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Iron overload can lead to multiple organ dysfunction/failure and poor quality of life in a variety of patients with different haematological conditions, including haemoglobinopathies, polycythaemias, haemochromatosis and post haematopoietic stem cell transplant. Patients entering into haematopoietic stem cell transplantation with iron overload have an increased risk of delayed engraftment, veno-oclusive disease (VOD), infection and GVHD.
In addition to oral or parenteral iron chelation, venesections may also be used as a treatment modality for the management of iron overload in selected patients. This SOP aims to define indications and contra-indications for the use of venesections in this clinical scenario, the competencies and equipment required, and to describe the procedures to be followed.
Children at risk of iron overload.
AUTHORISED PERSONNEL/SPECIFIC STAFF COMPETENCIES
Whatever the aetiology (ie: multiple transfusions, increased iron absorption in haemoglobinopathies or haemochromatosis), the diagnosis of iron overload and estimation of its clinical impact (ie: iron content in tissues, organ dysfunction) should include at least the following:
Consider intervention/treatment for the following patients:
Patients can be offered venesection if:
The venesection will not proceed if the patient has an intercurrent viral infection. Delay venesection until fit to proceed. If the child is unwell, treat as appropriate for illness.
This procedure involves the removal of a specified amount of blood by venepuncture, every 3 to 4 weeks and as tolerated, to control iron overload. Venesections should continue, if well tolerated, until ferritin reaches values < 300 microg/L or the liver iron concentration is <5mg/g dry weight.
Prior to each venesection procedure the following should be done, as a baseline:
Ensure that the patient is fully informed of the procedure and any questions are answered.
If there is a history of fainting - lie flat for procedure and 30 minutes after completion.
The nurse must always ensure that the patient is feeling well and that he/she has eaten as hunger/dehydration can lead to fainting during or post procedure.
The patient’s blood count must be checked prior to carrying out procedure and results from last venesection (e.g. ferritin and iron levels).
The amount of blood to be venesected must be calculated prior to each venesection based on the patient's weight (5-7mls/kg to max 350mls) or previous amount venesected/comments on chart (e.g. fainted after 200mls taken)
Patient is cannulated and venesected over 30 mins or slower.
First blood specimen removed is used for laboratory tests.
Patient should be allowed to sit up after procedure and have a sugary drink (parents are asked to bring a sweet drink at each visit). If required 5-10ml/kg of normal saline can be administered.
After 15-30 minutes patient may be discharged if well.
Precautions explained to child/parent prior to each discharge:
For further information contact:
Franchini M, Gandini G et al 2004. Efficacy and safety to reduce transfusional iron overload in adult, long-term survivors of acute leukaemia. Transfusion 44: 833-837
Angelucci E et al, 1997. Phlebotomy to Reduce Iron Overload in Patients Cured of Thalassemia by Bone Marrow Transplantation. Blood 90(3): 994-998
Sucak G et al, 2012. The prognostic role of hemochromatosis H63D allele in allogeneic hematopoietic stem cell transplantation. Ann Hematol 91: 1281-1287
Majhail N et al, 2010. A Prospective Study of Iron Overload Management in Allogeneic Hematopoietic Cell Transplantation Survivors. Biol Blood Marrow Transplant 16: 832-837
Fred Hutch & Seattle Cancer Care Alliance. Information for physicians: resources for physicians treating LTFU patients.
PDWP Management of Iron Overload in Stem Cell Transplant 2019 - Nava T et al. Supportive care during pediatric hematopoietic stem cell transplantation: beyond infectious diseases. A report from workshops on supportive care of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020.
Last reviewed: 01 April 2020
Next review: 30 April 2022
Author(s): F Pinto
Approved By: Schiehallion Clinical Governance Group
Document Id: RHC-HAEM-ONC-010