Introduction
“Blood on the streets, blood on the rocks. Blood in the gutter, every last drop. You want blood, you got it.” ACDC
In the mediaevil period, bloodletting was a common medical practice. Barber surgeons would aim to remove various ‘humors’ or toxins from the body by bleeding patients. This is where the red pole outside of the hairdresser’s comes from.
Blood letting still goes on today; chiefly to get rid of extra iron. Iron is a key metal that the body needs to make red blood cells. However, in certain genetic conditions or non specific chronic disease, it can build up in the liver and cause inflammation.
In this setting, doctors will often recommend blood donation or blood letting. This article describes iron overload.
What is Iron Overload?
Iron is used for the creation of red blood cells, which carry oxygen around the body.
The body carefully balances how much iron it absorbs from the gut. A protein called hepcidin is vital in balancing iron absorption. In certain conditions, such as liver disease or a genetic condition, called haemochromatosis, too much iron can be absorbed and build up in the body and cause damage to the cells.
During states of distress, such as infection, the liver will take up iron from the blood circulation into the liver; this can also cause iron overload. This is probably an evolutionary defence mechanism; if the body is infected, it will take iron away from the circulation where potential bacteria could use it for fuel against the body.
What are the signs of iron overload?
The signs of this can be varied and include fatigue, joint pains, bronzed skin, erection issues and also liver inflammation with blood tests showing a highly raised ferritin, transferrin saturation > 45%. Sometimes, genetic tests will show abnormalities of the HFE genes either C282Y and or H63D however, many cases of iron overload can occur due to genetic problems we cannot identify or other causes.
Sometimes, iron overload presents later in life due to menstruation, iron consumption or vitamin C consumption delaying iron overload.
How is iron overload treated?
Firstly, the cause of excess iron should be pursued and treated. In some cases, this is a primary liver issue such as fatty liver and for others, it may be a genetic condition called haemochromatosis.
Either way, excess iron needs to be removed and this can be done by taking blood, called venesection. Everybody is different, so starting slow by taking 250mL each week and checking the blood after to make sure that the Hemoglobin (molecule on red blood cell that carries oxygen) is above 110, and continuing each week or fortnight until the ferritin is below 100 is recommended. Thereafter, treatment may be needed every 1-4 months based on blood tests. The transferrin saturation is less useful as it takes a while to come down.
What else should I do?
You should not take any extra vitamin C whilst you are undertaking venesection as it will encourage iron absorption. You do not need to change your diet. It is recommended not to drink alcohol before your follow up blood tests as it can change the results.
What are the risks associated with venesection?
Venesection is a low risk procedure that is very similar to donating blood; you are encouraged to eat a good meal and drink plenty of water before coming in; the nurse will place a needle in your arm to take some blood whilst you relax and read a book or carry on as you like. Before leaving, your blood pressure and heart rate will be checked and arrangements made to check your bloods a few days after. You should be taking B12 and folate supplements. There is a small risk of infection, pain and discomfort and some people may faint during the procedure or feel a bit dizzy and collapse; however this is rare as only small amounts of blood are being removed and you will be monitored.
What are the risks of not having venesection?
For people with evidence of iron overload, this is associated with toxicity to many parts of the body. The oxidative damage of iron can lead to liver failure, heart disease and also diabetes due to stress on the pancreas. It can also lower testosterone due to testicle insult. Diet cannot be used to treat iron overload.
What other considerations are there for iron overload?
Those with iron overload are recommended to be very careful with raw seafood and warm waters due to vibrio vulnificus, an infection common to marine environments. In general, treat marine cuts aggressively as iron overload creates a particular susceptibility to this infection.
