Anemia of immobility: caused by adipocyte accumulation in bone marrow

Anemia of chronic disease has long been used to classify a non-regenerative, low-grade, chronic, normocytic, normochromic anemia that presents with no obvious etiology. Within this group, some patients have a chronic inflammatory condition that limits erythrocyte generation or access to iron stores. This specific type of anemia has been termed anemia of chronic inflammation. However, a substantial remainder of patients diagnosed with anemia of chronic disease present with no active inflammation. These include many clinical populations with reduced limb loading, such as spinal cord injured patients, astronauts, elderly people with limited mobility and experimental bed-rest subjects. In some populations with decreased mobility, accumulation of fat in the bone marrow has been demonstrated. We hypothesize that adipocyte accumulation in bone marrow both passively and actively impairs erythropoiesis and thus defines a new type of anemia called anemia of immobility. The non-specific umbrella term anemia of chronic disease thus becomes obsolete in favour of either the diagnosis of anemia of immobility or anemia of chronic inflammation according to the distinct mechanism involved.