Causes and Treatments for Excess Iron in the Blood

What is iron overload and how can you prevent it?

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Iron overload occurs when there is excess iron in the blood. It is usually caused by hemochromatosis, an inherited condition. You may be able to help get rid of excess iron in the body naturally by adjusting your diet, but the most effective way to lower iron levels is by having blood drawn.

Symptoms of iron overload can include fatigue, joint pain, and abdominal pain. Untreated iron overload may lead to complications like heart failure, diabetes, cirrhosis of the liver, cancer, and other serious health conditions.

This article discusses iron overload and its symptoms and complications. It also goes over the treatments for iron overload and how you may be able to reduce iron levels naturally through diet.

Symptoms

In 75% of cases, a person with hemochromatosis will have no symptoms, although feelings of fatigue may begin early in the course of the condition.

However, once iron has built up in various organs, you may begin to experience more prominent symptoms. These can include:

  • Joint pain (when in the knuckles, this is called "iron fist")
  • Abdominal pain
  • Loss of sex drive
  • Gray or bronze skin color

Untreated, the accumulation of iron can lead to:

  • Heart failure
  • Infertility
  • Diabetes
  • Cirrhosis of the liver
  • Arthritis
  • Hypothyroidism (under-active thyroid)
  • Impaired growth
  • Erectile dysfunction
  • Cancer
  • Depression

Some evidence also suggests bacterial infection may be one of the consequences of iron overload, as iron buildup in the white blood cells impairs their ability to fight invading organisms.

Causes

Iron plays a part in many biological processes. You take it in through food and it's mostly used to form hemoglobin, the substance in red blood cells that transports the oxygen through your body. Iron that isn't used is stored in the liver. However, if the body’s maximum iron storage capacity is reached, iron builds up in other parts of the body, leading to iron overload.

When iron has overwhelmed the body’s ability to safely store it, it can cause harm in several ways:

  • When there is more iron in the body than transferrin for it to bind to, it circulates by itself as non-transferrin-bound iron (NTBI). This form of iron is toxic to the body and causes damage to tissues and organs at a cellular level.
  • Excessive iron accumulates in the heart, lungs, brain, endocrine glands, liver, and even the bone marrow.

Hemochromatosis

Hemochromatosis is a common hereditary disorder that occurs in 1 out of 300 non-Hispanic whites and 1 out of 150 people with northwestern European ancestry. It is caused by mutations in genes that increase the absorption of iron from the diet.

There are several variations, with some being inherited in an autosomal recessive manner. In this case, the condition only becomes apparent if an individual receives the mutation from both parents, who may be asymptomatic carriers.

Transfusion-Related Iron Overload

In healthy individuals, only about 1 to 2 milligrams (mg) of iron is turned over in a given day—that is, iron that’s taken in from the diet and lost through the shedding of skin cells and gastrointestinal cells.

Red blood cell transfusions deliver a very large amount of iron, which can be a concern. A single unit of packed red blood cells (PRBCs) contains about 200 to 250 mg of iron. Most often, patients receive two units each time they are transfused, so that’s an extra 500 mg of iron in just one day.

Multiple blood transfusions are a fact of life for some patients with leukemia, lymphoma, and myeloma. Transfusions are used to improve blood cell counts and to treat the signs and symptoms of anemia, such as fatigue, foggy thinking, shortness of breath, and weakness. While the decision to administer these transfusions means the pros outweigh the cons in these patients, multiple blood transfusions over time can potentially cause iron overload.

People who are at risk of transfusional iron overload are those who have received many transfusions of red blood cells. Adults who regularly receive transfusions are at risk after about 20 lifetime units of PRBCs, or 10 transfusions if you get two units at a time. The risk is significant when more than 40 units have been transfused.

Patients with blood and marrow cancers, such as leukemia and lymphoma, usually require a greater number of transfusions after chemotherapy, after radiotherapy to their pelvic region, or following stem cell transplantation.

Patients with myelodysplastic syndromes (MDS) often have persistently low hemoglobin and many are transfusion-dependent, putting them at high risk for iron overload. MDS with sideroblastic anemia may also cause patients to absorb an excessive amount of iron from their food, making the problem even worse.

Diagnosis

Iron overload occurs over time, and often patients will not show any signs. It is more likely that iron overload will be detected by laboratory results before the person has symptoms.

Serum Ferritin Level Blood Test

The most common test to assess iron saturation is called serum ferritin level. This is a blood test that may be done on a regular basis for high-risk individuals.

Why might I need a serum ferritin test?
Illustration by Brianna Gilmartin, Verywell 

Healthy men usually have a serum ferritin of 24 to 336 micrograms per liter (mcg/L); healthy women's results are usually 12 to 307 mcg/L. Serum ferritin levels increase as the amount of NTBI increases in the blood, and results that are greater than 1,000 mcg/L indicate serious iron overload.

Genetic Testing

Genetic testing may be done to confirm hereditary hemochromatosis. This is a blood test looking for the HFE gene defect. This may also be done as a screening test to detect the defect before it becomes symptomatic and damage has occurred.

Imaging and Biopsy

Imaging studies can also reveal findings suggestive of iron overload. Magnetic resonance imaging (MRI) may be used to detect iron accumulation in the liver and the heart. However, iron deposition is not reliably predicted by MRI in some instances, such as when iron deposition occurs in the pancreas.

MRI may be used together with a liver biopsy to diagnose iron overload or these can be done independently. A liver biopsy can check iron concentration. While this test may give slightly more accurate results than serum ferritin levels, it requires a fairly invasive procedure that can lead to complications, such as infection and bleeding.

Treatment

There are two main ways that iron overload is treated—therapeutic phlebotomy and iron chelation therapy.

Therapeutic Phlebotomy

Therapeutic phlebotomy is the quickest and most effective way to get iron levels down in a patient. During a therapeutic phlebotomy, a nurse or healthcare provider will insert a large needle into your vein, usually in your arm. They will then remove about 500 milliliters (ml) of blood from your body over about 15 to 30 minutes. If you have ever donated blood, the process is similar.

This amount of blood contains about 250 mg of iron. As this iron is removed through your blood, your liver releases some of its stores and eventually the amount of circulating iron can be returned to normal ranges.

Phlebotomy may be done once or twice a week as necessary to reach the goal of serum ferritin levels of 50 to 100 mcg/L.

Iron Chelation Therapy

Iron chelation therapy uses medications that bind, or chelate, iron and facilitate its removal from the body. The goal of this type of therapy is to remove excess iron from the blood and organ tissues. Although this therapy works well on plasma iron and liver deposits, it is not as effective in removing iron deposits from the heart.

Iron chelator medications—Exjade (deferasirox) and Ferriprox (deferiprone)—are effective at reducing NTBI levels, but these levels rebound quickly if the therapy is discontinued. Therefore, these medications must be taken exactly as directed for them to work properly. This can be a big commitment for some patients.

Iron chelators are also not without side effects, and the risks and benefits of iron chelation need to be weighed carefully.

Diet

In addition to these therapies, you may be able to get rid of excess iron in the body naturally by changing your diet.

A hemochromatosis diet involves limiting or excluding foods that contain large amounts of heme iron, such as red meat. Heme iron is more easily absorbed by the body than non-heme iron, which is the type of iron found in plants.

Nutritionists recommend eating no red meat at all and limiting poultry consumption to 200 grams per week. Seafood should be limited to 350 to 500 grams per week. Half of the fish consumed should be the fatty variety. Other recommended foods include:

  • Vegetables
  • Eggs
  • Legumes
  • Non-fortified whole grains

Foods containing non-heme iron should not be eaten along with certain foods that increase the absorption of iron, such as:

  • Alcohol
  • Citrus and other foods containing vitamin C
  • Fermented foods like sauerkraut and kombucha
  • Sourdough bread
  • Foods high in sugar
  • Fruit juice

Calcium inhibits the absorption of iron, so drinking milk with meals may help reduce the amount of iron your body takes in. Green or black tea, coffee, and water are also good choices for beverages to have with meals.

Coping

For those with hereditary hemochromatosis and iron overload, regular phlebotomy and testing of iron and ferritin levels will be necessary throughout life. You should avoid iron-fortified foods and iron-containing vitamins and supplements.

If you require blood transfusions for blood cancer or other disorders, there are things that you can do to ensure that your iron levels are monitored properly. Inform your current healthcare team of your past blood transfusion history. You may have received PRBCs years ago for a completely unrelated condition, but your healthcare provider needs to know about that now.

You should also try to keep track of each transfusion you receive. This may not be easy, and there may be times in your therapy when it seems like all you do is get transfused, but it will be important later on.

If you receive regular transfusions, your healthcare team should monitor your serum ferritin levels and implement chelation therapy to keep your iron levels under control. If they are not already doing this, ask for it.

Summary

Iron overload happens when there's too much iron in your blood. The cause is usually a genetic condition called hemochromatosis, though it can also be caused by blood transfusions and other conditions. Untreated, iron overload can lead to serious medical conditions such as heart failure, hypothyroidism, and others.

The condition is generally treated with therapeutic blood draws. Medications that help bind and remove iron can also help. You will likely also need to follow a diet that limits iron and foods that increase iron absorption.

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By Karen Raymaakers
Karen Raymaakers RN, CON(C) is a certified oncology nurse that has worked with leukemia and lymphoma patients for over a decade.