Management of Elevated Red Blood Cell Count, Hemoglobin, Hematocrit, and Ferritin

Diagnostic Approach

Measure transferrin saturation and serum ferritin to evaluate iron overload, as recommended by the European Association for the Study of the Liver, with typical transferrin saturation >50% and ferritin markedly elevated in hemochromatosis 1, 2
Consider genetic testing for HFE mutations, such as C282Y homozygosity, which is diagnostic for hemochromatosis, as suggested by the American Association for the Study of Liver Diseases 1, 2

Therapeutic phlebotomy is the cornerstone of treatment, with the goal of removing excess iron, as recommended by the European Association for the Study of the Liver, with a target serum ferritin of 50-100 μg/L 1, 2, 3
During the induction phase, remove 400-500 mL of blood weekly or every 2 weeks, and monitor hemoglobin before each phlebotomy session, as suggested by the American Association for the Study of Liver Diseases 1, 3, 6
In the maintenance phase, phlebotomy is performed every 1-4 months to maintain ferritin 50-100 μg/L and transferrin saturation <60%, as recommended by the European Association for the Study of the Liver 1, 3
Dietary and lifestyle modifications include avoiding iron supplementation and iron-fortified foods, avoiding supplemental vitamin C, limiting red meat consumption, and restricting alcohol intake, as suggested by the American Association for the Study of Liver Diseases 1, 2, 6

Monitor ferritin every 6 months during the maintenance phase, and investigate unexpected changes in ferritin or transferrin saturation, as recommended by the European Association for the Study of the Liver 1, 3
Check hemoglobin at each phlebotomy session, and adjust the phlebotomy frequency based on hemoglobin levels, as suggested by the American Association for the Study of Liver Diseases 1, 6