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The Harmful Effects of Iron Overload in Patients with Myelodysplastic Syndrome
These guidelines converge towards a consensus on the The guidelines all agree that RBC transfusions are clinically beneficial
subgroups of patients with MDS who should receive chelation therapy. to treat symptomatic anaemia in MDS. Patients with low-risk MDS
The Italian guidelines recommend that adult patients with MDS who receiving transfusions are the most likely to benefit from iron chelation
have previously received more than 50 units of blood and with an therapy. The NCCN guidelines emphasise that iron chelation should, in
expected lifespan longer than six months should receive iron chelation particular, be considered for patients with low-risk MDS whose clinical
The UK guidelines recommend that iron chelation should be course suggests the need for continuing red blood cell transfusions
considered once a patient has received 5g of iron or approximately along with those with concurrent cardiac or hepatic dysfunction.
25 units of blood, but only if long-term transfusional therapy is likely.
These guidelines recognise that patients with MDS may have
The most recent National Comprehensive Cancer Network (NCCN) additional factors that make them more vulnerable to the toxic effects
practice guidelines strongly recommend that iron chelation therapy be of iron overload.
considered in patients who have received 20–30 units of blood and for
whom ongoing blood transfusions are anticipated.
The Nagasaki consensus statement provides more detailed eligibility
criteria. Patients with refractory cytopenia with multilineage dysplasia
The Nagasaki consensus recommends starting iron chelation therapy when (RCMD) or refractory sideroblastic cytopenia with multilineage dysplasia
serum ferritin levels reach 1,000-2,000µg/l, dependent on the transfusion (RSCMD), coupled with a low IPSS score, are also good candidates for
Expert opinion is now of the view that a serum ferritin level of iron chelation therapy. These patients are likely to survive for about five
1,000µg/l is a suitable threshold for starting iron chelation therapy. years. Patients with RCMD, RSCMD and an IPSS intermediate-1 score
Chelation therapy should continue for as long as transfusion therapy with a life expectancy of about three years may also benefit, though the
continues and as long as iron overload remains clinically relevant.
The indication is less clear.
aim is to reach and maintain a serum ferritin level below 1000µg/l.
The MDS patient tends to have multiple clinical problems. The causes of
The MDS Foundation guidelines recommend that iron chelation therapy decreased survival are likely to be multifactorial and not always related to
should be initiated when the serum ferritin reaches 1,000µg/l, and/or after transfusions. Retrospective and prospective evidence is accumulating on the
the patient has received two units of RBCs per month for at least one year. deleterious role of iron in MDS especially in liver and heart dysfunctions.
Iron chelation therapy should be proposed to patients with an anticipated More prospective studies are difficult to interpret. Current guidelines for iron
survival superior to one year, without co-morbidities, limiting prognosis or chelation therapy in patients with MDS who have a reasonable survival
candidates for allograft.
prognosis are largely based on clinical experience. ■
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