What are the indications for phlebotomy?

Indications for Phlebotomy

Phlebotomy is primarily indicated for hereditary hemochromatosis and other conditions with iron overload, with the goal of reducing iron stores to prevent morbidity and mortality from organ damage. 1

Primary Indications

Hereditary Hemochromatosis

• Initial treatment phase: Weekly or biweekly phlebotomy (removal of 500 mL blood) until serum ferritin reaches 50-100 μg/L 1
• Maintenance phase: Periodic phlebotomy to maintain ferritin between 50-100 μg/L 1
• Monitoring requirements:
  • Check hemoglobin/hematocrit before each procedure
  • Ensure hemoglobin/hematocrit does not fall by more than 20% of prior level
  • Check ferritin levels every 10-12 phlebotomies 1

Secondary Iron Overload Conditions

1. Porphyria Cutanea Tarda (PCT)

   • Clearly indicated to reduce skin manifestations 1
   • Total iron stores typically do not exceed 4-5g

2. Post-transfusional iron overload

   • In long-term survivors of acute leukemia 2
   • In patients post-hematopoietic cell transplantation 3
   • In patients on hemodialysis with transfusional iron overload 4

3. Non-alcoholic fatty liver disease (NAFLD) with iron overload

   • May improve insulin resistance parameters and reduce ALT levels 1

4. Non-HFE iron overload with elevated hepatic iron concentration 1

Polycythemia

• Therapeutic phlebotomy is indicated in polycythemia to reduce blood viscosity
• Caution: Patients with cardiovascular disease require special consideration:
  • Slow removal of small blood volumes
  • Continuous blood pressure monitoring
  • Effective plasma volume restoration with plasma or colloid unless volume overload is present 5

Contraindications and Precautions

• Severe anemia: Phlebotomy may worsen symptoms
• Unstable cardiovascular disease: Risk of myocardial infarction or cardiovascular collapse 5
• Decompensated liver disease: Consider liver transplantation instead of phlebotomy 1
• Patients with cardiac arrhythmias or cardiomyopathy: Higher risk of sudden death with rapid iron mobilization 1

Protocol Considerations

1. Standard procedure:

   • Remove 500 mL of blood weekly or biweekly
   • Check hemoglobin/hematocrit before each procedure
   • Allow hemoglobin/hematocrit to fall by no more than 20% 1

2. Safety measures:

   • Appropriate vein selection to avoid nerve injury
   • Emergency equipment availability (bed, oxygen, utility cart with drugs)
   • Use of sterilized collection tubes and single-use holders to prevent infections 6
   • Monitor for vasovagal reactions (hypotension, pallor, syncope) 6

3. Adjunctive considerations:

   • Avoid vitamin C supplements in iron-loaded patients (accelerates iron mobilization) 1
   • No dietary adjustments necessary during treatment 1
   • For patients unable to tolerate phlebotomy, iron chelation therapy may be considered 1

Monitoring Effectiveness

• Serum ferritin levels (target 50-100 μg/L for hemochromatosis) 1
• Transferrin saturation 3
• Liver function tests (ALT, AST, alkaline phosphatase, bilirubin) 3
• Hemoglobin/hematocrit levels before each procedure 1

Phlebotomy efficacy may vary based on genetic factors, with patients carrying mutant HFE gene variants potentially showing a slower decline in serum ferritin levels 3.