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Blood transfusions represent an important component of supportive therapy for many patients with myelodysplastic syndromes (MDS). However, in the absence of appropriate iron reduction therapy, blood transfusions are an independent mortality risk factor for patients with MDS. Patients with refractory anemia may be more susceptible to the risks of iron overload than patients with other MDS subtypes, because of their longer mean survival time post-diagnosis.

Transfusion burden and mortality in MDS

A recent retrospective analysis by Malcovati and colleagues of 467 patients with MDS demonstrated a significant correlation between transfusion burden and prognosis in pooled data across all MDS subtypes (1).

Divergent prognosis among MDS subgroups

Mortality risk differs among MDS subgroups. The Malcovati study demonstrated significantly different prognoses and survival times among WHO subgroups (1). Patients with refractory anemia (RA) had a mean survival of 108 months, compared to 49 months in patients with refractory cytopenia with multilineage dysplasia (RCMD) (1). These findings may be especially relevant for patients with refractory anemia, whose longer survival expectancy makes them more prone to long-term iron toxicity from blood transfusions (1).

Significant differences in survival times among MDS subgroups Half of all patients with refractory anemia can expect to survive over 9 years after diagnosis (108 months). Adapted with permission from Malcovati, et al (2).

Predictive value of serum ferritin

Serum ferritin can predict mortality risk. Secondary iron overload (defined as serum ferritin >1000 µg/L) was found to be an independent survival risk factor in transfusion-dependent patients with MDS (1). A survival analysis of patients with MDS found a 30% higher risk of death for every 500 µg/L increase in serum ferritin above the threshold of 1000 ng/mL (1).

Recommendations for monitoring iron overload

Consensus recommendations developed by leading MDS researchers and clinicians recommend baseline assessment of body iron stores at diagnosis of MDS and at regular intervals — at least every 3 months — thereafter (3). They recommend that monitoring be performed with a combination of serum ferritin, serum transferrin, and liver MRI (3).

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