Management of Iron Saturation

Assessment of Iron Status

Comprehensive evaluation of iron status should include plasma iron, transferrin, transferrin saturation, ferritin, CRP, hepcidin, and evaluation of red blood cell morphology 3
Transferrin saturation below 16% in adults often confirms iron deficiency, with a specificity of 93% for iron deficiency defined by absence of bone marrow iron 4, 5
Serum ferritin is the most specific indicator of depleted iron stores, with levels ≤15 μg/L confirming iron deficiency in anemic patients 4, 6
For accurate assessment after intravenous iron administration, measure iron status 24-48 hours after iron sucrose or iron gluconate doses, and 1-2 weeks after iron dextran doses 1

Intravenous iron is indicated for patients with chronic inflammatory conditions, such as CKD, heart failure, IBD, and cancer 3
In CKD patients with low transferrin saturation (<25%) but elevated ferritin (500-1200 ng/ml), intravenous iron can still improve hemoglobin levels 9
Use caution with intravenous iron in patients with active infection 1
For rapid replacement, newer carbohydrate-bound iron formulations allow administration of large single doses with lower risk of adverse reactions 3

All patients with hereditary hemochromatosis who have evidence of iron overload should undergo regular phlebotomies until iron stores are depleted 7, 8
Maintenance phlebotomy should be continued for life, with frequency determined by serum ferritin levels 7, 8
Patients with cirrhosis due to hemochromatosis should undergo regular screening for hepatocellular carcinoma 7, 8
Treatment for secondary iron overload should be tailored to the underlying cause 2, 7, 8
Phlebotomy is effective for certain forms of secondary iron overload, including African iron overload and porphyria cutanea tarda 7, 8
Iron chelation therapy with parenteral deferoxamine is the treatment of choice for secondary iron overload associated with ineffective erythropoiesis 7, 8

In patients requiring iron and/or ESA therapy, measure serum ferritin and transferrin saturation every 1-3 months depending on clinical status 1
In stable patients with mild anemia not receiving iron or ESA therapy, assessment can be performed yearly 1
More frequent monitoring is required in clinical situations such as bleeding, surgery, initiation of iron therapy, or rapid change in hemoglobin 1
To measure success of iron treatment, basic blood tests should be repeated after 8-10 weeks 3