Hemochromatosis is a common genetic disorder where the body absorbs too much iron from the diet, leading to a buildup of excess iron in organs like the liver, heart, and pancreas. This iron overload can eventually cause organ damage if left untreated. Therapeutic phlebotomy, the controlled removal of blood, is the primary and most effective method to manage this condition. By removing red blood cells, which contain iron, this procedure forces the body to pull stored iron from the tissues to make new blood cells, gradually depleting the harmful excess. The frequency of this treatment is highly individualized and depends on the specific goals set by a healthcare provider to safely reduce the iron burden.
Defining Treatment Targets
The goal of therapeutic phlebotomy is to reduce the amount of stored iron to a safe level, which is monitored using specific blood tests. The two primary targets are serum ferritin (SF) and transferrin saturation (TS). Serum ferritin measures the iron stored in the body, while transferrin saturation indicates how much iron is circulating and readily available.
International guidelines recommend aiming for a serum ferritin level below 50 micrograms per liter (\(\mu\)g/L) during the initial phase of treatment. Once the maintenance phase begins, the target range is set between 50 and 100 \(\mu\)g/L. Keeping the ferritin level below 100 \(\mu\)g/L prevents the re-accumulation of iron that could lead to organ damage.
A secondary goal is to keep the transferrin saturation below 50 percent, and ideally below 40 percent, to ensure circulating iron is controlled. Careful monitoring of these metrics guides the treatment schedule. This ensures that iron stores are depleted without causing iron-deficiency anemia, which is monitored by checking hemoglobin levels before each procedure.
The Initial Iron Reduction Schedule
The initial phase of treatment, often called the depletion phase, requires the most frequent phlebotomy sessions to aggressively reduce iron stores. The schedule is highly intensive and depends directly on the patient’s starting ferritin level and overall health. Patients typically have one unit of blood (450 to 500 milliliters) removed once or twice per week. This volume removes approximately 200 to 250 milligrams of iron in each session.
The duration of this intensive phase can vary significantly, lasting from several months to a few years, depending on the severity of the iron overload. For a patient with a very high initial ferritin level (e.g., over 1,000 \(\mu\)g/L), the total number of phlebotomies required can be substantial. Regular monitoring of hemoglobin and ferritin levels tracks progress and adjusts the schedule. If the hemoglobin level drops too low, the frequency must be reduced or the procedure paused to prevent anemia.
The process continues until the serum ferritin target is reached. As the patient approaches this goal, ferritin testing becomes more frequent to avoid causing an iron-deficient state.
Lifetime Monitoring and Maintenance Frequency
Once the intensive iron depletion phase is complete and target ferritin levels are reached, the patient transitions to the maintenance phase, which continues for life. The goal shifts from actively reducing iron stores to preventing their re-accumulation. The frequency of phlebotomy is much lower and is determined by how quickly the individual re-accumulates iron.
The typical maintenance schedule involves a phlebotomy session every two to four months, but this can range from monthly draws to just one or two per year. Factors influencing this frequency include a patient’s diet, alcohol consumption, and any residual organ damage. Patients with hereditary hemochromatosis experience an average rise in ferritin of about 100 \(\mu\)g/L per year without treatment.
Monitoring remains a permanent requirement, with serum ferritin and transferrin saturation checked periodically, often every six months. This testing ensures the iron level stays within the safe range. The healthcare provider adjusts the phlebotomy interval based on these test results to keep the patient stable and prevent the return of iron overload.