Anemia of chronic disease (ACD) is a common complication in malignant tumor patients, and the correlated clinical manifestations can reduce the quality of life (Experts Committee on Cancer -Related Anemia, 2015; Wang and Xia, 2018). Thus, exploration on pathogenesis and malignant tumor-related ACD and how to improve anemia has become a research focus of scientists, which has important clinical significance to improve the quality of life of these patients. It has been reported that hepcidin, interleukine-6 (IL-6), and tumor necrosis factor α (TNF-α) play very important roles during ACD attack (Liu et al., 2015; Kalyani and Jamil, 2015; Sharma et al., 2018). In this study, ELISA method was used to measure serum hepcidin, IL-6 and TNF-α levels in patients admitted in our hospital to explore the effect of serum hepcidin, IL-6 and TNF-α levels in malignant tumor patients with ACD. The study was reported as follows.

1 Results

1.1 General Information

Among the 40 patients meeting enrollment criteria in the research group, there were 18 men and 22 women. The age range was 35-78 years old and median age was 60 years old. A total of 20 malignant tumor patients without anemia were admitted simultaneously. Among them, there were 8 men and 12 women. The age range was 38-72 years old, and the median age was 56 years old. There was no statistical difference in sex ratio and age between the two groups (P>0.05).

1.2 Serum hepcidin, IL-6 and TNF-α expression levels and Hb concentration in the patients from two groups

The serum hepcidin, IL-6, and TNF-α levels in the 40 patients from the research group were 49.48±18.38 ng/mL, 11.79±4.11 pg/mL, and 10.73±3.94 pg/mL, respectively. The serum hepcidin, IL-6, and TNF-α levels in the 20 patients in the control group were 10.36±5.28 ng/mL, 5.46±2.37 pg/mL, and 6.48±3.26 pg/mL, respectively. The serum hepcidin, IL-6, and TNF-α levels in the research group were all higher than those in the control group with statistical significance (P＜0.05). As shown in Table 1.

Table 1 Results of serum hepcidin, IL-6, and TNF-α levels in each group Note: Compared with the control group, *P<0.05

1.3 Correlations of serum hepcidin, IL-6 and TNF-α expression levels with anemia

The correlations of Hb value with hepcidin, IL-6 and TNF-α in the research group were analyzed, and the correlations of hepcidin with IL-6 and TNF-α were also analyzed. The result indicated that the Hb value in the patients from the research group had negative correlations with serum hepcidin and IL-6 (r values were -0.739 and -0.379, and P＜0.05, Figure 1, Figure 2), but had no correlation with TNF-α (r=-0.213, P>0.05). The serum hepcidin in the patients from the research group had a positive correlation with IL-6 (r=0.377, P＜0.05, Figure 3), but had no correlation with TNF-α (r=0.268, P>0.05).

Figure 1 Correlation of Hb with Hepcidi index

Figure 2 Correlation of Hb with IL-6 index

Figure 3 Correlation of Hepcidi with IL-6 index

2 Discussion

Anemia of chronic disease (ACD) is also named as anemia of inflammation (AI). The pathogenesis of ACD is very complicated, and also not clearly confirmed. Currently, domestic and overseas studies reported that the main pathogenesis of ACD was related with shortened red blood cell survival time, decrease in release of stored iron from monocyle-macrophage system (MMS), and reduction in reactivity of bone marrow to hemopoietin (Weiss et al., 2019). Hepcidin is a small peptide hormone synthesized in hepatocytes, and participates in iron metabolism and mainly binds with ferroportin to block intestinal iron absorption and lead to MMS iron retention, which further results in generation of iron restricted erythrocytes (Detiavaud et al., 2005). Our research data suggested that the serum hepcidin of malignant tumor patients with ACD was 49.48±18.38 ng/mL, which was significantly higher than that of the tumor patients without anemia (49.48±18.38 ng/mL) (P＜0.05). Besides, Hb value in the research group had a negative correlation with serum hepcidin level (P＜0.05). Our data supported previous studies (Katodritou et al., 2009; Ibricevic-Balic et al., 2016). It indicated that hepcidin participated in the occurrence of anemia.

Previous studies proved that multiple inflammatory mediators participated in the processes of hepcidin expression and regulation of iron metabolism. Inflammatory mediator and hepcidin participated together in the occurrence and development of ACD. A series of oversea studies combined cytokines and hepcidin expression, which realized the regulation on hepcidin expression mediated by IL-6. IL-6 takes a core regulatory effect in inflammatory response, and is an important medium in inflammatory immune response (Nicolas et al., 2002; Ganz, 2011; Lichtenstein, 2014). Our research data suggested that serum IL-6 and TNF-α levels in the malignant tumor patients with ACD were 11.79±4.11 pg/mL and 10.73±3.94 pg/mL, respectively. The results were significantly higher than those in the tumor patients without anemia (5.46±2.37 pg/mL and 6.48±3.26 pg/mL, respectively) (P＜0.05). Besides, the Hb value had a negative correlation with serum IL-6 level in the patients from the research group (P＜0.05), but had no correlation with TNF-α (P>0.05). It suggested that cytokine IL-6 mainly participated in the ACD onset of tumor patients. However, there are some other studies suggested that in Hb value in the tumor patients with anemia had no correlations with serum hepcidin, IL-6 and TNF-α levels, which might be related with difference in selection on study subjects (Li et al., 2014).

Above all, the pathogenesis of malignant tumor combined with ACD is extremely complicated. Our study suggested that it was mainly related with serum hepcidin and IL-6. The above indices caused iron metabolic disorder and further led to occurrence of anemia. The detection on the indices could evaluate the occurrence and development of anemia, which possessed clinical value to a certain degree.

3 Materials and Methods

3.1 Case information

From Jan. 2017 to Jan. 2019, a total of 40 malignant tumor patients with ACD admitted in our hospital met the diagnostic criteria for ACD in Criteria for the diagnosis and treatment of hematologic diseases (Zhang, 2007). Among them, there were 18 men and 22 women. The age range was 35-78 years old and the median age was 60 years old. The disease types were as follows: 9 patients with breast cancer, 7 patients with lymphoma, 5 patients with lung cancer, 4 patients with colorectal cancer, 3 patients with endometrial carcinoma, 3 patients with pancreatic cancer, 2 patients with gastric cancer, 2 patients with liver cancer, 2 patients with ovarian cancer, 2 patients with cervical cancer, and 1 patient with esophagus cancer. A total of 20 malignant tumor patients without anemia were admitted simultaneously. Among them, there were 8 men and 12 women. The age range was 38-72 years old, and the median age was 56 years old. The disease types were as follows: 6 patients with colorectal cancer, 5 patients with breast cancer, 2 patients with gastric cancer, 2 patients with lymphoma, 2 patients with lung cancer, 2 patients with endometrial carcinoma, and 1 patient with cervical cancer. The study was approved by Ethics Committee of Heilongjiang Province Hospital, and performed following the standards of Declaration of Helsinki.

3.2 Methods

Five milliliter of fasting peripheral venous blood was collected. The anticoagulated blood was stood still at 4°C. After serum was separated and coagulated, the serum was collected by centrifugation, and frozen at -80 °C for the measurement of serum hepcidin, IL-6 and TNF-α concentrations. Hepcidin, IL-6, and TNF-α kits were provided by Invitrogen (USA), and double antibody sandwich ELISA is used in each kit. Measurement was carried out following instructions.

3.3 Statistical method

SPSS 24.0 software (SPSS, USA) was used to analyze the data. Measurement data were expressed as mean ± SD, and analyzed by t test and Spearman rank correlation method. P<0.05 was termed as statistical significance.

Authors’ Contributions

Liru Wang wrote and translated the manuscript. Yinghui Wang read and approved the final manuscript. Menglin Liu, Jing Zhao and Wenxin Wang collected materials. All authors read and approved the final manuscript.

Acknowledgements

The study was supported by Science and technology plan of Heilongjiang Provincial health and family planning commission (2017-476)

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