From the Guidelines
Phlebotomy is not indicated for patients with non-alcoholic steatohepatitis (NASH) who have hyperferritinemia, as the elevated ferritin levels typically reflect inflammation rather than true iron overload. The management of NASH should focus on addressing the underlying metabolic factors through lifestyle modifications, including weight loss, dietary changes, and increased physical activity 1. According to the EASL clinical practice guidelines on haemochromatosis, serum iron parameters alone are often insufficient to ascertain iron overload, and alternative causes of elevated ferritin, such as inflammatory and neoplastic conditions, should be considered 1.
In patients with NASH, the primary goal of treatment remains addressing insulin resistance and metabolic dysfunction rather than targeting ferritin levels directly, as the hyperferritinemia typically improves when the underlying liver inflammation is reduced. If iron overload is suspected, further evaluation with transferrin saturation and possibly liver biopsy to assess hepatic iron concentration would be warranted before considering phlebotomy 1. However, there is no conclusive evidence to support the use of iron depletion through phlebotomy in patients with metabolic syndrome, including those with NASH, and the use of phlebotomy in these patients should be determined on a case-by-case basis.
Some key points to consider in the management of NASH patients with hyperferritinemia include:
- Elevated ferritin levels in NASH patients typically reflect inflammation rather than true iron overload
- Management should focus on addressing underlying metabolic factors through lifestyle modifications
- If iron overload is suspected, further evaluation with transferrin saturation and possibly liver biopsy would be warranted before considering phlebotomy
- Phlebotomy may be considered in cases where true iron overload coexists with NASH, but this should be determined on a case-by-case basis 1.
From the Research
Phlebotomy in NASH with Hyperferritinemia
- Phlebotomy is a treatment option for patients with nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia, as it can help reduce iron levels and improve liver damage 2.
- A randomized trial found that iron depletion by phlebotomy was associated with a higher rate of improvement in histological liver damage and liver enzymes compared to lifestyle changes alone in patients with NAFLD and hyperferritinemia 2.
- However, phlebotomy is only effective when hepatocellular iron overload is present, and not when hyperferritinemia is related to inflammation 3.
- In patients with NASH, hyperferritinemia is often associated with hepatocellular injury rather than hemochromatosis, and careful evaluation is necessary to establish an appropriate clinical approach 4.
- The decision to use phlebotomy in patients with NASH and hyperferritinemia should be based on individual patient characteristics, including the presence of iron overload and the severity of liver damage 2.
Key Considerations
- The presence of hyperferritinemia in patients with NASH does not necessarily indicate iron overload, and other causes such as inflammation should be considered 3, 4.
- Liver biopsy and measurement of liver iron concentration can help determine the presence of iron overload and guide treatment decisions 5, 2.
- Phlebotomy can be an effective treatment option for patients with NASH and hyperferritinemia, but it should be used in conjunction with lifestyle changes and other treatments as needed 2.