Human recombinant erythropoietin and phlebotomy in the treatment of iron overload in uremic patients

Six chronic hemodialysis patients suffering from iron overload (serum ferritin ranged between 2053-15704 μg/L) were treated with human recombinant erythropoietin (EPO) alone for eighteen months. An initial rapid decrease of serum ferritin was observed in all six patients when the loading dose of EPO was given. Three patients (cases, 4, 5, 6) who suffered from chronic blood loss maintained a continuous decline of serum ferritin in the subsequent stage of maintenance dose EPO therapy, however, the decrease of serum ferritin became sluggish under a maintenance dose in the other three patients (cases 1, 2 and 3). The serum ferritin eventually decreased to a satisfactory level (975-1761 μg/L) in cases 4, 5 and 6, whereas it remained high (4232-8196 μg/L) in cases 1, 2, and 3 who had higher basal levels of serum ferritin (5641-15704 μg/L) and a plateau of response under a maintenance dose of EPO. These three patients were then treated with EPO and phlebotomy. Their serum ferritin decreased quickly from 6752 ± 1264 μg/L to 2454 ± 482 μg/L after six months of phlebotomy therapy; it was a dramatic improvement in contrast to the stagnant response under a maintenance dose of EPO alone. Our experience indicates that EPO therapy alone has its limitations in treating severe iron overload. Although there is an initial rapid decrease of serum ferritin during the period of the loading dose, the response might become stagnant during the period of maintenance dose. Phlebotomy effectively eliminated the excessive iron stores in these refractory cases. Therefore, we suggest that plebotomy be considered in severe iron overload if a stagnant response is observed under a maintenance dose EPO therapy.