Which feature best distinguishes iron deficiency anemia from anemia of chronic disease in a 52-year-old man with chronic kidney disease?

Question

Accepted Answer

C. Serum ferritin level. ## Distinguishing Iron Deficiency Anemia from Anemia of Chronic Disease

### Key Laboratory Discriminator

**Key Point:** Serum ferritin is the single best discriminating feature between iron deficiency anemia (IDA) and anemia of chronic disease (ACD).

### Comparative Table

| Feature | Iron Deficiency Anemia | Anemia of Chronic Disease |
| --- | --- | --- |
| **Serum Ferritin** | **Low (<30 ng/mL)** | **Normal or elevated (>100 ng/mL)** |
| Serum Iron | Low | Low |
| TIBC | Elevated | Normal or low |
| Transferrin Saturation | Low (<16%) | Low |
| Hemoglobin | Variable | Variable |
| MCV | Microcytic (early) | Normocytic (usually) |
| Reticulocyte Count | Low (relative) | Low (relative) |
| Bone Marrow Iron | Absent | Present |

### Pathophysiology

**High-Yield:** In IDA, total body iron stores are depleted, so ferritin is genuinely low. In ACD, iron is sequestered in macrophages due to elevated hepcidin (from IL-6 in chronic inflammation), so ferritin is normal or high because ferritin is an acute phase reactant.

### Why Ferritin Wins

1. **Hemoglobin and MCV** are non-specific; both conditions can present with overlapping values.
2. **Reticulocyte count** is similarly suppressed in both conditions due to inadequate erythropoietin response.
3. **Serum ferritin** directly reflects total body iron stores and is the gold standard discriminator.

**Clinical Pearl:** When ferritin is borderline (30–100 ng/mL), use transferrin saturation or bone marrow iron staining to confirm IDA.

**Mnemonic:** **FERRITIN = IRON STORES** — Low ferritin = depleted iron (IDA); high ferritin = sequestered iron (ACD).

Answer

A. Hemoglobin concentration

Answer

B. Reticulocyte count

Answer

D. Mean corpuscular volume

Which feature best distinguishes iron deficiency anemia from anemia of chronic disease in a 52-year-old man with chronic kidney disease?

Explanation

Distinguishing Iron Deficiency Anemia from Anemia of Chronic Disease

Key Laboratory Discriminator

Comparative Table

Pathophysiology

Why Ferritin Wins

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Feature	Iron Deficiency Anemia	Anemia of Chronic Disease
Serum Ferritin	Low (<30 ng/mL)	Normal or elevated (>100 ng/mL)
Serum Iron	Low	Low
TIBC	Elevated	Normal or low
Transferrin Saturation	Low (<16%)	Low
Hemoglobin	Variable	Variable
MCV	Microcytic (early)	Normocytic (usually)
Reticulocyte Count	Low (relative)	Low (relative)
Bone Marrow Iron	Absent	Present