Further Inpatient Care

Hospital admissions in cases of transfusion-induced iron overload may result from complications of cirrhosis, sepsis, and heart failure, amongst other causes. These cases should be managed with a multidisciplinary team approach.

Transfer

Compliance with chelation therapy for transfusion-induced iron overload is specific to the treatment center, with better long-term survival in centers that have experience in chelation management than in centers where small numbers of patients are treated.^[119]

Deterrence/Prevention

All patients who are transfusion dependent require careful monitoring of their iron stores. It is advisable to measure ferritin levels at least every 3 months and iron studies every year. Liver iron levels should be measured annually (either by biopsy or noninvasively) and every 3–6 months in patients who undergo intensive chelation for heart failure. If MRI is available, cardiac iron levels and cardiac function should also be measured by MRI yearly and every 6 months in patients who have intensive chelation therapy.^[48]

Complications

Monitoring liver function test results and kidney function, especially in sickle cell patients, is recommended during chelation therapy.

Prognosis

Complications of iron overload have been steadily falling since the introduction of deferoxamine. For thalassemia major patients in Italy who were started on deferoxamine after subcutaneous infusions became widely available in 1980, death from cardiac disease fell from 5% at 20 years to 1%, and the incidence rates hypogonadism, diabetes, and hypothyroidism also fell significantly.

Better survival has been demonstrated for patients born in more recent years (P< 0.00005) and for females (P = 0.0003). In a study by Borgna-Pignatti et al, 68% of patients were alive at age 35 years, with 67% of the patient deaths due to heart disease.^[78]In some patients treated with deferoxamine (particularly those who start treatment late or who fail to comply with treatment), high levels of iron (>15 mg iron per gram of liver dry weight) are still present—a level that is associated with a high risk of cardiac disease and early death over a long period.^[86]Failure to control serum ferritin over prolonged periods is also associated with an increased risk of cardiac disease and death.^[25]

Patient Education

Compliance is the major limiting factor of chelation therapy in cases of transfusion-induced iron overload, and continuous re-enforcement is needed. Patients should be educated about signs and symptoms of heart failure, cirrhosis, and diabetes.

Questions

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Media Gallery

Complications of iron overload as manifested in various organs in the body
Iron absorption

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Author

Geneva E Guarin, MD, MBA Resident Physician, Department of Internal Medicine, Einstein Medical Center Philadelphia

Disclosure: Nothing to disclose.

Coauthor(s)

Claudia M da Costa Dourado, MD Clinical Assistant Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Program Director, Hematology and Medical Oncology Fellowship Program, Attending Physician, Division of Hematology and Medical Oncology, Department of Medicine, Einstein Medical Center Philadelphia

Claudia M da Costa Dourado, MD is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald A Sacher, MD, FRCPC, DTM&H Professor Emeritus of Internal Medicine and Hematology/Oncology, Emeritus Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MD, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Pradyumna D Phatak, MBBS, MD Chair, Division of Hematology and Medical Oncology, Rochester General Hospital; Clinical Professor of Oncology, Roswell Park Cancer Institute

Pradyumna D Phatak, MBBS, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Received honoraria from Novartis for speaking and teaching.

Muhammad A Mir, MD, FACP Assistant Professor of Medicine (Hematology, Blood/Marrow Transplant) Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Muhammad A Mir, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Hematology, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Gerald L Logue, MD Professor of Medicine, Head of the Division of Hematology, Vice Chairman for Education, Department of Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Gerald L Logue, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Physicians, American Society of Hematology, American Federation for Clinical Research

Disclosure: Nothing to disclose.