Can hemodialysis (HD) remove iron from the blood in cases of iron poisoning?

Hemodialysis for Iron Removal in Iron Poisoning

Hemodialysis can effectively remove iron in cases of severe iron poisoning, particularly when combined with gastrointestinal decontamination and chelation therapy with deferoxamine. 1

Mechanism of Iron Removal by Hemodialysis

• Hemodialysis primarily removes non-transferrin-bound iron (NTBI), which is the toxic form of iron in cases of iron overload or poisoning 2
• When blood circulates through dialysis membranes, NTBI can cross the membrane pores and be removed from circulation 2
• Removal of circulating iron stimulates iron release from larger proteins and tissue stores, establishing a continuous flow of iron that can be eliminated 2

Efficacy of Hemodialysis for Iron Removal

• In severe iron intoxication cases, hemodialysis has been shown to significantly decrease serum iron concentration (from 2150 to 160 mcg/dL within 24 hours in one documented case) 1
• Hemodialysis can remove approximately 50% of non-transferrin-bound iron from circulation during a session 2
• The effectiveness is limited by iron that is tightly bound to transferrin, which cannot be readily removed by dialysis 2

Clinical Application in Iron Poisoning

• Hemodialysis should be considered in cases of:

  • Severe iron poisoning (ingestion of >60 mg/kg of elemental iron) 1, 3
  • Patients with life-threatening toxicity including severe metabolic acidosis 1
  • Cases where standard therapy with deferoxamine is insufficient 3

• The optimal approach combines:

  • Gastrointestinal decontamination to prevent further absorption 1, 3
  • Deferoxamine chelation therapy to bind circulating iron 1, 3
  • Hemodialysis to enhance iron elimination 1

Important Clinical Considerations

• Hemodialysis should be reserved for severe cases where more conservative therapy is unsuccessful 3
• Early recognition and prompt initiation of treatment is crucial for improving outcomes and reducing mortality 3
• Supportive care with particular attention to maintaining intravascular volume is essential during treatment 3
• Correction of acidosis and coagulation disorders should be addressed concurrently 3

Contrast with Routine Dialysis Patients

• Ironically, most maintenance hemodialysis patients actually require iron supplementation due to:

  • Blood losses related to the dialysis procedure itself 4
  • Regular blood sampling for laboratory tests 4
  • Occult intestinal bleeding due to uremic enteropathy 4
  • Increased iron requirements when treated with erythropoiesis-stimulating agents 4

• In routine dialysis patients, iron overload is a concern due to excessive intravenous iron administration rather than poisoning 4

Monitoring and Follow-up

• Serum iron levels should be monitored throughout treatment to assess the effectiveness of hemodialysis 1
• Mental status and clinical symptoms should be closely observed for improvement 1
• Once stabilized, patients should be monitored for potential late sequelae such as hepatic necrosis and gastrointestinal scarring 3