Why to Avoid Iron if We Don't Really Need It: Anemia in CLL

I was asked what is the risk of getting too much iron.

Here is an extended version of my answer.


Hi Bill,

Iron overload is a difficult issue should one become transfusion dependent.  That means we can not longer maintain an adequate hemoglobin without the help of getting someone else's blood.

But too much iron can seriously damage the liver, the heart and other organs. It needs to be prevented when possible and treatment should be considered when the iron (or ferritin) is at a level that can cause damage. Yet the treatment with the new chelation agent, EXJADE or deferasirox, while admittedly very effective, is fraught with risks, especially if you have any pre-existing renal or liver impairment.

In the absences of anemia, we treat patients with too much iron by bleeding them, not by chelating them.

Yes, we doctors still bleed patients for some conditions, we still use leeches for some wound treatments, and we still occasionally trephine skulls.

Back to the subject at hand.

Iron overload happens when multiple transfusions are needed because the marrow is impacted with CLL and we are not  making enough red cells, or if there in a rapid and severe drop from auto-immune hemolytic anemia or AIHA where we rapidly destroy our our red cells (though benefits from blood transfusions are very temporary and are best avoided), or if one develops a damaged bone marrow such as in secondary myelodysplastic syndrome or MDS.

After a transfusion, the red blood cells counts climbs quickly and generally feel more vigorous. Unfortunately, then the hemoglobin starts to fall quickly or slowly depending on the underlying problem that created the need for more blood. The iron, however, remains in the body, and it hard to get rid off.

I would not take an iron supplement unless you are certain that iron deficiency is the cause of your anemia. Most anemia in CLL is NOT from low iron, but from bone marrow failure and iron will not help. Not a bit.

There are inexpensive blood tests to nail the diagnosis. Measuring serum iron, total iron binding capacity, and ferritin can usually sort this out. There are other tests and information included in the CBC itself that can be helpful with the diagnosis.

If indeed there is iron deficient anemia (IDA), you need to find the source of the blood loss. Barring any recent trauma, it is almost always from either heavy menstrual flow (not a common problem due to the age of most with CLL, but certainly a possibility in some younger female CLLers) or the more worrisome concern of bleeding from the gastrointestinal tract. Colon cancer can present with anemia and no other symptoms and we are at higher risk for all secondary cancers including the ones in the gut.

A strict vegan diet may also result in IDA after many years, but the data is conflicting.

Even too many blood draws from the vampires at the labs can lead to IDA.

Diagnosing IDA is just the first step, it demands its own work-up.

Take a look at this very cool anemia app that I put together with Dr. Steensma, a world expert in MDS,  for practicing healthcare providers. It is pretty simple and clear.

Here's the link to the free Iphone and Ipad versions.

Stay strong

Brian