Initial Treatment for Hereditary Hemochromatosis with Elevated Liver Enzymes
Therapeutic phlebotomy should be initiated immediately as the first-line treatment for patients with hereditary hemochromatosis (HH) who have elevated liver enzymes. 1
Treatment Protocol
Initial Phlebotomy Regimen
- Remove one unit of blood (approximately 500 mL, containing 200-250 mg iron) weekly or biweekly as tolerated
- Check hemoglobin/hematocrit before each phlebotomy session
- Ensure hemoglobin/hematocrit does not fall more than 20% below baseline
- Monitor serum ferritin levels every 10-12 phlebotomies (approximately every 3 months)
Target Goals
- Continue regular phlebotomy until serum ferritin reaches 50-100 μg/L
- Once target is reached, transition to maintenance phlebotomy to keep ferritin in this range
Monitoring During Treatment
Laboratory Parameters
- Check liver enzymes (ALT, AST) monthly to assess improvement
- Monitor serum ferritin to track iron depletion progress
- Measure transferrin saturation (will remain elevated until iron stores are depleted)
- For patients with elevated liver enzymes, more frequent monitoring may be warranted initially
Expected Response
- Normalization of elevated liver enzymes is an expected benefit of phlebotomy
- Improvement in liver function typically occurs within the first few months of treatment
- Reversal of hepatic fibrosis may occur in approximately 30% of cases 1
Important Considerations
Avoid During Treatment
- Vitamin C supplements (can increase iron absorption and mobilization)
- Iron supplements
- Raw shellfish (risk of Vibrio vulnificus infection in iron-overloaded patients)
No Need For
- Dietary restrictions (the amount of iron absorbed from diet is minimal compared to phlebotomy removal)
- Initial liver biopsy if ferritin is <1000 μg/L with elevated liver enzymes 1
Clinical Benefits of Treatment
Early treatment with phlebotomy before the development of cirrhosis significantly reduces morbidity and mortality in HH patients 1. Specific improvements include:
- Normalization of elevated liver enzymes
- Potential reversal of early hepatic fibrosis
- Improved survival when initiated before cirrhosis develops
- Reduced risk of hepatocellular carcinoma
- Improvement in other symptoms (fatigue, skin pigmentation, abdominal pain)
Special Considerations
Potential Pitfalls
- Phlebotomy requirements cannot be accurately predicted from initial ferritin levels or hepatic iron concentration 2
- Avoid iron deficiency by not reducing ferritin below 50 μg/L
- In patients with advanced cirrhosis, phlebotomy will not reverse established cirrhosis but may still improve liver enzymes and prevent further damage
- Patients with cardiac involvement require more cautious phlebotomy to avoid rapid iron mobilization which can trigger arrhythmias
Long-term Management
- After initial iron depletion, patients require individualized maintenance phlebotomy schedules
- Monitor for reaccumulation of iron with periodic ferritin measurements
- Continue screening for hepatocellular carcinoma in patients who had cirrhosis at diagnosis
Early diagnosis and treatment with phlebotomy is crucial to prevent progression to irreversible organ damage, particularly liver cirrhosis and its complications.