What is the role of hemoperfusion in treating severe iron toxicity?

Hemoperfusion in Severe Iron Toxicity

Hemoperfusion is an effective treatment modality for severe iron intoxication when combined with gastrointestinal decontamination and deferoxamine therapy, especially in cases with life-threatening toxicity and high serum iron levels. 1

Understanding Iron Toxicity

• Acute iron poisoning is a potentially serious condition that requires early recognition and treatment to prevent morbidity and mortality 1
• The human body lacks a physiological mechanism to excrete excess iron, leading to accumulation and toxicity 2
• When iron levels exceed the binding capacity of transferrin, non-transferrin bound iron is released into circulation, causing significant organ damage 2

Treatment Algorithm for Severe Iron Toxicity

First-Line Interventions

• Gastrointestinal decontamination should be performed immediately for acute ingestions 1, 3
• Deferoxamine (DFO) infusion is the primary chelation therapy for severe iron toxicity 1, 3
• Supportive care including fluid resuscitation and management of metabolic acidosis is essential 3

Role of Hemoperfusion

• Hemoperfusion should be considered in cases with:

  • Massive overdose (>60 mg/kg of elemental iron) 3
  • Serum iron concentrations >1000 μg/dL 1
  • Severe clinical manifestations (coma, shock, severe metabolic acidosis) 1
  • Inadequate response to conventional therapy 1

• Hemoperfusion has been shown to significantly decrease serum iron concentration and improve clinical status in patients with life-threatening toxicity 1

  • In one documented case, hemoperfusion helped reduce serum iron concentration from 2150 to 160 mcg/dL within 24 hours post-ingestion 1

Comprehensive Management Approach

Assessment of Severity

• Determine the amount of elemental iron ingested (acute ingestions >60 mg/kg are potentially serious) 3
• Measure serum iron concentration and total iron-binding capacity 3
• Assess for clinical manifestations of toxicity (GI symptoms, shock, metabolic acidosis, altered mental status) 1, 3

Treatment Protocol

1. Gastrointestinal Decontamination:

   • Gastric lavage with solutions containing sodium bicarbonate 3
   • Whole-bowel irrigation with polyethylene glycol-electrolyte solution for patients with visible tablets on imaging 3

2. Chelation Therapy:

   • Deferoxamine infusion (standard chelating agent) at appropriate dosing 3, 4
   • Consider oral chelators (deferiprone, deferasirox) in specific situations 5, 6

3. Extracorporeal Removal:

   • Implement hemoperfusion in severe cases with high serum iron levels and significant clinical toxicity 1
   • Hemodialysis may assist in decreasing serum iron concentration in massive overdose 1

4. Supportive Care:

   • Blood product transfusion for necrotizing gastroenteritis if needed 3
   • Management of shock, metabolic acidosis, and other complications 1, 3

Important Considerations and Caveats

• Hemoperfusion should be considered as an adjunctive therapy, not a replacement for standard treatments 1
• The decision to implement hemoperfusion should be made early in severe cases to maximize efficacy 1
• Close monitoring of serum iron levels and clinical status is essential during and after hemoperfusion 1
• While hemoperfusion has shown promise in case reports, it is not universally available and requires specialized equipment and expertise 1
• Excessive blood transfusions should be avoided as they can worsen iron overload and potentially increase portal pressure in patients with liver disease 7