Iron chelation therapy in myelodysplastic syndromes and allogeneic hematopoietic cell transplantation, a delicate balance.

Anemia is a hallmark of myelodysplastic syndromes/neoplasms (MDS) and most patients with MDS chronically require red blood cell transfusions. Due to the body's inability to excrete excess iron, patients are at increased risk of iron overload, often defined by ferritin levels >1000 ng/mL. Iron overload can cause progressive organ damage from iron deposition in tissues and has been linked to increased mortality. In MDS patients undergoing allogeneic hematopoietic cell transplantation (HCT), iron overload has also been associated with increased non-relapse mortality, decreased overall survival, and a higher incidence of relapse. Prospective and retrospective studies have demonstrated the safety and clinical benefit of iron chelation therapy (ICT) in lower-risk MDS. Despite some common adverse effects associated with ICT, such as renal toxicity and gastro-intestinal symptoms, managing iron levels remains essential in transfusion-dependent MDS patients, and those who are undergoing HCT to optimize pre-transplant conditions, and enhance post-transplant outcomes.