[Red blood cell transfusion and iron overload management in bone marrow failure diseases]

Restrictive red blood cell (RBC) transfusions with a trigger hemoglobin value of 6-7 g/dl are recommended for anemic patients with bone marrow failure diseases, such as aplastic anemia or myelodysplastic neoplasms (MDS). However, frequent transfusions can lead to iron overload, which can damage various organs through the production of reactive oxygen species. Higher ferritin levels are also known to be a negative prognostic factor for lower-risk MDS. Therefore, in transfusion-dependent patients, iron chelation therapy (ICT) is considered to prevent and reduce organ damage due to iron overload and to improve the prognosis of lower-risk MDS. When regular RBC transfusions are started, it is recommended to monitor serum ferritin levels regularly. Transfusional iron overload is diagnosed when ferritin levels exceed 500 ng/ml and cumulative RBC transfusion volume exceeds 20 units. ICT should be started when ferritin levels exceed 1,000 ng/ml, and should be continued to maintain ferritin levels below 500 ng/ml.