the quality of life [50]. Due to the presence of erythropoietin
receptors on cells of certain types of malignant tumors (lung cancer, breast cancer, squamous cell
carcinomas of the head and neck area), EPO preparations in these patients may, despite a temporary
improvement in well-being, cause disease progression or premature death [40,41]. The latest guidelines
limit the use of rhEPO preparations for the treatment of anemia associated with chronic kidney disease
in persons without a history of neoplastic disease, and for the treatment of anemia associated with
chemotherapy of solid tumors, but only among patients with hemoglobin in the range of 9–11 g/dL and
only until reaching the concentration of 12 g/dL. Administration of erythropoietin derivatives requires
the constant monitoring of blood counts, including the red cell system, and observation for possible
long-term adverse effects of these drugs (deep vein thrombosis, stroke, myocardial infarction) [58].
The Figure 2 below shows methods of treating anemia of chronic disease.

Figure 2. Treatment of anemia of chronic diseases.

8. The Role of Nutrition and Supplementation of Hematopoietic Factors in the Treatment of

Anemia of Chronic Diseases
The correct diet pattern of an adult should take into account the real demand of the system
for individual micronutrients, bioelements or vitamins. Thanks to a well-balanced and varied diet,
maintaining stability of red blood cell parameters becomes much easier, even if there is periodic blood
loss, impaired production or excessive destruction, which occurs in the anemia of chronic diseases.
Nutrients 2020, 12, 1784 9 of 17

Although isolated deficiencies of hematopoietic factors in most situations determine the nature of
anemia, in the case of anemia of chronic diseases are only part of the complex pathomechanism of this
disorder. Among the causes of anemia of chronic diseases, a deficit of several hematopoietic factors is
sooner perceived than isolated deficiency of each individual. This justifies extensive iron, folate and
vitamin B12 supplementation during the treatment of this type of anemia [60,61].

9. Oral Iron
Iron offers the widest selection of administration routes. It is available in oral, intramuscular
and intravenous forms. Each of these possible routes of administration of this element requires
consideration of the potential benefits that the patient may receive, but also of the risks associated with
side effects. Iron is usually supplemented by the oral route in the form of tablets, dragees or capsules,
although its supplementation is associated with a relatively high risk of side effects (according to
some reports, even in about 30% of patients) [62]. These mainly include gastrointestinal disorders
(nausea, vomiting, constipation or diarrhea), the severity of which generally depends on the type of
preparation used. Less common complaints are skin allergic reactions in the form of itching, rash or
erythema. When iron is administered orally, black stools appear, which is associated with the presence
of iron sulphides. The absence of such a color indicates then irregular use of the drug. The absorption
of iron from the gastrointestinal tract in most people with anemia of chronic diseases is impaired,
which is associated, among others with hepcidin production. Considering the other factors affecting its
absorption (plant or animal origin of iron, taking drugs interacting with iron preparations), one can
expect difficulties in obtaining effective supplementation, which, as expected, would not require
another way to supplement the deficiency of this element. Although oral iron administration can be
troublesome for the patient, the side effects are certainly not life threatening. This feature gives this
form of supplementation an advantage over others, unless there are indications for intramuscular or
intravenous supplementation of this element. Oral preparations are also safer because they decrease
the presence of a free fraction of iron in the blood known as non-transferrin bound iron (NTBI).
Free iron predisposes to the occurrence of infections, exacerbates the symptoms of sepsis and intensifies
inflammatory reactions and oxidative stress, thus damaging the endothelium, which accelerates the
process of atherogenesis. Macio and Madeddu evaluated dietary supplements taken by older people
that would stimulate erythropoiesis and antioxidant activity, so that they could potentially be used
to treat anemia of chronic diseases. Salidroside obtained from the extract of Rhodiolarosea, which
stimulates the synthesis of erythrocytes, belongs to such substances. Cyanobacteria spirulin also
raises high hopes. Its administration to humans increases the mean hemoglobin content of red blood
cells [20].

10. The Impact of Diet and Drugs for the Treatment of Iron Deficiency
Iron consumed by humans occurs naturally in two forms (heme and non-heme). Heme iron is
very well absorbed by the human body and is found in the largest amounts in red meat and offal
such as the liver, kidneys, heart. Non-heme iron is, however, poorly absorbed and is found mainly
in products of plant origin. Its bioavailability increases significantly when the plant also contains
vitamin C. It has been shown that the administration of ascorbic acid at a dose of 250 mg significantly
improves gastrointestinal absorption of iron administered orally. In addition, vitamin C facilitates
its uptake in the bone marrow, thus accelerating erythropoiesis [63]. Plant-derived products with a
high iron content include dry pulses, parsley, cocoa, nuts and spinach. Iron absorption is inhibited
by drugs such as calcium and magnesium carbonate, pancreatic extracts, cholestyramine, neomycin,
tetracyclines and proton pump inhibitors. The abovementioned drugs form hard-absorbed compounds
or complexes with iron. Therefore, it is important to keep at least 2 h between taking these drugs
and taking iron preparations. The same principle should also be adopted when consuming milk
and its products, certain vegetables and drinking coffee or tea, which contain substances perfectly
complexing iron, i.e., phytates, phosphates and oxalates. Taking oral iron preparations in the form
Nutrients 2020, 12, 1784 10 of 17

of an iron hydroxide III complex with polymaltose together with food or medicines (tetracyclines,
antacids) is acceptable and does not expose the patient to the risk of interaction. Iron alone, in turn,
can reduce the absorption of simultaneously administered zinc salts, tetracyclines, bisphosphonates,
entacapone, methyldopa, carbidopa, levodopa, fluoroquinolones, penicillins, penicillamines and
thyroxine, which also requires a 2-h interval between their administration and iron intake. Adverse
interaction is taking iron together with nonsteroidal anti-inflammatory drugs. The risk of irritation
of the gastrointestinal mucosa increases then, which may promote the development of peptic ulcer
disease and secondary anemia. The presence of peptic ulcer disease or other gastrointestinal diseases
accompanied by inflammation (Crohn’s disease, ulcerative colitis) disqualify the patient from oral iron
supplementation, as this increases the risk of bleeding. High bioavailability of iron adversely affect the
course of diseases associated with chronic inflammation. Iron sequestration taken by host cells is a
strategy that prevents the proliferation of pathogens. It has long been known that the development of
bacteria depends on the presence of iron, and its elimination effectively limits the growth of pathogens.
It appears that iron chelating compounds play a key role in this process. Well-known polyphenols
have long been recognized as antimicrobials. The iron-polyphenol complex cannot be absorbed by
epithelial cells and is excreted in faeces, suggesting that intestinal bacteria are also unable to absorb iron
chelated by polyphenols [64]. During studies using mouse models of colitis, it was found that increased
oxidative stress caused by oral iron administration is a major cause of exacerbation of the disease.
Changes in the intestinal microflora, consisting in the uncontrolled growth of pathogenic strains, largely
contributed to the exacerbation of inflammation in the large intestine in mice. The intestinal microflora
absorbs the iron needed for growth thanks to low molecular weight chelators, called siderophores.
The most common siderophore is enterobactin, which is found mainly in gram-negative bacteria such
as Salomenlla typhimurium. In inflammatory bowel disease, lipocalin-2 is secreted by epithelial cells.
It binds enterobactin and reduces the availability of iron for the intestinal microflora. The production
of lipocalin-2 is an innate defense system used to limit the growth of microorganisms. However, there
are pathogens that have developed modified siderophores which are insensitive to lipocalin-2. These
include Salmonella enterica, which produces salmochelin instead of enterobactin. Pathogens that are
not dependent on enterobactin then gain an advantage due to commensal growth [65]. Heme is an
important source of iron for both the host and intestinal microorganisms. It has been proven that
pathogenic strains grow particularly well in places rich in heme. Constante et al. showed that a diet
rich in heme in mice with sodium sulfate-induced colitis (DSS) changes the composition of the colonic
microflora by increasing the number of Proteobacteria, eliminating most of the positive G bacteria
from the Firmicutes group, and increasing the protective effect of probiotics [66]. In inflammatory
bowel disease, the role of the intestinal microflora should be appreciated and the possibility of using
natural iron chelating agents to suppress the inflammatory response of immune cells while inhibiting
the growth of pathogenic pathogens should be considered [67].

11. Parenteral Iron

If anemia is significant enough that it requires rapid correction of iron deficiency, its supplementation
becomes necessary by the intramuscular or intravenous route. According to recommendations parenteral
iron administration is only permissible in certain situations (in the case of intolerance to oral preparations,
their impaired absorption from the gastrointestinal tract or the current high demand for this element,
especially in patients with blood loss or treated with preparations stimulating erythropoiesis) [68].
The undisputed advantage of parenteral iron deficiency supplementation is the administration and
dosage regimen. While oral treatment must be regular and long-term, intramuscular or intravenous
therapy is generally interventional in nature, consisting of higher doses of iron being administered once
or several times. In a randomized clinical trial, Quinibi et al. demonstrated the superiority of the iron III
hydroxide and carboxymaltose complex applied intravenously over oral preparations, thus obtaining
higher hemoglobin and ferritin levels while reducing adverse effects on the patient [69]. Similar
conclusions were drawn from the Macdougall review, where better tolerance of new intravenous
Nutrients 2020, 12, 1784 11 of 17

iron preparations such as carboxymaltose or ferumoxytol was demonstrated. This is probably due
to the fact that the above preparations do not cause anaphylactic reactions and do not require the
administration of a test dose [70]. In fact, however, parenteral iron administration has more serious side
effects that are not seen in case of oral administration. Therefore, intravenous administration of iron
preparations requires the greatest caution, as apart from the occurrence of hypersensitivity reactions,
a sharp increase or decrease in blood pressure may occur. Moreover, the parenteral administration of
iron reduces its absorption from the gastrointestinal tract, therefore oral supplementation should be
considered no earlier than 5 days after the last injection. In conclusion, intramuscular or intravenous
iron supplementation is carried out only in the hospital, where it is possible to observe the patient and
react quickly when intolerance to the given preparation occurs. Iron administered intramuscularly
often exposes the patient to taste disturbances (metallic taste in the mouth), which are usually of a
transient nature. Less common are general symptoms such as headache, dizziness, shortness of breath,
palpitations or gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea). At the injection
site, pain, bleeding, abscess, necrosis or local tissue atrophy may occur. Although intravenous iron
administration gives satisfactory effects mainly expressed in the increase of hematological parameters
and good tolerance, there is still a lack of research and thus no evidence of their safe use in the long
term [71].Therefore, oral supplementation in iron deficiency remains the method of choice in the
treatment of anemia of chronic diseases, regardless of its severity. The presence of free iron in the blood
is dangerous, it can promote the development of infections or exacerbate an ongoing inflammatory
process. It can also lead to overloading of this element in the body (secondary hemochromatosis), which
may later be manifested by diabetes, liver, heart or kidney failure. However, iron supplementation is
contraindicated in patients with active inflammatory process and sepsis [71].

12. Folic Acid

The high demand for iron needed for hemoglobin synthesis also requires an adequate supply
of folic acid and vitamin B12 . Folic acid participates in the synthesis of purine and pyrimidine bases
forming deoxyribonucleic acid and in the transformation of amino acids and formates. It is necessary
for proper cell division, and therefore it plays an important role in tissues characterized by high
proliferative intensity, including the hematopoietic system. It is also absolutely essential in the process
of producing a myelin sheath of nerve fibers. The daily requirement of folic acid in an adult humans is
about 400 µg. Folic acid deficiency is most often manifested by megaloblastic anemia accompanied by
leukopenia and thrombocytopenia. Supplemented by women during the preconception period and
during pregnancy, it reduces the risk of birth defects associated with abnormal neural tube closure.
That is why the demand for folic acid increases significantly during pregnancy and breastfeeding.
Its sources are liver, kidneys, yeast, green vegetables and nuts. Treatment of folic acid deficiency
consists mainly of its oral supplementation and consumption of the above-mentioned products. Orally
administered, it is well absorbed from the small intestine, binds to plasma proteins and goes to the
liver, where it is stored and metabolized [60]. It should be remembered that a high supply of folic acid
often masks B12 deficiency, which can contribute to cognitive decline, especially in the elderly [72].

13. Vitamin B12

Vitamin B12 (cyanocobalamin) is a water-soluble vitamin that regulates hematopoietic processes
and the functioning of the nervous system (including myelin synthesis). Like folic acid, it participates in
the synthesis of nucleic acids. The average daily requirement for cyanocobalamin is 1–2 µg. Deficiency
of this vitamin leads to megaloblastic anemia, changes in peripheral nerves, followed by degenerative
changes of the spinal cord in the range of posterior cords and cortical spinal ducts. A deficiency that
persists for more than 3 months may result in consolidation of changes in the nervous system. The source
of vitamin B12 is mainly animal-derived food. Therefore, its supplementation is recommended for
people on a vegetarian diet. Released from food under the influence of gastric juice, vitamin B12 is
combined by an intrinsic factor (IF), which is a glycoprotein produced by the stomach’s parietal cells.
Nutrients 2020, 12, 1784 12 of 17

The complex formed reaches the small intestine, where cyanocobalamin is disconnected and absorbed
in the presence of calcium ions into the portal circulation. The transport of vitamin B12 in plasma
occurs with the support of binding proteins (transcobalamin I and II) and, as in the case of folic acid,
ends in the liver—the organ responsible for the storage of vitamin B12 .Cyanocobalamin is very poorly
absorbed from the gastrointestinal tract after oral administration (about 1%), so at the time of its deep
deficiency other forms of supplementation (usually intramuscular) are recommended. Deficiencies
in iron or folic acid may reduce or completely inhibit the response to cyanocobalamin treatment.
Therefore, the concentration of all three hematopoietic factors should be monitored simultaneously
and, if necessary, their supplementation should be implemented [61]. Advantages and disadvantages
of various hematopoietic factors supplementation taking account the routes of administration are
presented in the Table 2 below.

Table 2. Summary of the advantages and disadvantages of hematopoietic factors supplementation

depending on the route of administration.

Type of Hematopoietic Factor Route of Administration Advantages Disadvantages

limited effectiveness, poor
high safety of use, absence of absorption, interaction with
oral non-transferrin bound iron (NTBI) other drugs, nausea, vomiting,
in the blood. constipation, diarrhea, itching,
rash, erythema
the need for hospital
quick correction of deficiency, less
administration, dysgeusia,
frequent dosing, longer effect, less
headache and dizziness,
iron intramuscular frequent gastrointestinal ailments,
palpitations, shortness of
an alternative for
breath, bleeding, abscess, skin
swallowing disorders
necrosis at the injection site
the need for hospital
quick correction of deficiency, less administration, possible
frequent dosing, longer effect, less anaphylactic reaction, possible
intravenous frequent gastrointestinal ailments, development of infection or
an alternative for exacerbation of sepsis, risk of
swallowing disorders iron overload, a sharp increase
or decrease in blood pressure
poorly absorbed from the
good tolerability, low risk of
gastrointestinal tract (1% of
oral overdose, rather as
the dose), difficulties in
maintenance treatment
compensating for deficiency
vitamin B12
pain at the injection site, rarely
the method of choice in
anaphylactic shock and death,
supplementing the large
intramuscular and hypersensitivity reactions,
deficiency, longer effect, less
pruritus, rash,
frequent dosing
transient diarrhea
allergic skin reactions,
the method of choice, good
gastrointestinal disorders,
tolerance, well absorbed from the
folic acid oral nausea, vomiting,
gastrointestinal tract, low risk
sleep disturbance,
of overdose
depression or agitation

14. Treatment Considerations

The unsatisfactory effect of the above methods in combating anemia of chronic diseases prompts
us to continue looking for other possible forms of treatment for this condition. The greatest hopes
are currently associated with blocking the action of hepcidin or limiting its hepatic production. It has
been observed that heparin administered prophylactically to cancer patients significantly reduces the
concentration of this protein in the blood serum. A similar phenomenon was observed among mice [73].
This is due to the binding of bone morphogenetic protein6 (BMP6) to heparin. Bone morphogenetic
protein6 is a cytokine from the transforming growth factor (TGF-β) family which, through auto-
and paracrine effects, stimulates hepcidin gene transcription in the liver [74]. Reduced hepcidin
production has also been observed in patients with rheumatoid arthritis receiving anti-TNF-α antibody
(golimumab) [75]. An even more promising result is the improvement of hematological parameters in
Nutrients 2020, 12, 1784 13 of 17

patients with non-small-cell lung carcinoma who received anti-IL-6 antibody [76]. Also noteworthy is
the thiamine derivative fursultiamine, which in vitro function antagonistically to the hepcidin receptor,
i.e., ferroportin [77]. The only indication for its use is vitamin B1 deficiency. A form of causal treatment
of anemia associated with malignant diseases is the use of transferrin conjugates to carry drugs,
e.g., cytostatics. Complex of transferrin with doxorubicin—an anthracycline antibiotic commonly used
in the treatment of leukemia, lymphoma or sarcoma, allows better penetration of this drug into cancer
cells that show much higher expression of transferrin receptors than healthy cells. Such directed action
on neoplastic cells allows, among others avoid cardiotoxicity of doxorubicin, which was proved for
instance in the studies of Kratz et al. where mice were given doxorubicin conjugate with transferrin at
a dose three times higher than the concentration of free drug, while showing a significant reduction of
side effects [78,79]. Recently, HIF-2α stabilizers and PHD inhibitors have attracted a lot of interest.
Hypoxia induces hypoxia-induced factor (HIF), which stimulates the synthesis of erythropoietin (EPO)
and reduces hepcidin production in the liver. Inhibition of the prolyl hydroxylase enzyme (PHD)
stabilizes hypoxia-induced factor (HIF), maintaining its positive effect on erythropoiesis and iron
metabolism. PHD inhibitors are now a new form of pharmacological treatment of anemia associated
with chronic diseases. Many active PHD inhibitors such as roxadustat, molidustat, vadadustat and
desidustat are already in a late phase of clinical trials [80].

15. Conclusions
1. Anemia of chronic diseases is still a type of anemia that is difficult to treat. This is the result of
the complex pathomechanism of this disease and the ability of the underlying disease to make a
multifactorial, pathological modulation of the erythropoiesis process.
2. Improper therapeutic management may result from diagnostic errors, inappropriate
treatment of the underlying disease and underestimation of the benefits of hematopoietic
factors supplementation.
3. Administration of recombinant erythropoietin analogues in patients during chemotherapy allows
us to reduce the necessity of transfusion of blood products, although the indications for their use
are very limited.
4. The supplementation of hematopoietic factors should be implemented simultaneously with
the diagnosis of the underlying disease and last until its cure or longer, with the exception of
recombinant erythropoietin analogues and derivatives.
5. Proper nutrition and prevention of food deficiencies remains the primary form of preventing any
type of anemia, including anemia of chronic diseases.
6. Better knowledge of proteins and mechanisms involved in the formation of anemia of chronic
diseases associated with, among others, malignant neoplasms gives a great chance of creating
molecularly targeted drugs for the treatment of these diseases. Potentially the most effective
is the inhibition of hepcidin production and activity, therapy with transferrin conjugates with
anti-cancer drugs, and increasing iron absorption from the gastrointestinal tract and synthesis of
erythropoietin using PHD inhibitors and HIF-2 α stabilizers.

Author Contributions: G.L., K.C. and B.M. contributed to data analysis, interpretation of findings and drafting
the article. T.K. and M.N. participated in data collection. M.W. participated in data collection, critical revision and
final approval. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding. The APC was funded by Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University, Toruń, Poland.
Conflicts of Interest: The authors declare no conflict of interest.
Nutrients 2020, 12, 1784 14 of 17

References
1. Kaushansky, K. Lineage-specific hematopoietic growth factors. N. Engl. J. Med. 2006, 354, 2034–2045.
[CrossRef]
2. Arcasoy, M.O. The non-haematopoietic biological effects of erythropoietin. Br. J. Haematol. 2008, 141, 14–31.
[CrossRef]
3. Maxwell, P.; Melendez-Rodríguez, F.; Matchett, K.B.; Aragones, J.; Ben-Califa, N.; Jaekel, H.; Hengst, L.;
Lindner, H.; Bernardini, A.; Brockmeier, U.; et al. Novel antibodies directed against the human erythropoietin
receptor: Creating a basis for clinical implementation. Br. J. Haematol 2015, 168, 429–442. [CrossRef]
[PubMed]
4. Abbaspour, N.; Hurrell, R.; Kelishadi, R. Review on iron and its importance for human health. J. Res. Med. Sci.
2014, 19, 164–174.
5. Imam, M.U.; Zhang, S.; Ma, J.; Wang, H.; Wang, F. Antioxidants Mediate Both Iron Homeostasis and
Oxidative Stress. Nutrients 2017, 9, 641. [CrossRef] [PubMed]
6. Yun-Jung, B.; Jee-Young, Y.; Chung-Ja, S.; Hyun-Sook, K.; Mi-Kyung, S. Dietary intake and serum levels of
iron in relation to oxidative stress in breast cancer patient. J. Clin. Biochem. Nutr. 2009, 45, 355–360.
7. Chiou, B.; Connor, J.R. Emerging and Dynamic Biomedical Uses of Ferritin. Pharmaceuticals (Basel) 2018,
11, 124. [CrossRef] [PubMed]
8. Dignass, A.; Farrag, K.; Stein, J. Limitations of Serum Ferritin in Diagnosing Iron Deficiency in Inflammatory
Conditions. Int. J. Chronic Dis. 2018, 2018, 9394060. [CrossRef]
9. Santana-Codina, N.; Mancias, J.D. The Role of NCOA4-Mediated Ferritinophagy in Health and Disease.
Pharmaceiticals (Basel) 2018, 11, 114. [CrossRef]
10. Bellelli, R.; Federico, G.; Matte, A.; Colecchia, D.; Iolascon, A.; Chiariello, M.; Santoro, M.; De Franceschi, L.;
Carlomagno, F. NCOA4 Deficiency Impairs Systemic Iron Homeostasis. Cell Rep. 2016, 14, 411–421.
[CrossRef]
11. McKie, A.T.; Barrow, D.; Latunde-Dada, G.O.; Rolfs, A.; Sager, G.; Mudaly, E.; Mudaly, M.; Richardson, C.;
Barlow, D.; Bomford, A.; et al. An Iron-Regulated Ferric Reductase Associated with the Absorption of Dietary
Iron. Science 2001, 291, 1755–1759. [CrossRef] [PubMed]
12. Sanyal, A.J.; Hirsch, J.I.; Moore, E.W. Evidence that bile salts are important for iron absorption. Am. J. Physiol.
1994, 266, 318–323. [CrossRef] [PubMed]
13. Sanyal, A.J.; Hirsch, J.I.; Moore, E.W. High-affinity Binding Is Essential for Enhancement of Intestinal Fe2+
and Ca2+ Uptake by Bile Salts. Gastroenterology 1992, 102, 1997–2005. [CrossRef]
14. Ganz, T.; Nemeth, E. Hepcidin and Iron homeostasis. Biochim. Biophys. Acta 2012, 1823, 1434–1443. [CrossRef]
15. Jordan, J.B.; Poppe, L.; Haniu, M.; Arvedson, T.; Syed, R.; Li, V.; Kohno, H.; Kim, H.; Schnier, P.D.; Harvey, T.S.; et al.
Hepcidin Revisited, Disulfide Connectivity, Dynamics, and Structure. J. Biol. Chem. 2009, 284, 24155–24167.
[CrossRef]
16. Tussing-Humphreys, L.; Pustacioglu, C.; Nemeth, E.; Braunschweig, C. Rethinking Iron Regulation and
Assessment in Iron Deficiency, Anemia of Chronic Disease, and Obesity: Introducing Hepcidin. J. Acad.
Nutr. Diet. 2012, 112, 391–400. [CrossRef]
17. Means R.T., Jr. Hepcidin and Anaemia. Blood Rev. 2004, 18, 219–225. [CrossRef]
18. Sophie, W.-A.; Gérard, W.; Christoph, G.; Andreas, B.; Beat, M.F.; Bernard, F.; Jean-Daniel, T. Physiology of
Iron Metabolism. Transfus. Med. Hemother. 2014, 41, 213–221.
19. Gkouvatsos, K.; Papanikolaou, G.; Pantopoulos, K. Regulation of Iron Transport and the Role of Transferrin.
Biochim. Biophys. Acta 2012, 1820, 188–202. [CrossRef]
20. Maccio, A.; Madeddu, C. Management of Anemia of Inflammation in the Elderly. Anemia 2012, 2012, 1–20.
[CrossRef]
21. Scheers, N. Regulatory Effects of Cu, Zn, and Ca on Fe Absorption: The Intricate Play between Nutrient
Transporters. Nutrients 2013, 5, 957–970. [CrossRef] [PubMed]
22. Richardson, D.R.; Kalinowski, D.S.; Lau, S.; Jansson, P.J.; Lovejoy, D.B. Cancer cell iron metabolism and the
development of potent iron chelators as anti-tumour agents. Biochim. Biophys. Acta 2009, 1790, 702–717.
[CrossRef] [PubMed]
23. Gomme, P.T.; McCann, K.B.; Bertolini, J. Transferrin: Structure, function and potential therapeutic actions.
Drug Disc. Tod. 2005, 10, 267–273. [CrossRef]
Nutrients 2020, 12, 1784 15 of 17

24. Renassia, C.; Peyssonnaux, C. New insights into the links between hypoxia and iron homeostasis. Curr. Opin.
Hematol. 2019, 26, 125–130. [CrossRef]
25. Semenza, G.L. Hypoxia-inducible Factors in Physiology and Medicine. Cell 2012, 148, 399–408. [CrossRef]
26. Lee, J.; Jiang, B.H.; Chin, B.Y.; Iyer, N.V.; Alam, J.; Semenza, G.L.; Choi, A.M. Hypoxia-inducible factor-1
Mediates Transcriptional Activation of the Heme oxygenase-1 Gene in Response to Hypoxia. J. Biol. Chem.
1997, 272, 5375–5381. [CrossRef]
27. Tacchini, L.; Bianchi, L.; Bernelli-Zazzera, A.; Cairo, G. Transferrin Receptor Induction by Hypoxia.
HIF-1-mediated Transcriptional Activation and Cell-Specific Post-Transcriptional Regulation. J. Biol. Chem.
1999, 274, 24142–24146. [CrossRef]
28. Rankin, E.B.; Biju, M.P.; Liu, Q.; Unger, T.L.; Rha, J.; Johnson, R.S.; Simon, M.C.; Keith, B.; Haase, V.H.
Hypoxia-inducible factor-2 (HIF-2) Regulates Hepatic Erythropoietin In Vivo. J. Clin. Invest. 2007, 117, 1068–1077.
[CrossRef]
29. Mastrogiannaki, M.; Matak, P.; Peyssonnaux, C. The gut in iron homeostasis: Role of HIF-2 under normal
and pathological conditions. Blood 2013, 122, 885–892. [CrossRef]
30. del Vecchio, L.; Locatelli, F. Investigational Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors (HIF-PHI)
for the Treatment of Anemia Associated with Chronic Kidney Disease. Expert Opin. Investig. Drugs 2018,
27, 613–621. [CrossRef]
31. Weiss, G.; Goodnough, L.T. Anemia of chronic disease. N. Engl. J. Med. 2005, 352, 1011–1023. [CrossRef]
[PubMed]
32. Tas, F.; Eralp, Y.; Basaran, M.; Sakar, B.; Alici, S.; Argon, A.; Bulutlar, G.; Camlica, H.; Aydiner, A.; Topuz, E.
Anemia in oncology practice: Relation to diseases and their therapies. Am. J. Clin. Oncol. 2002, 25, 371–379.
[CrossRef] [PubMed]
33. Grogan, M.; Thomas, G.M.; Melamed, I.; Wong, F.L.; Pearcey, R.G.; Joseph, P.K.; Portelance, L.; Crook, J.;
Jones, K.D. The importance of hemoglobin levels during radiotherapy for carcinoma of the cervix. Cancer 1999,
86, 1528–1536. [CrossRef]
34. Caro, J.J.; Salas, M.; Ward, A.; Goss, G. Anemia as an independent prognostic factor for survival in patients
with cancer: A systemic, quantitative review. Cancer 2001, 91, 2214–2221. [CrossRef]
35. Lee, W.R.; Berkey, B.; Marcial, V.; Fu, K.K.; Cooper, J.S.; Vikram, B.; Coia, L.R.; Rotman, M.; Ortiz, H. Anemia
is associated with decreased survival and increased locoregional failure in patients with locally advanced
head and neck carcinoma: A secondary analysis of RTOG 85-27. Int. J. Radiat. Oncol. Biol. Phys. 1998,
42, 1069–1075. [CrossRef]
36. Bergamaschi, G.; Vilani, L. Serum hepcidin: A novel diagnostic tool in disorders of iron metabolism.
Haematologica 2009, 94, 1631–1633. [CrossRef] [PubMed]
37. Sheikh, N.; Dudas, J.; Ramadori, G. Changes of gene expression of iron regulatory proteins during turpentine
oil-induced acute-phase response in the rat. Lab. Investig. 2007, 87, 713–725. [CrossRef]
38. Jelkmann, W. Proinflammatory cytokines lowering erythropoietin production. J. Interferon Cyt. Res. 1998,
18, 555–559. [CrossRef]
39. Faquin, W.C.; Schneider, T.J.; Goldberg, M.A. Effect of inflammatory cytokines on hypoxia-induced
erythropoietin production. Blood 1992, 79, 1987–1994. [CrossRef]
40. Lai, S.Y.; Grandis, J.R. Understanding the presence and function of erythropoietin receptors on cancer cells.
J. Clin. Oncol. 2006, 24, 4675–4676. [CrossRef]
41. Acs, G.; Acs, P.; Beckwith, S.M.; Pitts, R.L.; Clements, E.; Wong, K.; Verma, A. Erythropoietin and erythropoietin
receptor expression in human cancer. Cancer Res. 2001, 61, 3561–3565. [PubMed]
42. Yasuda, Y.; Fujita, Y.; Masuda, S.; Musha, T.; Ueda, K.; Tanaka, H.; Fujita, H.; Matsuo, T.; Nagao, M.;
Sasaki, R.; et al. Erythropoietin is involved in growth and angiogenesis in malignant tumours of female
reproductive organs. Carcinogenesis 2002, 23, 1797–1805. [CrossRef] [PubMed]
43. van Eijk, L.T.; Kroot, J.C.; Tromp, M.; van der Hoeven, J.G.; Swinkels, D.W.; Pickkers, P.
Inflammation—Induced hepcidin-25 is associated with the development of anemia in septic patients:
An observational study. Crit. Care 2011, 15, R9. [CrossRef] [PubMed]
44. de Mast, Q.; Syafruddin, D.; Keijmel, S.; Riekerink, T.O.; Deky, O.; Asih, P.B.; Swinkels, D.W.; van der
Ven, A.J. Increased serum hepcidin and alterations in blood iron parameters associated with asymptomatic P.
falciparum and P. vivax malaria. Haematologica 2010, 95, 1068–1074. [CrossRef] [PubMed]
Nutrients 2020, 12, 1784 16 of 17

45. Wilson, A.; Reyes, E.; Ofman, J. Prevalence and outcomes of anemia in inflammatory bowel disease:
A systemic review of the literature. J. Med. 2004, 116, 44S–49S. [CrossRef]
46. Müller, H.M.; Horina, J.H.; Kniepeiss, D.; Tripolt, M.B.; Stadelbauer, V.; Schweiger, M.; Tscheliessnigg, K.H.
Characteristics and clinical relevance of chronic anemia in adult heart transplant recipient. Clin. Transpl.
2001, 15, 343–348. [CrossRef]
47. Cullis, J.O. Diagnosis and management of anemia of chronic disease: Current status. Br. J. Haematol. 2011,
154, 289–300. [CrossRef]
48. Madu, A.J.; Ughasoro, M.D. Anaemia of Chronic Disease: An In-Depth Review. Med. Princ. Pract. 2017,
26, 1–9. [CrossRef]
49. Jander, A.; Wierciński, R.; Bałasz-Chmielewska, I.; Miklaszewska, M.; Zachwieja, K.; Borzecka, H.;
Zachwieja, J.; Olszak-Szot, I.; Kubicki, D.; Ziółkowska, H.; et al. Anaemia treatment in chronically
dialysed children: A multicentre nationwide observational study. Scand. J. Urol. Nephrol. 2012, 46, 375–380.
[CrossRef]
50. Winczura, P.; Jassem, J. Recombinant human erythropoietin in treatment of the cancer patients with anemia:
Hopes and threats. Oncol. Clin. Pract. 2007, 3, 198–204.
51. Davis, S.L.; Littlewood, T.J. The investigation and treatment of secondary anaemia. Blood Rev. 2012, 26, 65–71.
[CrossRef] [PubMed]
52. Joshi, A.D.; Holdford, D.A.; Brophy, D.F.; Harpe, S.E.; Mays, D.; Gehr, T.W. Utilization Patterns of IV Iron
and Erythropoiesis Stimulating Agents in Anemic Chronic Kidney Disease Patients: A Multihospital Study.
Anaemia 2012, 2012, 1–11. [CrossRef] [PubMed]
53. Styszyński, A. Anemia of inflammation in older persons. Part II. Impact of age-dependent diseases, diagnostic
and therapeutic options. Geriatria 2013, 7, 1–8.
54. Hashizume, M.; Uchiyama, Y.; Horai, N.; Tomosugi, N.; Mihara, M. Tocilizumab, a humanized
anti-interleukin-6 receptor antibody, improved anemia in monkey arthritis by suppressing IL-6-induced
hepcidin production. Rheumatol. Int. 2010, 30, 917–923. [CrossRef] [PubMed]
55. Hashimoto, M.; Fujii, T.; Hamaguchi, M.; Furu, M.; Ito, H.; Terao, C.; Yamamoto, K.; Yamamoto, W.; Matsuo, T.;
Mori, M.; et al. Increase of hemoglobin levels by anti-IL-6 receptor antibody (tocilizumab) in rheumatoid
arthritis. PLoS ONE 2014, 9, e98202. [CrossRef] [PubMed]
56. Sasu, B.J.; Cooke, K.S.; Arvedson, T.L.; Plewa, C.; Ellison, A.R.; Sheng, J.; Winters, A.; Juan, T.; Li, H.;
Begley, C.G.; et al. Antihepcidin antibody treatment modulates iron metabolism and is effective in a mouse
model of inflammation- induced anaemia. Blood 2010, 115, 3616–3624. [CrossRef]
57. Zaritsky, J.; Young, B.; Gales, B.; Wang, H.J.; Rastogi, A.; Westerman, M.; Nemeth, E.; Ganz, T.; Salusky, I.B.
Reduction of serum hepcidin by hemodialysis in pediatric and adult patients. Clin. J. Am. Soc. Nephrol. 2010,
5, 1010–1014. [CrossRef]
58. Egrie, J.C.; Strickland, T.W.; Lane, J.; Aoki, K.; Cohen, A.M.; Smalling, R.; Trail, G.; Lin, F.K.; Browne, J.K.;
Hines, D.K. Characterization and biological effects of recombinant human erythropoietin. Immunobiology
1986, 172, 213–224. [CrossRef]
59. Egrie, J.C.; Browne, J.K. Development ad characterization of darbepoetin alfa. Oncology 2002, 16, 13–22.
60. Kapka-Skrzypczak, L.; Niedźwiecka, J.; Skrzypczak, M.; Wojtyła, A. Folic acid—effects of deficiency and
justification for supplementation. Med. Ogólna i Nauki o Zdrowiu. 2012, 18, 65–69.
61. Kośmider, A.; Czaczyk, K. Witamina B12 —budowa, biosynteza, funkcje i metody oznaczania. Żyw. N.
Tech. Jak. 2010, 5, 17–32.
62. Charytan, C.; Quinibi, W.; Bailie, G.R. Comparison of intravenous iron sucrose to oral iron in the treatment
of anemic patients with chronic kidney disease not on dialysis. Nephron. Clin. Pract. 2005, 100, 55–62.
[CrossRef] [PubMed]
63. Salovaara, S.; Sandberg, A.-S.; Andlid, T. Organic acids influence iron uptake in the human epithelial cell line
caco-2. J. Agric. Food Chem. 2002, 50, 6233–6238. [CrossRef] [PubMed]
64. Daglia, M. Polyphenols as Antimicrobial Agents. Curr. Opin. Biotechnol. 2012, 23, 174–181. [CrossRef]
65. Raffatellu, M.; George, M.D.; Akiyama, Y.; Hornsby, M.J.; Nuccio, S.; Paixao, T.A.; Butler, B.P.; Chu, H.;
Santos, R.L.; Berger, T.; et al. Lipocalin-2 Resistance Confers an Advantage to Salmonella Enterica Serotype
Typhimurium for Growth and Survival in the Inflamed Intestine. Cell Host Microbe 2009, 5, 476–486.
[CrossRef] [PubMed]
Nutrients 2020, 12, 1784 17 of 17

66. Constante, M.; Fragoso, G.; Lupien-Meilleur, J.; Calvé, A.; Santos, M.M. Iron Supplements Modulate Colon
Microbiota Composition and Potentiate the Protective Effects of Probiotics in Dextran Sodium Sulfate-induced
Colitis. Inflamm. Bowel Dis. 2017, 23, 753–766. [CrossRef]
67. Chieppa, M.; Giannelli, G. Immune Cells and Microbiota Response to Iron Starvation. Front Med. (Lausanne)
2018, 5, 109. [CrossRef]
68. Myśliwiec, M. Oral iron supplementation in renal anemia. For. Nefrol. 2012, 5, 195–203.
69. Quinibi, W.Y.; Martinez, C.; Smith, M.; Benjamin, J.; Mangione, A.; Roger, S.D. A randomized controlled
trial comparing intravenous ferric carboxymaltose with oral iron for treatment of iron deficiency anaemia
of non-dialysis-dependent chronic kidney disease patients. Nephrol. Dial. Transplant. 2011, 26, 1599–1607.
[CrossRef]
70. Macdougall, I.C. Iron supplementation in the non-dialysis chronic kidney disease (ND-CKD) patient: Oral or
intravenous? Curr. Med. Res. Opin. 2010, 26, 473–482. [CrossRef]
71. Macdougall, I.C. Iron supplementation in nephrology and oncology: What do we have in common? Oncologist
2011, 16, 25–34. [CrossRef] [PubMed]
72. Smith, A.D. Folic acid fortification: The good, the bad, and the puzzle of vitamin B-12. Am. J. Clin. Nutr.
2007, 85, 3–5. [CrossRef] [PubMed]
73. Poli, M.; Girelli, D.; Campostrini, N.; Maccarinelli, F.; Finazzi, D.; Luscieti, S.; Nai, A.; Arosio, P. Heparin:
A potent inhibitor of hepcidin expression in vitro and in vivo. Blood 2011, 117, 997–1004. [CrossRef] [PubMed]
74. Andriopoulos, B., Jr.; Corradini, E.; Xia, Y.; Faasse, S.A.; Chen, S.; Grgurevic, L.; Knutson, M.D.; Pietrangelo, A.;
Vukicevic, S.; Lin, H.Y.; et al. BMP6 is a key endogenous regulator of hepcidin expression and iron metabolism.
Nat. Gen. 2009, 41, 482–487. [CrossRef] [PubMed]
75. Doyle, M.K.; Rahman, M.U.; Frederick, B.; Birbara, C.A.; de Vries, D.; Toedter, G.; Wu, X.; Chen, D.;
Ranganath, V.K.; Westerman, M.E.; et al. Effect of subcutaneous and intravenous golimumab on inflammatory
biomarkers in patients with rheumatoid arthritis: Results of a phase 1, randomized, open-label trial.
Rheumatology 2013, 52, 1214–1219. [CrossRef] [PubMed]
76. Bayliss, T.J.; Smith, J.T.; Schuster, M.; Dragnev, K.H.; Rigas, J.R. A humanized anti-IL-6 antibody (ALD518) in
non-small cell lung cancer. Exp. Opin. Biol. Ther. 2011, 11, 1663–1668. [CrossRef]
77. Fung, E.; Sugianto, P.; Hsu, J.; Damoiseaux, R.; Ganz, T.; Nemeth, E. High-throughput screening of small
molecules identifies hepcidin antagonists. Mol. Pharmacol. 2013, 83, 681–690. [CrossRef] [PubMed]
78. Kratz, F.; Beyer, U.; Roth, T.; Tarasova, N.; Collery, P.; Lechenault, F.; Cazabat, A.; Schumacher, P.; Unger, C.;
Falken, U. Transferrin conjugates of doxorubicin: Synthesis, characterization, cellular uptake, and in vitro
efficacy. J. Pharm. Sci. 1998, 87, 338–346. [CrossRef]
79. Xu, X.; Persson, H.L.; Richardson, D.R. Molecular pharmacology of the interaction of anthracyclines with
iron. Mol. Pharmacol. 2005, 68, 261–271. [CrossRef]
80. Joharapurkar, A.A.; Pandya, V.B.; Patel, V.J.; Ranjit, C.; Desai, M.R.J. Prolyl Hydroxylase Inhibitors:
A Breakthrough in the Therapy of Anemia Associated with Chronic Diseases. J. Med. Chem. 2018,
61, 6964–6982. [CrossRef]

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).